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If a healthcare professional tells you to stop breastfeeding to take a medication….

I’m going to prescribe drug x but I’m afraid it means you need to stop breastfeeding.

Does this sound familiar. It seems to come up frequently on social media platforms but is it true?

In 2008 I was part of the guideline development group for maternal and infant nutrition PH11 https://www.nice.org.uk/Guidance/PH11. It includes a recommendation on prescribing that: sources other than solely the BNF should be consulted when prescribing for a breastfeeding mother e.g. UKDILAS (https://www.sps.nhs.uk/articles/information-resources-for-advice-on-medicines-and-breastfeeding/)  or LactMed (https://www.sps.nhs.uk/articles/information-resources-for-advice-on-medicines-and-breastfeeding/). To discuss the benefits and risks associated with the prescribed medication and encourage the mother to continue breastfeeding, if reasonable to do so. As well as to recognise that there may be adverse health consequences for both mother and baby if the mother does not breastfeed. Finally, to acknowledge that it may not be easy for the mother to stop breastfeeding abruptly – and that it is difficult to reverse.

In 2021 the Medicines Health Regulatory Authority (MHRA) published  The Safer Medicines in Pregnancy and Breastfeeding Consortium information strategy (https://www.gov.uk/government/publications/safer-medicines-in-pregnancy-and-breastfeeding-consortium) . Its aim was to set up a partnership of 16 leading organisations who are working together to improve the health information available to women thinking about becoming pregnant, are pregnant, or are breastfeeding. As part of the output of the consortium the BNF team worked with UKDILAS to present more information on breastfeeding rather than relying on the statement that manufacturers advise drug y is avoided by breastfeeding mothers. So, for example the information on antidepressant drugs now reads “Specialist sources indicate that sertraline and paroxetine are the SSRIs of choice in breast-feeding based on passage into milk, half-life, and published evidence of safety. However, all SSRIs can be used in breast-feeding with caution, and since there are risks with switching an SSRI, it may be more clinically appropriate to continue treatment with an SSRI that has been effective, or restart treatment with an SSRI that has previously been effective. With all SSRIs, infants should be monitored for drowsiness, poor feeding, adequate weight gain, gastro-intestinal disturbances, irritability, and restlessness.”

So, if a healthcare professional tells you that you can’t breastfeed on a drug or need to dump your milk for a period after a procedure maybe that may not be based on the most up to date evidence but based on older beliefs.

Prescribing nearly every drug for a breastfeeding mother needs the professional to take responsibility for the outcomes because the manufacturers are not required to do so unless they have conducted clinical trials. One of the few exceptions is Cimzia ™ (Certolizumab pegol). However, they need only show that they reached a decision that a similarly experienced practitioner might make. Using specialist sources and documenting the information shared with the breastfeeding mother would substantiate this.

I asked a Facebook group what they would say to a practitioner who said they had to stop breastfeeding in order to take a named medication. Their responses were strong and empowered whilst remaining polite. This is so different to when I first became interested in the compatibility of drugs in breastmilk in 1995. Hope this information helps you to reach your own shared decision making about what is right for you and your baby.

Suggested comments.

  • Thank you for that, could you please show me the sources that you have used to come to that conclusion?
  • Have you consulted specialist sources or just the BNF?
  • I appreciate your opinion, but I plan to consult a specialist pharmacist before deciding to interrupt breastfeeding.
  • Thank you for that information. What are the risks of the medication if I continue to breastfeed?
  • Where did you get that information?
  • What is the risk if I don’t take medication?
  • Are you aware of the risks of stopping breastfeeding suddenly to take medication?
  • If I wasn’t breastfeeding, what would you prescribe?
  • Are you aware of the following resources?
  • Please may I ask where you’ve checked that drug’s safety for breastfeeding?
  • What are the possible risks of taking versus not taking? Is there anyone in the pharmacy team that can help? Are there any alternatives? Is there anyone you or I can consult?

Ivabradine and Breastfeeding

Recently there have been several questions on the use of Ivabradine in breastfeeding mothers with Postural tachycardia syndrome (POTS ) and I confess I know little about this condition so am simply compiling the information from other sources. https://www.nhs.uk/conditions/postural-tachycardia-syndrome/

“Ivabradine is a hyperpolarization-activated cyclic nucleotide-gated channel blocker indicated to reduce the risk of hospitalization for worsening heart failure in patients with stable, symptomatic chronic heart failure with left ventricular ejection fraction ≤ 35%, who are in sinus rhythm with resting heart rate ≥ 70 beats per minute and either are on maximally tolerated doses of beta-blockers or have a contraindication to beta-blocker use.

