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Monthly Archives: April 2022

Clinically extremely vulnerable, COVID 19 infection and breastfeeding

Because I am immunocompromised myself, I am all too well aware of the information on protection from COVID 19 including the recommendations launched in December 2021 by the government on sotrovimab (Xevudy) and molnupiravir (Lagevrio) . This may affect some breastfeeding mothers e.g. those with IBD or on biologicals for other reasons . There are no simple answers but this is the information I have been able to find in one place. The factsheet was updated in April 2022 following the licence change by the FDA of sotrovimab, and added data on Evusheld and remdesivir .

Clinically extremely vulnerable, COVID 19 infection and breastfeeding factsheet

Inflammatory Bowel Disease and Breastfeeding

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 35 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 1.6K members from all over the world, climbing steeply recently January 2022).

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

See also Facebook live video

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.

With the help of the Breastfeeding and IBD facebook page I wrote this article:

what would you like your healthcare tean to know about IBD and breastfeeding

Finally I have put together all the information on studies on anything to do with prescribing, procedures and vaccines for breastfeeding mums with IBD. If you have IBD take this with you to appointments. If you are a professional please make sure everyone in the team has a copy. I am happy to offer Teams Training to any group of professionals who support mums with IBD.

All you need to know about investigating and treating IBD in breastfeeding mothers factsheet

Apple Cider Vinegar and Breastfeeding

Apple cider vinegar seems the “in” thing for weight loss at the moment, sipped in water and sometimes sweetened with honey. As the pandemic loosens it’s hold it seems that more breastfeeding mothers than usual are looking for an answer to weight loss.

There is no research data on whether it is safe in breastfeeding. It certainly isn’t something I would advocate: not least because there is no evidence, that I found, that it’s effective for weight loss although culinary use is unlikely to be an issue. Back to less in, more out – healthy eating and exercise – sigh!

I would NOT advocate this for any breastfeeding mother – or anyone else for that matter

I found this link interesting

https://www.health.harvard.edu/blog/apple-cider-vinegar-diet-does-it-really-work-2018042513703?fbclid=IwAR037-joCZ_XbvfuIv48c3cGekHN6e35U1kP618RLh5tnJ5A-42Q_A5ZL

from Robert H. Shmerling, MD Senior Faculty Editor, Harvard Health Publishing. His words not mine:

What is the apple cider vinegar diet?

Apple cider vinegar comes from apples that have been crushed, distilled, and then fermented. It can be consumed in small quantities or taken as a supplement. Its high levels of acetic acid, or perhaps other compounds, may be responsible for its supposed health benefits. Although recommendations for “dosing” vary, most are on the order of 1 to 2 teaspoons before or with meals.

What can the apple cider vinegar diet do for you?

For thousands of years, compounds containing vinegar have been used for their presumed healing properties. It was used to improve strength, for “detoxification,” as an antibiotic, and even as a treatment for scurvy. While no one is using apple cider vinegar as an antibiotic anymore (at least, no one should be), it has been touted more recently for weight loss. What’s the evidence?

Studies in obese rats and mice suggest that acetic acid can prevent fat deposition and improve their metabolism. The most widely quoted study of humans is a 2009 trial of 175 people who consumed a drink containing 0, 1, or 2 tablespoons of vinegar each day. After three months, those who consumed vinegar had modest weight loss (2 to 4 pounds) and lower triglyceride levels than those who drank no vinegar. Another small study found that vinegar consumption promoted feeling fuller after eating, but that it did so by causing nausea. Neither of these studies (and none I could find in a medical literature search) specifically studied apple cider vinegar.  A more recent study randomly assigned 39 study subjects to follow a restricted calorie diet with apple cider vinegar or a restricted calorie diet without apple cider vinegar for 12 weeks.  While both groups lost weight, the apple cider vinegar group lost more.  As with many prior studies, this one was quite small and short-term.

In all, the scientific evidence that vinegar consumption (whether of the apple cider variety or not) is a reliable, long-term means of losing excess weight is not compelling. (On the other hand, a number of studies suggest that vinegar might prevent spikes in blood sugar in people with prediabetes and type 2 diabetes by blocking starch absorption — perhaps that’s a topic for another day.)

