Drug Use During Lactation

Question 1

What is the best form of nutrition for young infants?

Answer 1

Breast milk

Question 2

Mothers should breast feed exclusively for ____, and continue until at least ___ while other foods are introduced.

Answer 2

6 months; 12 months

Question 3

Breast feeding provides:

Answer 3

1) Protection of the infant against gastric, respiratory, and urinary tract infections.

2) Reduction in the rate of obesity, and juvenile onset diabetes mellitus.

3) Reduction in the rate of atopic diseases.

Question 4

Maternal benefits of beast feeding include:

Answer 4

1) Reduced risk of developing pre-menopausal breast cancer
2) Strengthens the mother-infant bond

Question 5

The drug dose ingested by the infant via breast milk ___(usually/rarely) causes adverse effects.

Answer 5

Rarely

Question 6

Almost all drugs enter breast milk by:

Answer 6

Passive diffusion through the lipid membrane of the alveolar cells of the breast.

Question 7

Drugs that enter the breast milk should be:

Answer 7

1) Un-ionized
2) Not protein bound

Question 8

Factors affecting rate and extent of passive diffusion of drug to breast milk include:

Answer 8

1) Maternal plasma drug level
2) Physiological differences between plasma and milk
3) Physicochemical properties of the drug

Question 9

What is the pH of breast milk?

Answer 9

6.8 – 7.0

Question 10

In which ways does breast milk differ from blood?

Answer 10

1) Lower pH
2) Lowering buffering capacity
3) Higher fat content

Question 11

What are the drug parameters affecting the extent of transfer
into milk?

Answer 11

1) pKa
2) Protein binding
3) Lipophilicity
4) Molecular weight

Question 12

What does the pKa determine?

Answer 12

Drug ionization at a given pH

Question 13

Do highly ionized drugs tend to concentrate in milk?

Answer 13

No

Question 14

Is Erythromycin acidic or basic?

Answer 14

Basic

Question 15

For basic drugs, a greater fraction will be ionized at a(n) ___(basic/acidic) pH. What does this mean?

Answer 15

Acidic; That the milk compartment tends to trap weak bases.

Question 16

Is Penicillin acidic or basic?

Answer 16

Acidic

Question 17

Acidic drugs are more ionized at ___(lower/higher) pH values and will be trapped in the __ compartment.

Answer 17

Higher; Plasma

Question 18

Drugs with higher pKa values generally have higher ____.

Answer 18

Milk/plasma ratios

Question 19

Is Warfarin highly bound to plasma proteins?

Answer 19

Yes

Question 20

Drugs that are highly bound to plasma proteins (warfarin) are likely to be retained in the __.

Answer 20

Plasma; because there is lower protein content in milk (~1%).

Question 21

__-active drugs usually cross to breast milk.

Answer 21

CNS

Question 22

Do water-soluble drugs effectively cross the alveolar epithelium of the breast?

Answer 22

No

Question 23

Drugs with what molecular weight readily pass into the milk?

Answer 23

Low molecular weight (<200)

Question 24

How do low molecular weight drugs pass into the breast milk?

Answer 24

Through small pores in the cell wall of alveolar cells

Question 25

How do high molecular weight drugs pass into the breast milk?

Answer 25

By dissolving in the lipid layer

Question 26

Which are virtually excluded from passing into breast milk?

Answer 26

Protein molecules (very large molecular weights >6000 daltons)

Question 27

Drugs that pass minimally to breast milk would be:

Answer 27

1) Acidic drugs 2) Drugs with high plasma protein binding 3) Drugs with low-to-moderate lipophilicity

Question 28

What is an example of a drug that would pass minimally into breastmilk?

Answer 28

Most NSAIDs

Question 29

Drugs that pass significantly to breast milk would be:

Answer 29

1) Basic drugs 2) Drugs with low plasma protein binding 3) drugs with relatively high lipophilicity

Question 30

What is an example of a drug that would pass significantly into breastmilk?

Answer 30

Sotalol

Question 31

Why is there enhanced passage of drugs into breastmilk in the first few days of life?

Answer 31

Because in the first week, large gaps exist between alveolar cells

Question 32

The large gaps between the alveolar cells close under the influence of:

Answer 32

Prolactin

Question 32

What is colustrum?

Answer 32

The first breast milk released in the first 2 days after giving birth

Question 32

Colustrum has high amounts of:

Answer 32

1) Immunoglobulins 2) Maternal lymphocytes 3) Maternal macrophages

Question 33

Greater amounts of drugs are present in colustrum, but the amounts received by infants are low. Why?

Answer 33

Because of the low volume of colustrum produced

Question 34

Which drug is actively pumped into breast milk?

Answer 34

Iodides

Question 35

Which drug is found in breast milk in high concentrations?

Answer 35

Iodides

Question 36

Which factors should be considered when assessing the risk to the infant?

Answer 36

1) Inherent toxicity of the drug 2) Multiple maternal therapy with drugs having similar adverse effects 3) Active metabolites 4) Drugs with long half-lives 5) Gestational age 6) Maternal drug regimen

Question 37

Which drugs are contraindicated during lactation for being hazardous to infants?