Ivabradine blocks the cyclic nucleotide-gated (HCN) channel responsible for the cardiac pacemaker . There are no data on its transfer of this drug into human milk, but the detrimental effects to the foetus are concerning which may carry on into early postpartum periods during breastfeeding. If used, close monitoring by a paediatric cardiologist is suggested.” Hale TW and Krutsch, K. Medications and Mothers Milk Springer Publ. accessed online 15.October 2024

It has a half life of 6 hours (Hale) but e-lactancia quotes 2 hours, but that of its active metabolite S18982 is 11 hours, plasma protein binding 70% but oral bioavailability only 40%

In a 2018 paper Kearney suggests that:

Its molecular weight (467) and protein binding (70 %) suggest that excretion into breast milk would be expected. However, ivabradine has low oral bioavailability (40 %) due to extensive first pass metabolism (Tse 2015). it is unclear what effect, if any, the potentially low levels in breast milk could have on the developing infant. Until more is known about ivabradine in breast milk, it must be used with extreme caution. The infant should be monitored for bradycardia and arrhythmias, and poor feeding and weight gain.

References

Hale TW and Krutsch, K. Medications and Mothers Milk Springer Publ.

Ivabradine and breastfeeding. Are they compatible? (e-lactancia.org)

Choi HY, Noh YH, Cho SH, Ghim JL, Choe S, Kim UJ, Ah Jung J, Bae KS, Lim HS. Evaluation of pharmacokinetic and pharmacodynamic profiles and tolerability after single (2.5, 5, or 10 mg) and repeated (2.5, 5, or 10 mg bid for 4.5 days) oral administration of ivabradine in healthy male Korean volunteers. Clin Ther. 2013 Jun;35(6):819-35.

Kearney L, Wright P, Fhadil S, Thomas M. Postpartum Cardiomyopathy and Considerations for Breastfeeding. Card Fail Rev. 2018

Tse S, Mazzola N. Ivabradine (Corlanor) for Heart Failure: The First Selective and Specific I f Inhibitor. P T. 2015 Dec;40(12):810-4.

Tattoo and Breastfeeding

A tattoo involves injecting an ink into the dermis of the skin. Worldwide 10-20% of the population is tattooed (https://pubmed.ncbi.nlm.nih.gov/34605159/) but there is little research on the effects of the inks. The most common reactions are allergies particularly to red ink and infections (https://pubmed.ncbi.nlm.nih.gov/34969030/). Most of the ink stays fixed in the area to which it is injected but some of the ink is transported away from the skin via the vasculature or lymphatic system; it will end up in other organs or will be excreted. Coloured lymph nodes near tattooed areas have been known. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400116/).

Tattoo artists use a hand-held electric machine that is fitted with solid needles coated in the ink to pierce the skin to a depth of a few millimeters. Tattoo ink is assumed to be too large to pass into breast milk, so the baby is not exposed to it.

It is important to choose a tattoo artist with clear hygiene precautions to minimise risk of infection. Many studios will refuse to perform a tattoo on a breastfeeding mother because of public liability and insurance. Many councils stipulate this as a criteria of licensing premises. This largely goes back to the AIDS epidemic and the risk of transferring the HIV virus through blood contamination.

Professional tattoo artists should follow standard hygiene precautions such as sterilization of the tattoo machine using an autoclave, single-use inks, ink cups, gloves and needles, bagging of equipment to avoid cross contamination, and thorough hand washing with disinfectant soap. Anaesthetic creams applied topically before the tattoo such as EMLA cream ™ are compatible with breastfeeding.

The decision to proceed should be an informed decision by the person choosing to have this body art.

Other sources of information

La Leche League International https://llli.org/breastfeeding-info/tattoos-and-breastfeeding/

E-lactancia Tattoo https://e-lactancia.org/breastfeeding/tattoo/product/

LactMed Tattooing https://www.ncbi.nlm.nih.gov/books/NBK500563/

Cannabis and Breastfeeding

Cannabis use on a regular basis by breastfeeding mothers concerns me. Cannabis has a long half life (25-57 hours) and it takes 5 times this to be removed from milk. THC crosses the blood brain barrier and it is known to accumulate in body fats. Although it is highly protein bound and subject to first pass metabolism, the milk plasma ratio is 8. We do not know enough about the impact on the developing brain to be sure that the amount passing through breastmilk is safe. Regular use is not recommended in the breastfeeding mother or other members of the family who may expose the baby through passive inhalation.

