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Yearly Archives: 2018
Bisoprolol use seems to be increasing from the queries I receive. It is difficult to assess safety as published information relies on one study where the level in milk was undetectable BUT the baby was not given any of its mother’s milk. If other beta blockers are not suitable then the baby should be monitored closely for side effects and particularly hypo-glycaemia if newborn.
BNF ” With systemic use in the mother, infants should be monitored as there is a risk of possible toxicity due to beta-blockade. However, the amount of most beta-blockers present in milk is too small to affect infants.”
That new title is going to take a lot of getting used to! I am very proud and delighted to have been nominated for an MBE for services to mothers and babies as a founder of the Breastfeeding Network Drugs in Breastmilk Service. I never thought this would happen to me following a path which I didnt really plan 22 years ago but has led me to this amazing place. I feel inspired to keep going and hopefully change some more professional attitudes that prescribing a medication doesnt mean that a mother needs to interrupt breastfeeding. Thank you to the many, many people who have sent messages of congratulations today – I appreciate them so much.
I also want to thank my wonderful family for their support – my husband Mike, my daughters Kerensa, Bethany and Tara, my son in laws Christian, Steve, Rich and Ian and of course my treasured grandchildren Stirling, Isaac, Beatrix and Elodie and the new bump due in 2019. I cant tell you how much I love you all
In a report today Public Health England have made recommendations on dental health and breastfeeding. Full information can be accessed at : www.gov.uk/government/publications/breastfeeding-and-dental-health/breastfeeding-and-dental-health#breastfeeding-and-dental-health
- dental teams should continue to support and encourage mothers to breastfeed
- not being breastfed is associated with an increased risk of infectious morbidity (for example gastroenteritis, respiratory infections, middle-ear infections)
- breastfeeding up to 12 months of age is associated with a decreased risk of tooth decay
- breast milk is the only food or drink babies need for around the first 6 months of their life, first formula milk is the only suitable alternative to breast milk
- bottle-fed babies should be introduced to drinking from a free-flow cup from the age of 6 months and bottle feeding should be discouraged from 12 months old
- only breast or formula milk or cooled, boiled water should be given in bottles
- only milk or water should be drunk between meals and adding sugar to foods or drinks should be avoided
Recent systematic reviews such as that by Tham and others (2015)6 included studies where children were breastfed beyond 12 months. When infants are no longer exclusively breast or formula fed, confounding factors, such as the consumption of potentially cariogenic drinks and foods and tooth brushing practices (with fluoride toothpaste), need to be taken into account when investigating the impact of infant feeding practices on caries development. Tham and others (2015) noted that several of the studies did not consider these factors and concluded that with regard to associations between breastfeeding over 12 months and dental caries “further research with careful control of pertinent confounding factors is needed to elucidate this issue and better inform infant feeding guidelines”. Good quality evidence on breastfeeding and oral health is an area with significant methodological challenges which have been outlined by Peres and others (2018)7.
Of course I would also have to highlight that dental procedures, including sedation, local and general anaesthetic and use of antibiotics and analgesics need not interrupt breastfeeding
We all know as parents how hard it is to comfort a baby who is teething and to witness their distress. As a pharmacist, mother and grandmother I know that the standard products often recommended in the past contained a local anaesthetic often lidocaine.
In 2014 the FDA in USA first raised concerns stating that “Topical pain relievers and medications that are rubbed on the gums are not necessary or even useful because they wash out of the baby’s mouth within minutes, and they can be harmful”.
Today the MHRA have announced that parents and caregivers are being advised that products containing lidocaine used for teething in babies and children will be sold only in pharmacies, under the supervision of a pharmacist from the beginning of 2019. The MHRA review concluded there is a lack of evidence of benefit to using products containing lidocaine for teething before non-medicinal options. Evidence of any risk associated with these products is very small given the wide usage of these medicines. A pharmacist or healthcare professional can provide appropriate guidance. Teething is a natural process and lidocaine containing teething products such as teething gels should only be used as a second line of treatment after discussion with and guidance of a healthcare professional.
It is suggested that parents try non-medicine options such as rubbing or massaging the gums or a teething ring before considering teething gels after discussion with a pharmacist.
Further information can be found :
And a patient information leaflet: https://assets.publishing.service.gov.uk/media/5c0fd7cbed915d0c736a1e64/Lidocaine-patient-sheet.pdf
La Leche League GB have produced an excellent article on teething which can be accessed www.laleche.org.uk/breastfeeding-and-teething/#Pain.
The NHS also has sound information: https://www.nhs.uk/conditions/pregnancy-and-baby/teething-tips/
Products include Dentinox gel ®, Calgel ®, Bonjela ®, Anbesol gel ®
MBRRACE–UK released their 5th report ‘Saving Lives, Improving Mothers’ Care’. It describes the lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity from 2014-2016. Here’s The Breastfeeding Network’s response.
