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Breastfeeding & Medication. Breastfeeding & Medication. The benefits of breastfeeding are sufficiently important to recommend that breastfeeding should be discouraged only when there is substantial evidence that : - The drug taken by the mother will be

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breastfeeding medication
Breastfeeding & Medication
  • The benefits of breastfeeding are

sufficiently important to recommend that

breastfeeding should be discouraged only

when there is substantial evidence that :

- The drug taken by the mother will be

harmful to infant

- No therapeutic equivalent can be given

slide3

General Informations

  • < 1 % of a drug will pass through breastmilk : < therapeutic dose level for infants
  • Only few drugs are totally contraindicated
  • Cautions required in

- premature infants

- low birth weight

- infants c impaired ability to metabolize /excrete drugs eg. sick babies

- infants c G6PD deficiency

factors influencing drug safety
Diffusion / active transport

Plasma level

Lipid solubility

Drug pH

Molecular weight

Protein binding

Half life

Oral bioavailability

Non-dose-related toxicity

Factors Influencing Drug Safety

Drugs factors :-

factors influencing drug safety5
Age

Body weight

Health status

Dose

Route of administration

Health status

Factors Influencing Drug Safety

Infants factors :-

Maternal factors :-

factors to be considered before prescription
Factors to be Considered before Prescription
  • Need for Rx & any particular drug
  • Age & maturity of baby
  • Volume of breast milk taken daily
  • Available drug information
general principles 1
General Principles(1)
  • Choose a route of admin. which minimizes maternal drug level :- topical, local, inhalation.
  • Choose medications :- shortest T1/2, highest protein binding ability, poorest oral absorption,lowest lipid solubility, well-studied in infants.
  • Use the lowest effective dose & for the shortest time.
  • To minimize drug level in the milk - administer the drug at / immediatelyafter the infant feeds.
general principles 2
General Principles(2)
  • Avoid long-acting drug.

In case of no available alternative, medication is best taken just prior to the longest sleep of the infant.

  • Infants should be monitored for AE :- feeding, sedation, irritability, rash, etc.
  • For some medications with potential harm, temporary suspension of breastfeeding may be necessary. ( Advice the mother about milk expression & cup feeding instead of bottle feeding to avoid nipple confusion)
lactation risk category
Lactation Risk Category
  • L1 Safest : taken by large No. of BF mothers without any observed SE
  • L2 Safer : studied in limited No. of BF mothers without any observed SE
  • L3 Mod.safe : no controlled studies, but poss. untoward effects; / controlled studies-->min. non-threatening AE
  • L4 Poss.hazardous : +ve evidence of risk to BF infant / to breast milk production
  • L5 Contraindicated : studies--> sig./ high risk to infants
antimicrobials 1
Antimicrobials (1)
  • Ciprofloxacin-L4 ( Arthropathies reported in animal embryo, no evidence in humans)
  • Nalidixic acid -L4 (reported case of hemolysis in infants with G6PD def.
  • Clindamycin - L3 (1 case of pseudomemb.colitis but rare, observe for diarrhoea, approved by AAP for use in BF mother
antimicrobials 112
Antimicrobials (1)
  • Sulfonamides - L2-3 (avoid in sick infants, prematurity, stress, hyperbilirubinemia, G6PD def.
  • Cotrimoxaxole - L3 (non reported, caution in hyperbilirubinemia & G6PD def.)
  • Metronidazole - L2 (BF should be withheld until 12-24 hr after 2 g dose)
antimicrobials 2
Antimicrobials (2)

MetronidazoleT1/2= 8.5 hr

In mother receiving 2 g dose

Av. drug conc. 2 hr = 45.8 mg/L

8 hr = 27.9 mg/L

12 hr = 19.1 mg/L

12 -24 hr = 12.6 mg/L

Rx level in infants /children = 7.5-30 mg/L

No report of AE in breastfed infants for 2 g dose or 250 mg X 3 /d X 10 d

analgesics nsaids
Analgesics & NSAIDS
  • Codeines-L3 (rare cases of neonatal apnea at high dose
  • Aspirin - L3 (metabolic acidosis 1 case, at high dose)
  • Indomethacin - L3 (seizure 1 case)
  • Cox-2 inhibitors - No available information
  • Diclofenac- L2 (non reported via milk) (Voltaren)
antidepressants 1
Antidepressants (1)

SSRI :

  • Fluoxetine -L3 in newborn, L2 in olders (Prozac)[ longer T1/2 --> relatively greater amount in breastmilk > sertraline (Zoloft) & paroxetine(Paxil) ]
  • Citalopram -L3 (2 cases of excessive somnolence, (Celexa)decreased feeding, & wt. loss )
antidepressants 2
Antidepressants (2)

Tricyclic antidepressants:

  • Doxepin - L5 (1 case of resp. depression & (Sinequan)sedation)
  • Nortryptilene (Aventyl )
  • Dothiepin (Prothiaden)
  • Nefazodone, reboxetine, venlafaxine, monoamine oxidase inhibitors - lack of published data