Breastfeeding and Cannabis factsheet

see also Cannabis and Breastfeeding: What We Know and What We Should Do – LCGB

https://www.nutritionfirstwa.org/wp-content/uploads/2017/11/Laurel-Wilson-Marijuana-and-Breastfeeding-Handout-docx.pdf

Osteoporosis and breastfeeding

Following on from the data on the menopause and breastfeeding, I know many women are advised to limit the duration of breastfeeding in order to protect their own bone density. This sadly often shows a mis understanding of breastfeeding and its importance to the ongoing health of mother and child.

I hope this information taken from Breastfeeding and Chronic Medical Conditions helps

Osteoporosis and breastfeeding fact sheet

” I have severe early onset osteoporosis causing 12 spinal compression fractures. The challenges were
managing my pain relief, deciding on a medication that could treat my low bone density whilst
breastfeeding…. but also positioning and attachment with a spine that is inflexible and incredibly
painful. Just lifting my new-born caused some fracturing. We nailed the pain relief and medication
for osteoporosis side of things and with help positioning side of things. I was an experienced breast
feeder but had never fed whilst so immobile and in pain before. Thankfully I am still feeding him now,
over 4 years later. I am not cured; I never will be as it is a degenerative disease. I continue to suffer
fractures. But looking back the help I had to enable me to breastfeed was the only way I was able to
independently care for my new baby. I was bed bound and could never have managed formula
preparation. Now that I too am in the shield group, I am thankful that I am still breastfeeding to help
boost his immune system in this most terrifying time.


Description
Osteoporosis is a condition that weakens bones, making them fragile and more likely to fracture. It
develops slowly over several years and is often only diagnosed when a fall or sudden impact causes a
bone to break. Osteoporosis affects over 3 million people in the UK. It is frequently diagnosed in
women after the menopause but not exclusively.
Other risk factors for osteoporosis:

  • taking high-dose steroid tablets for more than 3 months
  • other medical conditions – such as inflammatory conditions, hormone-related conditions, or
    malabsorption problems
  • a family history of osteoporosis – particularly a hip fracture in a parent
  • long-term use of certain medicines that can affect bone strength or hormone levels, such as
    anti-oestrogen tablets that many women take after breast cancer having or having had an eating disorder such as anorexia or bulimia
  • having a low body mass index (BMI)
  • not exercising regularly
  • heavy drinking and smoking
    It can be prevented by taking regular, weight bearing exercise, eating a diet rich in calcium and
    vitamin D (or taking supplements), abstaining from smoking and high alcohol use.
    Treatment
  • Calcium and vitamin D supplements: minimum 10 micrograms vit d and 700mg -1200mg
    calcium
  • Bisphosphonates: bisphosphonates should always be taken on an empty stomach with a full
    glass of water, standing or sitting upright for 30 minutes after taking them. Other drinks or
    foods should be avoided for 30 minutes and 2 hours.
    Alendronic acid (Alendronate ™) https://www.ncbi.nlm.nih.gov/books/NBK501621/
    Ibandronic acid (Bonviva ™) https://www.ncbi.nlm.nih.gov/books/NBK501616/
    Risedronic acid (Actonel™) – no information on levels in breastmilk but poor oral
    bioavailability
    Zoledronic acid – no information on levels in breastmilk but poor oral bioavailability
    Raloxifene – no information and may suppress lactation
  • Denosumab: an alternative for women with osteoporosis who have been through the
    menopause if a bisphosphonate is not suitable or is not tolerated. It is given twice a year by
    injection and helps to slow down bone loss. As with bisphosphonates, there is a small risk of
    a rare problem of the jawbone, called osteonecrosis
  • Breastfeeding and Bone Density Research
    The effects of breastfeeding on mothers’ bone health (UNICEF Baby Friendly Hospital Initiative
    https://www.unicef.org.uk/babyfriendly/news-and-research/baby-friendly-research/maternalhealth-research/maternal-health-research-bone-density/
  • Caroline J. Chantry et al (2004). Lactation Among Adolescent Mothers and Subsequent Bone
    Mineral Density. Arch Pediatr Adolesc Med. 158:650-656
  • Paton LM et al (2003). Pregnancy and lactation have no long-term deleterious effect on
    measures of bone mineral in healthy women: a twin study. Am J Clin Nut 77: 707-14
  • Kalkwarf HJ, Specker BL (1995) Bone mineral loss during lactation and recovery after
    weaning. Obstet Gynecol 86: 26-32
    Kalkwarf HJ (1999) Hormonal and dietary regulation of changes in bone density during
    lactation and after weaning in women. J Mammary Gland Biol Neoplasia 4: 319-29
    Further information on Osteoporosis
    Royal Osteoporosis Society https://theros.org.uk

please email me wendy@breastfeeding-and-medication.co.uk if you need more information

Breastfeeding and Chronic Medical Conditions, Wendy Jones

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