Answer 37

1) Antiarrhythmic drugs 2) Anticholinergic drugs 3) Anti-infective drugs 4) CNS stimulants 5) Cytotoxic agents 6) Illicit substances 7) Immunosuppressants 8) Thalidomide 9) Lithium 10) MAOIs 11) Radioactive substances 12) Skeletal muscle relaxants 13) Tetracyclines 14) Tricyclic antidepressants 15) Retinoic acid derivatives

Question 38

Anticonvulsants should not be given with:

Answer 38

Psychotropic drugs

Question 39

What is a drug with active metabolites?

Answer 39

Benzodiazepines

Question 40

Fluoxetine has a ___(short/long) half-life

Answer 40

Long

Question 41

Why are drugs with active metabolites contraindicated during lactation?

Answer 41

They may prolong infant drug exposure and lead to drug accumulation.

Question 42

Premature infants are more susceptible to drugs because of:

Answer 42

Low clearance

Question 43

What are some strategies to reduce the risk of drugs in breast fed infants?

Answer 43

1) Choose medications considered safe for use in infants 2) Give the maternal dose immediately after the infant has been fed 3) If the mother is receiving a single dose of a hazardous material (radiopharmaceuticals), avoid breast feeding and resume after a reasonable washout period 4) Administer once-daily meds before the infant’s longest sleep period to increase the interval to next feeding. 5) Breastfeeding mothers should avoid self-medication 6) When drug use is indicated, the lowest effective dose should be used for the shortest possible period of time. 7) Simplify maternal regimen as much as possible 8) New drugs are best avoided if a therapeutic equivalent is available for which data on safe use during lactation is available 9) Monitor exposed infants for adverse effects. 10) During short-term drug therapy, and if the medication is NOT compatible with breastfeeding, the mother can pump milk out and discard it to preserve here milk-producing capability

Question 44

What is the usual washout period for drugs?

Answer 44

5 half-lives

Question 45

Which drugs should be selected during lactation?

Answer 45

1) Short half-lives 2) High protein binding

Question 46

______ are at greater risk of developing adverse effects to drugs after exposure via breast milk.

Answer 46

Neonates and premature infants

Question 47

Gastric emptying time in neonates and premature infants is ___(shortened/prolonged) and may alter drug absorption.

Answer 47

Prolonged

Question 48

Protein binding in neonates and premature infants is ___(increased/decreased).

Answer 48

Decreased

Question 49

Do neonates and premature infants have higher or lower total body water?

Answer 49

Higher

Question 50

Oxazepam is eliminated by:

Answer 50

Direct conjugation with glucuronide

Question 51

Neonates and premature infants should not be exposed to oxazepam. Why?

Answer 51

Because their conjugation capacity is deficient

Question 52

What does a Glucose-6 phosphate dehydrogenase (G6PD) deficiency do to erthyrocytes?

Answer 52

Makes them more susceptible to oxidative stress = hemolysis

Question 53

Should you breastfeed with a G6PD deficiency if you're taking hemolysis-inducing drugs?

Answer 53

No, even small amounts of the drug can cause hemolysis

Question 54

What does a high intake of alcohol in breastfeeding mothers do?

Answer 54

1) Decreases milk let down reflex 2) Disrupts nursing 3) Causes sedation, fluid retention, and hormone imbalances in infants.

Question 55

What does nicotine do during lactation?

Answer 55

Decreases basal prolactin production

Question 56

Caffeine appears in breast milk __(slowly/rapidly) after maternal intake.

Answer 56

Rapidly

Question 57

10 or more cups of coffee per day by the mother causes what in breast fed infants?

Answer 57

1) Fussiness 2) Jitteriness 3) Poor sleep patterns

Question 58

Preterm and newborn infants metabolize caffeine ___(rapidly/slowly) and are at increased risk.

Answer 58

Slowly

Question 59

Which drugs are the main cause of effects on milk production?

Answer 59

Drugs that affect dopamine activity

Question 60

Cabergoline is a dopamine __(agonist/antagonist).

Answer 60

Agonist

Question 61

Dopamine agonists __(increase/decrease) milk production.

Answer 61

Decrease

Question 62

Domperidone is a dopamine __(agonist/antagonist).

Answer 62

Antagonist

Question 63

Dopamine antagonists __(increase/decrease) milk production

Answer 63

Increase

Question 64

Early postpartum use of ___ may reduce the volume of milk.

Answer 64

Estrogens

Question 65

Milk production can be abolished by the use of:

Answer 65

1) Estrogens 2) Oral contraceptives

Question 66

Breast milk production can be increased by:

Answer 66

Metoclopramide

Question 67

Metoclopramide stimulates ___ secretion

Answer 67

Prolactin

Question 68

Can we give Amantadine during lactation?

Answer 68

No, it decreases milk production

Question 69

What is Fenugreek?

Answer 69

A botanical galactagogue

Question 70

Does Fenugreek increase or decrease milk production?

Answer 70

Increase

Question 71

Do botanical galactagogues increase or decrease milk production?

Answer 71

Increase

Question 72

Which botanical galactagogues are common?

Answer 72

1) Fenugreek 2) Fennel 3) Anise 4) Milk thistle 5) Barley