The Breastfeeding Network (BfN) welcomes the report. While the research has found that the number of women dying as a consequence of complications during or after pregnancy remains low in the UK – with fewer than 10 out of every 100,000 pregnant women dying in pregnancy or around childbirth, the report highlights the unacceptable disparity in care for black and ethnic minority women. Shereen Fisher, Chief Executive for the Breastfeeding Network said, ‘The almost five-fold higher mortality rate amongst black women compared with white women requires urgent explanation and action. BfN welcome further exploration into this unacceptable disparity to ensure there is real change for black and ethnic minority women’.
A key concern, is the tragic case of a mother dying several weeks after her baby was born (Commencing treatment, dose and compliance page 39). There were delays in prescribing thromboprophylaxis because of concerns over breastfeeding.
Dr Wendy Jones, lead pharmacist for the BfN Drugs in Breastmilk Information service, said ‘I have long feared such a scenario. Physicians need to be aware how to check that a drug treatment is compatible with breastfeeding quickly, using evidence-based sources. The drugs in this case are widely used in the immediate postnatal period yet emergency medicine teams are often unable to access readily available evidence-based information on medication and breastfeeding as quickly as they need. The information should have been readily available in guidelines or a reference source including specialist information. The wording of the BNF: “Due to the relatively high molecular weight and inactivation in the gastro-intestinal tract, passage into breast-milk and absorption by the nursing infant are likely to be negligible, however manufacturers advise avoid” needs to be updated where the manufacturer is merely not taking responsibility in licensing the product. The removal of the words “manufacturer advises avoid” makes the information read very differently to a busy practitioner’.
Shereen Fisher, Chief Executive for the Breastfeeding Network said, ‘This sad case highlights the need for mothers to be able to access skilled support in their local communities, with staff alert for symptoms needing attention; the mother in question had multiple ‘fainting’ episodes postnatally that were not investigated until day 44. This emphasises the need for health care professionals in all front-line services to understand how to treat pregnant and breastfeeding mothers – until this happens women will continue to be exposed to risk and potentially loss of life. It feels that no-one listened to the mother or observed her and her baby as a dyad as closely as they should have done, possibly because breastfeeding was seen as a barrier to medication. Women should not be disadvantaged in the management of acute illness just because they are pregnant or breastfeeding, and communication needs to be improved throughout the multidisciplinary team.’
To read more you can download the full report, lay summary and the infographic here: https://www.npeu.ox.ac.uk/mbrrace-uk/reports
Sometimes mothers want to reduce their breastmilk supply. I’ve provided some information and links on herbs and medications – some things have evidence of effectiveness, many do not.
Mothers who have suffered the trauma of previous miscarriages may be prescribed progesterone pessaries as soon as they become pregnant. This information sheet is designed to ease some of the worries in this situation or in the use of progesterone in IVF where a mother continues to breastfeed
Many people know that I have had Crohns disease since I was 22 years old – that was when it was officially diagnosed but probably from 4 years before when I was 18 years old. It has had an immense effect on my life firstly medically – I have had 3 bowel resections and been on medications since the last one in 2002 which very nearly killed me. The only times when I was really fit in and well were when I was pregnant and breastfeeding which sparked my interest in becoming a breastfeeding counsellor 31 years ago. It meant I fed my second and third daughters for much longer (I became very ill soon after I weaned my first) and became passionate about supporting women to breastfeed. As a pharmacist that rolled into an interest and then passion about drugs in breastmilk.
When I regularly had contact with mums with IBD asking about their medication I decided to set up the Facebook group as a mutual support group. Mums who understood the urgency of toilet visits when out shopping, understood how debilitating it was to be in constant pain, that we could discuss anything in a private forum with others in the same situation. Coincidentally it has become a place where people ask each other about drugs and look to me to provide evidence of safety in breastfeeding – that wasn’t the original intent but an excellent spin off.
I havent set up any other specialist interest groups – this is out of my personal interest. Unsurprisingly the diagnosis and treatment of inflammatory bowel disease has taken up a lot of space in my book Breastfeeding and Medication and I am keen that professionals understand that breastfeeding protects our babies but is also something which we value above many things.
As of this morning we have 556 members from all over the world, climbing steeply recently.
Specialists seem to be very concerned about the safety of the drugs – which are strong admittedly and breastfeeding. But we also need to bear in mind that IBD is at least partly linked with being formula fed so we want to maintain breastfeeding and use specialist sources.
Live vaccines may be delayed or omitted – particularly the rotavirus vacc. However, this is as much to protect the mother who may contract the illness from the viral particles shed through the faeces, Exclusively breastfed babies are at low risk if contracting rotavirus in any case.
I am going to admit that I am passionate about the subject – this is the core of my life
CONCLUSIONS: In a study of women receiving treatment for IBD and their infants, we detected low concentrations of infliximab, adalimumab, certolizumab, natalizumab, and ustekinumab in breast milk samples. We found breastfed infants of mothers on biologics, immunomodulators, or combination therapies to have similar risks of infection and rates of milestone achievement compared with non-breastfed infants or infants unexposed to these drugs. Maternal use of biologic therapy appears compatible with breastfeeding.