Medications in Lactation

1. See Also
   1. Medications in Pregnancy
2. General
   1. Assess benefit versus risk for medication
   2. Choose medications safe for Lactation
   3. Preferred medication characteristics
      1. Short half life
      2. Relative concentration in Breast Milk is less than in maternal blood
      3. Low oral absorption by infant
      4. Medications that do not interfere with Breast Milk supply
      5. Medications that do not alter Breast Milk taste
   4. Take medications just before or after Lactation or before infant's longest sleep time
   5. Ask women of child-bearing age if they are lactating when prescribing medications
   6. Pumping and Dumping is not benign (especially in early Lactation)
      1. Even 1-2 days of Lactation interruption can result in stopping Breast Feeding altogether
   7. Patient Education
      1. Lactating women should ask physician or pharmacist before new medication
3. Management: Antibiotics considered safe in Lactation
   1. Penicillin Antibiotics
   2. Cephalosporin Antibiotics
   3. Erythromycin (concentrated in human milk, increased risk of Pyloric Stenosis)
   4. Clindamycin
   5. Aminoglycosides
   6. Fluoroquinolones (considered safe by AAP, risk of Arthropathy)
   7. Sulfa antibiotics
      1. Avoid in infants with G6PD and in the first month of life due to Hyperbilirubinemia risk
4. Management: Analgesics
   1. Agents considered safe in Lactation
      1. Acetaminophen (Tylenol)
      2. Ibuprofen (preferred NSAID over Naproxen)
      3. Toradol (probably safe, but parenteral dosing has not been studied)
   2. Agents to use with caution
      1. Aspirin (AAP recommends use with caution)
      2. Naproxen (long half-life and case reports of infant adverse effect on LactMed)
      3. Opioids in general result in infant sedation
         1. Morphine
         2. Fentanyl
         3. Hydrocodone (Vicodin, <30 mg/day)
   3. Agents to avoid in Lactation
      1. Hydromorphone (Dilaudid, long half life)
      2. Oxycodone (concentrates in Breast Milk)
      3. Demerol
      4. Codeine
         1. Poor Analgesic with variable activity, and generally not recommended as an Analgesic for anyone
5. Management: Procedural Sedation
   1. Agents considered safe in Lactation
      1. Midazolam
      2. Propofol
      3. Etomidate
   2. Agents with unknown safety in Lactation
      1. Ketamine
6. Management: Anticonvulsants in Lactation
   1. Very low Breast Milk concentrations (highly bound)
      1. Phenytoin (Dilantin)
      2. Tiagabine (Gabitril)
      3. Valproate
   2. Low to moderate Breast Milk concentrations
      1. Carbamazepine
      2. Phenobarbital
      3. Lamotrigine
      4. Topiramate (Topamax)
      5. Zonegran
      6. Primidone (metabolized in part to Phenobarbital)
         1. Risk of infant sedation
         2. AAP recommends using with caution
   3. High Breast Milk concentration (minimally bound)
      1. Gabapentin
      2. Levetiracetam (Keppra)
      3. Ethosuximide (AAP: Compatible with Lactation)
7. Management: Antidepressants considered potentially safe in Lactation
   1. AAP recommends use with caution
      1. Unknown longterm effect
      2. Use if benefits outweigh risk
   2. Preferred agents
      1. Fluoxetine (risk of colic, irritability, Sleep Disorders, feeding problems, decreased growth)
      2. Sertraline
      3. Paroxetine
8. Management: Cardiovascular Medications in Lactation
   1. Antihypertensives safe in Lactation
      1. ACE Inhibitors (avoid in first 6 weeks, risk of renal toxicity in Premature Infants)
         1. Captopril
         2. Enalapril
         3. No data on Lisinopril
      2. Hydrochlorothiazide (may decrease milk production)
      3. Methyldopa
   2. Miscellaneous drugs considered safe in Lactation
      1. Digoxin
      2. Coumadin
      3. Heparin (not excreted into Breast Milk)
9. Management: Imaging Contrast and Radiation
   1. Imaging studies requiring no interruption in Breast Feeding
      1. MRI imaging wih gadolinium
      2. CT IV Contrast
         1. Does not require interruption of Breast Feeding (i.e. pump and dump)
         2. Only 1% of IV contrast reaches Breast Milk, and only 1% of that is absorbed by the infant
         3. Newman (2007) Can Fam Physician 53(4): 630–631 [PubMed]
      3. Hepatobiliary Iminodiacetic Acid (HIDA Scan)
   2. Many nuclear medicine scans require pumping Breast Milk and storing for set period until radiation has dissipated
      1. Example: V/Q requires 13 hour interruption in Breast Feeding (but may pump and store)
   3. Radioactive Chemicals used in Nuclear Medicine
      1. Gallium-67 (in Breast Milk up to 14 days)
      2. Indium-111 (in Breast Milk up to 20 hours)
      3. Iodine 131 (in Breast Milk up to 14 days)
      4. Radioactive Sodium (in Breast Milk up to 96 hours)
      5. Technetium-99m (in Breast Milk up to 3 days)
10. Management: Assorted medications considered safe in Lactation
    1. Magnesium Sulfate
    2. RhoGAM
    3. RubellaVaccine
    4. Oral Contraceptives (avoid until Breast Feeding is established, after 60-90 days)
    5. Antihistamines and Decongestants (use with caution)
       1. Risk of decreased milk supply
11. Management: Herbs and Teas considered safe in Lactation
    1. Avoid Caffeine more than 2 beverages per day
    2. Herbs
       1. Chamomile
       2. Garlic
       3. Ginger
       4. Ginseng
       5. Valerian
    3. Teas
       1. Chicory
       2. Orange Spice
       3. Peppermint
       4. Raspberry
       5. Red bush tea
       6. Rose hips
12. Management: Contraindicated Drugs in Lactation
    1. Medications that decrease milk production
       1. Bromocriptine
       2. Diuretics
    2. Chemotherapeutic Medications
       1. Cyclophosphamide
       2. Cyclosporine
       3. Doxorubicin
       4. Methotrexate
       5. Gold salts
       6. Propylthiouracil
       7. Methimazole
    3. Cardiovascular medications to avoid in Lactation
       1. Avoid Atenolol and use other Beta Blockers only with caution
       2. Avoid Acebutolol
       3. Avoid Amiodarone
    4. Miscellaneous Medications
       1. Dextroamphetamine
       2. Ergotamine
       3. Lithium
       4. Metronidazole (esp. if 2 gram dose)
       5. Chloramphenicol
       6. Potassium iodide
       7. Phenindione (Anticoagulant)
    5. Drugs of Abuse
       1. Amphetamine
       2. Cocaine
       3. Heroin
       4. Marijuana
       5. Nicotine
       6. Phencyclidine
13. Resources
    1. LactMed
       1. https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm
    2. InfantRisk
       1. https://www.infantrisk.com/
14. References
    1. (2000) Harriet Lane Handbook, Mosby, p. 913
    2. Hale (2006) Medications and Mother's Milk, Hale Publishing
    3. Briggs (1998) Drugs in Pregnancy and Lactation, 5th ed
    4. Mason and Wheaton in Herbert (2018) EM:Rap 18(11): 8-9
    5. Middleton (1998) Allergy, Mosby, p. 941
    6. Sakas and Welsh (2022) Crit Dec Emerg Med 36(3): 9
    7. (1994) Pediatrics 93:137-50 [PubMed]
    8. Howard (2001) Pediatr Clin North Am 48(2):485-504 [PubMed]