Am Fam Physician. 2002;65(5):979-980
Women commonly stop breastfeeding because of medication use and advice from a physician, according to a report from the American Academy of Pediatrics (AAP). The AAP states that this advice may not be warranted. Most drugs likely to be Prescribed to a nursing mother should have no effect on milk supply or on the infant's well being. The report, titled “The Transfer of Drugs and Other Chemicals into Human Milk,” appears in the September 2001 issue ofPediatrics. It includes discussions of nicotine, psychotropic drugs, silicone breast implants, and other drug therapies.
Before prescribing drugs to lactating women, the AAP recommends that the following should be considered:
| Acetaminophen Acetazolamide Acitretin* Acyclovir† Allopurinol* Amoxicillin Antimony* Atropine Azapropazone (apazone)* Aztreonam B1(thiamin) B6 (pyridoxine) B12 Baclofen Bishydroxycoumarin (dicumarol) Butorphanol Captopril Carbamazepine Carbetocin Cascara Cefadroxil Cefazolin | Cefotaxime Cefoxitin Cefprozil* Ceftazidime Ceftriaxone Chloroform Chloroquine Chlorothiazide Cimetidine† Ciprofloxacin Cisapride Clindamycin Clogestone Codeine Colchicine* Cycloserine Diatrizoate Digoxin Diltiazem Dipyrone Disopyramide Domperidone Dyphylline† Enalapril* | Erythromycin† Ethambutol Fentanyl* Fexofenadine Flecainide* Fluconazole Flufenamic acid Fluorescein* Folic acid Gadopentetic (Gadolinium) Gentamicin Gold salts Halothane Hydralazine Hydrochlorothiazide* Hydroxychloroquine† Ibuprofen Iohexol Iopanoic acid Interferon-α* Ivermectin K1(vitamin) Kanamycin | Ketoconazole Ketorolac* Labetalol Levonorgestrel* Levothyroxine Lidocaine Loperamide* Loratadine Magnesium sulfate Medroxyprogesterone Mefenamic acid Meperidine Methadone Methimazole (active metabolite of carbimazole) Methohexital Methyldopa Metoprolol† Metrizamide Metrizoate Mexiletine Minoxidil Moxalactam | Nadolol† Naproxen* Nefopam Nifedipine* Norethynodrel Norsteroids Noscapine Ofloxacin Oxprenolol Phenylbutazone Piroxicam Prednisolone Prednisone Procainamide Progesterone Propoxyphene Propranolol Propylthiouracil Pseudoephedrine† Pyridostigmine Pyrimethamine Quinidine Quinine Riboflavin | Rifampin Scopolamine* Secobarbital Senna Sotalol* Spironolactone Streptomycin Sulbactam Sumatriptan Suprofen Terbutaline Terfenadine Thiopental Ticarcillin Timolol Tolmetin Trimethoprim/sulfamethoxazole Triprolidine Valproic acid Verapamil Warfarin Zolpidem |
Is drug therapy necessary? If drugs are required, the safest drug should be chosen.
If there is a possibility of risk to the infant, consideration should be given to measurement of blood concentrations of the drug in the nursing infant.
Drug exposure to the nursing infant may be minimized by having the mother take the medication just after breastfeeding the infant or just before the infant is ready for a lengthy sleep period.
| Drug | Reported signs or symptoms |
|---|---|
| Alcohol (ethanol) | With large amounts, drowsiness, diaphoresis, deep sleep, weakness, decrease in linear growth, abnormal weight gain; maternal ingestion of 1 g per kg daily decreases milk ejection reflex |
| Aspirin (salicylates)† | Metabolic acidosis (one case) |
| Atenolol† | Cyanosis; bradycardia |
| Barbiturate | Should be given with caution; blood concentration in the infant may be of clinical importance |
| Bendroflumethiazide | Suppresses lactation |
| Bromide | Rash, weakness, absence of cry with maternal intake of 5.4 g per day |
| Caffeine | Irritability, poor sleeping pattern, excreted slowly; no effect with moderate intake of caffeinated beverages (2 to 3 cups per day) |
| Carbimazole | Goiter |
| Chloral hydrate | Sleepiness |
| Chlorthalidone | Excreted slowly |
| Cisplatin | Not found in milk |
| Contraceptive pill with estrogen/ progesterone | Rare breast enlargement; decrease in milk production and protein content (not confirmed in several studies) |
| D (vitamin) | Follow up infant's serum calcium level if mother receives pharmacologic doses |
| Danthron | Increased bowel activity |
| Dapsone | Sulfonamide detected in infant's urine |
| Dexbrompheniramine maleate with d-isoephedrine | Crying, poor sleeping patterns, irritability |
| Estradiol | Withdrawal, vaginal bleeding |
| Ethosuximide | Drug appears in infant serum |
| Fleroxacin | One 400-mg dose given to nursing mothers; infants not given breast milk for 48 hours |
| Indomethacin | Seizure (one case) |
| Iodides | May affect thyroid activity; see iodine |
| Iodine | Goiter |
| Iodine (povidone-iodine, e.g., in a vaginal douche) | Elevated iodine levels in breast milk, odor of iodine on infant's skin |
| Isoniazid | Acetyl (hepatotoxic) metabolite secreted but no hepatotoxicity reported in infants |
| Lithium† | One third to one half therapeutic blood concentration in infants |
| Methyprylon | Drowsiness |
| Morphine | Infant may have measurable blood concentration |
| Nalidixic acid | Hemolysis in infant with glucose-6-phosphate dehydrogenase (G6PD) deficiency |
| Nitrofurantoin | Hemolysis in infant with G6PD deficiency |
| Phenobarbital† | Sedation; infantile spasms after weaning from milk containing phenobarbital, methemoglobinemia (one case) |
| Phenytoin | Methemoglobinemia (one case) |
| Sulfapyridine | Caution in infant with jaundice or G6PD deficiency and ill, stressed, or premature infant |
| Sulfisoxazole | Caution in infant with jaundice or G6PD deficiency and ill, stressed, or premature infant |
| Tetracycline | Negligible absorption by infant |
| Theophylline | Irritability |
| Thiouracil | Drug not used in the United States |
| Tolbutamide | Possible jaundice |
Physicians who encounter adverse effects in infants who have been receiving drug-contaminated breast milk are urged to document these events with the U.S. Food and Drug Administration (http://www.fda.gov/medwatch/index.html). This report should include the generic and brand names of the drug, the maternal dose and mode of administration, the concentration of the drug in milk and maternal and infant blood in relation to the time of ingestion, the method used for laboratory identification, the age of the infant, and the adverse effects.
If a pharmacologic or chemical agent does not appear in the tables, it does not mean that it is not transferred into breast milk or that it does not have an effect on the infant; it only indicates that there were no reports found in the literature.