L2 - safer

antipsychotics
Antipsychotics
  • Haloperidol - L2 ( dose < 10 mg / d = safe)
  • Diazepam - L3, L4 in chronic use (hypotonia, lethargy & reduced suckling)
  • Temazepam - L3 (safer than diazepam for (Restoril) shorter T 1/2 )
  • Clozapine, olanzapine,quetiapine, risperidone - lack of published data
immunological drugs
Immunological drugs
  • Sera and immunoglobulins
  • Vaccines
others 1
Others(1)
  • PTU:L2 (non reported, observe closely for thyroid function
  • Thyroxine :L1 (extremely low in breastmilk) (Eltroxin)
  • Prednisolone : L2, L4 for chronic high dose
  • Propanolol :L3 (none reported via breastmilk in numerous studies)
  • Phenobarbital : L3 ( Sedation, infantile spasm after weaning from milk containing phenobarbital, methemoglobinuria 1 case)
others 2
Others(2)
  • Domperidone :L2 (Motilium) (Galactagogue dose~10-20 mg X 3-4/d)
  • Gliabendazide : L3 (non reported, observe for (Daonil) hypoglycemia)
  • Clemastine :L4 ( Drowsiness, irritability,(Tavist)feeding refusal, high pitch cry, nuchal rigidity 1 case)
  • Primidone : L3 ( Sedation, feeding problem ) (Mysoline )
  • Flunarizine :L4 (non reported, use with caution )(Sibelium)
others 3
Loratadine ( Claritine ) : L2

Loraxepam ( Ativan) : L 3

Metyldopa (Aldomet) : L2

Nifedipine (Adalat) : L2

Griseofulvin : L2

Furosemide (Lasix) : L3

Others(3)
  • Dopamine / Dobutamine : L2
  • Oxytocin : L2
  • Cisapride (Prepulsid): L2
  • Cimetidine (Tagamet): L2
  • Bisacodil ( Dulcolax ) : L2
  • Loperamide (Imodium) : L2
  • Metopropamide (Plasil) : L2
drugs contraindicated during breastfeeding
Hypothyroidism reported

Possible immune suppression, effect on growth

(May-->idiosyncratic BM supp. at high conc. in breast milk )

Vomiting,diarr.,convulsion (dose>migraine)

Possible facial edema in one infant 3 mo. after Rx in mother

Severe rash reported

Increased PT & PTT in 1 infant

Drugs Contraindicated During Breastfeeding
  • Amiodarone
  • Antineoplastic agents
  • Chloramph. .
  • Ergotamine .
  • Gold salts .
  • Lithium
  • Phenindione
drugs contraindicated
Very lipid soluble,wide range of AEs in adult, mutagenic & carcinogenic in animals

Staining immature teeth, change in epiphyseal bone growth

Unpublished result, may inhibit prolactin & milk production significantly

Temporary cessation of BF, based on presence of radioactivity in milk

Dec.breast milk productn, dec.protein & nitrogen content of milk

Drugs Contraindicated
  • Retinoids. .
  • Tetracycline (chronic-months)
  • Pseudoephedrine . .
  • Radioactives .
  • Combined oral contraceptives
drugs of abuse contraindicated 1
Irritability, poor sleeping pattern ( conc. in human milk )

Cocaine intoxication (N/V, diarrhea, tremulousness, agitatn, gasping,HT, inc.HR)

Tremor, restlessness, vomiting, poor feeding

Only 1 report; no effect mentioned

Shock,vomiting,diarrhea, rapid HR, restlessness, dec.milk production

Potent hallucinogen

Drugs of Abuse : Contraindicated (1)
  • Amphetamine
  • .
  • Cocaine. .
  • Heroin .
  • Marihuana
  • Nicotine (smoking).
  • Phencyclidine

Committee on drugs # hazardous to infant, detrimental to physical & mental health of mother

drugs of abuse contraindicated 2
Alcohol( Acetaldehyde)

Caffeine

milk production

พัฒนาการอายุ 1 ปี

half life ในทารกนาน

ธาตุเหล็กในน้ำนมน้อยลง

Drugs of Abuse : Contraindicated(2)
drugs having been associated with sig effects on some nursing infants use with caution
Reported effectsDrugs having been associated with sig. effects on some nursing infants, use with caution
  • 5- Aminosalicylic a.
  • Aspirin
  • Clemastine .
  • Phenobarbital ..
  • Primidone
  • Sulfasalazine

Diarrhea (1 case)

Metabolic acidosis (1 case, high dose)

Drowsiness, irritability, feeding refusal, high pitch cry, nuchal rigidity (1 case)

Sedation, infantile spasm after weaning from milk containing phenobarbital, methemoglobinuria (1 case)

Sedation, feeding problem

Bloody diarrhea (1 case)

