Balancing the Use of Medications While Maintaining Breastfeeding

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Key points

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    Use of medications during lactation is common.

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    It is essential to understand the physiochemical properties that facilitate the transfer of drugs and the pharmacokinetics of individual drugs in human breast milk.

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    Studies of the effect of drugs in breast milk on infant wellbeing and subsequent development are limited.

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    Most drugs can safely be used in breastfeeding mothers, but a risk versus benefit assessment is always required before use for each drug.

Physiology of lactation

A basic understanding of the physiology of breast milk production is important to make decisions regarding medications for the breastfeeding mother.4 Lactogenesis is defined as the process by which the mammary glands produce and secrete milk, and occurs in 4 stages. The alveolar cell is the principal site for milk production. Neville5 describes 5 steps for milk synthesis and secretion by the mammary alveolus, including 4 major transcellular and 1 paracellular pathway. They are (1) exocytosis

Factors determining transfer of drugs into breast milk

It is essential to understand the mechanisms associated with the passage of drugs, proteins, and lipids across the apical membrane of the alveolar cell. The state of the alveolar cells, and the physiochemistry of the medication itself, are 2 important factors that control the transport of drugs. The following physiochemical factors affect the transfer of drugs into breast milk:

Estimation of drug exposure

Another measure of the ability of a drug to transfer into human milk is the M/P ratio. Drugs with a high M/P ratio are often lipid soluble and small in molecular weight. A high M/P ratio may lead one to assume that the dose of the drug transferred is high, which may not necessarily be the case. Ultimately, the maternal plasma concentration of a drug is the most important factor that determines the dose transferred to the infant. Drugs that are highly protein bound and produce low “free plasma”

Pharmacokinetics and bioavailability of drugs

The metabolic capacity of infants changes as they age and is almost that of an adult at 12 months of age. However, little is known about the oral absorption and bioavailability of medications in infants.15 In newborn infants, gastric emptying time is delayed and intestinal absorption is irregular. Slower intestinal absorption tends to be advantageous, as this would tend to keep plasma concentrations of medications lower in the infant.16 Premature infants, who have more vulnerable renal and

Analgesics

Pain experienced during the early postpartum period is common in breastfeeding mothers. Ibuprofen and acetaminophen are perhaps the 2 most widely used analgesics in this setting. Fortunately, a moderate amount of data exists on these drugs and their use in breastfeeding mothers (Table 1).17

Acetaminophen is a good choice for the treatment of pain or fever in lactating mothers because adverse effects are rare in breastfed infants. Levels of acetaminophen depend largely on the maternal dose, but

Summary

Infants have little to gain from exposure to medication via breast milk, but they do have much to gain from continued breastfeeding. Several strategies are available to allow mothers to continue breastfeeding while taking certain medications. These include: (1) avoiding breastfeeding for 4 to 6 hours after ingestion of a drug to avoid peak levels (ie, pump and discarding), (2) the combined use of formula and breast milk in cases in which the risk or dose of the drug is exceptionally high,

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    Disclosure Statement: The authors declare no conflict of interest.

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