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New Guidelines on Medication Safety for Breastfeeding Mothers

New AAP guidelines and the LactMed database

New Guidelines on Medication Safety for Breastfeeding Mothers Do you have concerns about breastfeeding while on certain medications? Good news: In the September 2013 issue of Pediatrics, the American Academy of Pediatrics (AAP) shares its revised guidelines on the transfer of drugs into breast milk, largely loosening the "rules" on medication safety for nursing mothers. The AAP says: "Many mothers are inappropriately advised to discontinue breastfeeding or avoid taking any essential medications because of fears of adverse effects on their infants. This cautious approach may be unnecessary in many cases, because only a small proportion of medications are contraindicated in breastfeeding mothers or associated with adverse effects on their infants."

To summarize more of the AAP's latest advice:

• In most cases, the benefits of breastfeeding a baby outweigh the typically minimal risks of taking most medications, but women should still consult their physician to weigh the risks and benefits before taking any over-the-counter or prescription drugs.
• Physicians and nursing moms should refer to a searchable database called LactMed for the most current and comprehensive information available on the safety of specific drugs. For example, a search for "Advil" will show the most recent studies and information on the drug amounts passed through breast milk, any known effects on breastfed infants' health and development (including short-term side effects), and any alternative drugs a mom should consider. Note: The LactMed database is filled with medical jargon and statistics, so you should review the information with your physician before taking any medications.
• Even if a medication is deemed safe, nursing mothers will often be advised to take the lowest possible dose for the shortest possible time to limit the baby's exposure to any drugs passed through breast milk.

The FDA is currently working on comprehensive new drug labeling for nursing mothers. Previously, most drug labels advised that women either discontinue breastfeeding or discontinue using the medication. Under the new labeling rules, a section called "Lactation" will summarize the risks and considerations specific to breastfeeding.

AAP advice on specific medicationsAlthough the AAP is primarily relaxing its guidelines and driving patients and physicians to the LactMed Database for the latest information, the AAP's September 2013 report states that people should continue to be careful with some types of medications:

• Antianxiety drugs, antidepressants, and mood stabilizers – Information on the long-term effects of these medications is still limited, and data is not available for up to one-third of mental-health medications, so they should be taken with caution. (Medications that have shown up in "clinically significant" levels in breastfed infants' bloodstreams include bupropion, diazepam, fluexotine, citalopram, lithium, lamotrigine, and venlafaxine.)
• Drugs for smoking cessation – Nicotine gum or lozenges are the preferred forms of smoking-cessation aids as long as the prescribed level of nicotine in the therapy used is less than the nicotine level in the number cigarettes the mother would smoke. The FDA discourages the use of bupropion (brand names include Aplenzin, Wellbutrin, and Zyban) and varenicline (brand name Chantix) in lactating women.
• Narcotic pain medications – Exercise caution with codeine and hydrocodone, watching for any effects on the nursing mother or infant. Oxycodone, pentazocine, propoxyphene, and meperidene are not recommended for nursing mothers. Some other narcotics are acceptable but should be used at the lowest dose for the shortest duration of time. Check the LactMed database for more information on pain medication safety.
• Non-narcotic pain medications – When over-the-counter pain relievers are adequate for pain mananagement, ibuprofen (brand names include Advil, Midol, Motrin) and acetaminophen (brand name Tylenol), are acceptable. Low doses of aspirin may also be acceptable. However, there is limited data on other NSAID pain relievers, so the FDA discourages their use by lactating women.
• Galactogogues (agents used to stimulate lactation, often in mothers of preterm infants or in adoptive mothers who wish to breastfeed) – These have a limited role in helping women lactate, and their effects on nursing infants have not been thoroughly studied. The AAP advises consulting a lactation specialist for assistance rather than using these drugs.
• Herbal products and dietary supplements – The use of the following herbs is not advised: kava, yohimbe, chamomile, black cohosh, blue cohosh, chastetree, echinacea, ginseng, gingko, Hypericum (St. John's wort), and valerian. Vitamins and iron supplements are safe for most nursing moms as long as recommended daily allowances are not exceeded, but the use of other nutritional supplements may not be safe because it is possible to "overdose" on certain vitamins and minerals.
• Radiopharmaceuticals (diagnostic imaging substances) – If possible, elective diagnostic imaging procedures should be delayed until a woman is no longer breastfeeding. Consult a radiologist for more information.
• Oncologic drugs (cancer treatment medications) – Cancer treatment may require multiple therapies that preclude women from breastfeeding. Consult an oncologist or specialist for more information.

One major rule hasn't changed: Breastfeeding women should consult their physician before taking any new type of prescription or over-the-counter medication, herbal remedy, or dietary supplement. The AAP report states that most maternal vaccines are safe for breastfeeding mothers and their infants, but women should still check with their doctor before getting immunizations.

The primary goal of these new AAP guidelines is to avoid the unnecessary restriction from breastfeeding for women who wish to do so. Keep open lines of communication with your doctor when it comes to medication use, and, in most cases, your baby will thrive on the hard-to-beat antibodies and nutrients of breast milk.