Drugs

drugs commonly prescribed 1
Drugs commonly prescribed (1)

ConditionRecommendedAlternative Caution

  • Allerg.rhinitisBeclomethasone Cetrizine (Beconase) Loratadine (Claritine)

Fluticasone Sedating antihist. (Flonase) Decongestants

Cromolyn

  • CVSHydrochlothiazide Nifedipine Atenolol (Tenormin)

Metoprolol tartrate Verapamil Soralol (Lopressor) Hydralazine Diltiazem Propanolol(Apresoline) LabetalolCaptoprilEnalapril

drugs commonly prescribed 2
Drugs commonly prescribed (2)

ConditionRecommendedAlternative Caution

  • DepressionSertraline Nortriptyline Fluoxetine (Zoloft)(Pamelor) (Prozac)Paroxetine Desipramine (Paxil)(Norpramin)
  • DMInsulin Acarbose Metformin(Precose) (Glucophage)Glyburide (Micronase)ThiazolinedionesGlipizide (Glucotrol) Tolbutamide (Orinase)
drugs commonly prescribed 3
Drugs commonly prescribed (3)

ConditionRecommendedAlternative Caution

  • EpilepsyPhenytoin Ethosuximide Phenobarbital (Dilantin)(Zarontin)

Carbamazepine Valproic sodium(Tegretol) (Depakine)

  • PainIbuprofenNaproxen (Brufen)(Naprosyn)MorphineMeperidineAcetaminophen(Demerol)(paracetamol)
  • AsthmaCromolyn Fluticasone Nedocromil Beclomethasone
slide33

อาการผิดปกติของมารดาที่ต้องมาพบแพทย์อาการผิดปกติของมารดาที่ต้องมาพบแพทย์

slide34

อาการผิดปกติของมารดาที่ต้องมาพบแพทย์อาการผิดปกติของมารดาที่ต้องมาพบแพทย์

 หัวนมเจ็บแตกเป็นแผล

 เต้านมคัด

 เต้านมอักเสบหรือเป็นฝี

slide36
สาเหตุ

 ลูกอมหัวนมไม่ถูกวิธี

 เต้านมคัดมากเกินไป

 ปล่อยให้หัวนมชื้นแฉะ

 ทำความสะอาดหัวนมด้วยสบู่หรือน้ำยาต่างๆ

 ถอนหัวนมจากปากลูกไม่ถูกวิธี

slide37
อาการ

 เจ็บมากเมื่อลูกดูดนม , อาจมีเลือดออก

 มักเป็นบ่อยในสัปดาห์แรก

 มักเป็นต้นเหตุทำให้การขับน้ำนมทำงานไม่ดี

slide39
1. ดูดถูกวิธี

2. ดูดข้างที่เจ็บน้อยกว่าก่อน

3. นวดเต้านมเบาๆก่อนดูด

4. ดูดข้างที่เจ็บบ่อยขึ้น

5. เลือกท่าที่เจ็บน้อยสุด

6. ไม่ควรเช็ดหัวนมหลังการดูด

7. ไม่ควรใช้ยาหรือสารอันใดทา

8. ช่วยอบด้วยหลอดไฟฟ้า

9. หยุดดูดถ้าเจ็บมาก

10. ไม่ทุเลาควรปรึกษาแพทย์

คำแนะนำ
slide42
สาเหตุ

 ดูดช้า

 ดูดไม่บ่อย

 ดูดไม่นาน

slide43
อาการ

ภาพเต้านมคัด

slide44

คำแนะนำ

1. พยายามทำให้น้ำนม ออกจากเต้านม

2. ประกบด้วยน้ำอุ่น

3. นวดเต้านมก่อนบีบน้ำนมออก

4. บีบน้ำนมด้วยมือก่อน ให้ลูกดูด

5. ให้ลูกดูดนมถูกวิธี

6. ใส่ยกทรง

7. หากปวดมากระหว่างมื้อนม ใช้ผ้าชุบน้ำแข็งประกบ , กินยาแก้ปวด

8. ปรึกษาแพทย์

slide46
เต้านมอักเสบหรือเป็นฝีเต้านมอักเสบหรือเป็นฝี
slide47
สาเหตุ

 เต้านมคัดมากเกินไป

 ท่อน้ำนมอุดตัน

 หัวนมแตกเป็นแผล

slide48
อาการ

 ปวด

 บวม

 แดงร้อน

 เป็นไข้

slide50
คำแนะนำ

1. ไม่ควรให้ลูกหยุดดูดข้างที่อักเสบ

2. นอนพักและดื่มน้ำให้มาก

3. ควรประกบด้วยผ้าชุบน้ำอุ่น

4. ใส่ยกทรง

5. เป็นมากจนกลายเป็นฝี , หยุดดูด , ปรึกษาแพทย์

slide51
การป้องกัน

หลีกเลี่ยงเต้านมคัด

การแตก , ถลอกของหัวนม