Is there a downside to the apple cider vinegar diet?

For many natural remedies, there seems to be little risk, so a common approach is “why not try it?” However, for diets with high vinegar content, a few warnings are in order:

  • Vinegar should be diluted. Its high acidity can damage tooth enamel when sipped “straight” — consuming it as a component of vinaigrette salad dressing is a better way.
  • It has been reported to cause or worsen low potassium levels. That’s particularly important for people taking medications that can lower potassium (such as common diuretics taken to treat high blood pressure).
  • Vinegar can alter insulin levels. People with diabetes should be particularly cautious about a high vinegar diet.

So what?

If you are trying to lose weight, adding apple cider vinegar to your diet probably won’t do the trick. Of course, you’d never suspect that was the case by the way it’s been trending on Google health searches. But the popularity of diets frequently has little to do with actual evidence. If you read about a new diet (or other remedy) that sounds too good to be true, a healthy dose of skepticism is usually in order.

Dental Health and Breastfeeding

As with most professionals, my own included, dentistry seems to lack education on breastfeeding as part of undergraduate training if questions sent to this page exemplify a wider issue. I have tried to provide information for CPD inline with that written for other healthcare professionals.

I have developed this powerpoint presentation on the pharmacokinetics of drugs which dentists may use or prescribe for CPD information in an effort to break down the barriers of continuation of breastfeeding.

I am happy to answer individual questions or training. Please contact wendy@breastfeeding-and-medication.co.uk

In summary:

  • Breastfeeding mothers can have local anaesthetic injections with/without adrenaline and continue to breastfeed as normal
  • Breastfeeding mothers can take analgesics for dental pain and continue to breastfeed as normal
  • Breastfeeding mothers can have dental sedation for procedures and continue to breastfeed as normal.

Powerpoint training for dental practitioners on the pharmacokinetics of drugs they may use in breastfeeding women

In a report 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

Delivering Better Oral Health (PHE, 2014 updated content 2017)4 recommends that:

  • 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

Powerpoint training for dental practitioners on passage of drugs in breastmilk

See also:

A Guide To Supporting Breastfeeding For The Medical Profession, Amy Brown and Wendy Jones

Pain relief when breastfeeding

It is not acceptable to leave any mother in pain because she is breastfeeding nor to suggest that she could have more effective pain relief if she stopped breastfeeding.

I’m often asked about the safety of opioids during breastfeeding so this is a really interesting study

Despite opioids being used first line in emergency settings to treat severe acute extremity pain, there is limited evidence available to inform this practice.

In a study in JAMA (7 November 2017), researchers randomly assigned 416 patients in the emergency department with moderate-to-severe acute extremity pain to one of the following groups: 400mg ibuprofen/1000mg paracetamol; 5mg oxycodone/325mg paracetamol; 5mg hydrocodone/300mg paracetamol; or 30mg codeine/300mg paracetamol[1].

https://jamanetwork.com/journals/jama/article-abstract/2661581?redirect=true

I have written this powerpoint presentation which I hope explains the analgesic ladder and helps professionals to understand the compatibility of analgesics and braestfeeding

  • Paracetamol or NSAID
  • Paracetamol + NSAID
  • Paracetamol+NSAID+Opioid (at the lowest possible dose for the shortest possible time co prescribed with a laxative)

Analgesics and breastfeeding Powerpoint 

see also https://www.breastfeedingnetwork.org.uk/analgesics/

https://breastfeeding-and-medication.co.uk/fact-sheet/dihydrocodeine-and-breastfeeding

https://breastfeeding-and-medication.co.uk/thoughts/breastfeeding-and-codeine

https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-neuropathic-pain-gabapentin-and-pregabalin

https://breastfeeding-and-medication.co.uk/fact-sheet/migraine-treatment-and-breastfeeding

https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-pain-relief-for-acute-back-injury

The substance exposed infant

This is an adapted version of a training powerpoint I gave some time ago. I plan to record it over the next few weeks and will upload it to my You Tube channel.

But hope it helpsin the meantime. Happy to answer any questions wendy@breastfeeding-and-medication.co.uk

Breastfeeding and the substance exposed infant