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Bal (CPT) > Module 1.3 (Medications and Breastfeeding) > Flashcards

Module 1.3 (Medications and Breastfeeding) Flashcards

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1
Q

What are breastfeeding benefits for mother

A
  • Assist in losing weight
  • Reduce risk of T2DM, blood pressure and heart disease
  • Lower rates of ovarian and breast cancer
  • Promotes bonding
  • Convenient
  • Free
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2
Q

What are the breastfeeding benefits for baby?

A
  • All nutritional requirements for growth and development
  • Easier to digest
  • Contains antibodies, immunoglobulins
  • Reduces risk of infectious diseases
  • Reduces risk of SIDS
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3
Q

96% new mothers initiate breastfeeding - 60% continue to 6 months. How many use medications?

A
  • Majority need at least one medication
  • Prescribed medication
  • OTC
  • Herbal and complementary medicines
  • Illicit substances
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4
Q

What are general safety comments about medications in breastfeeding?

A

Most medications transfer into milk

Amount received by breastfed infant is LOW

Very few pose significant risk

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5
Q

What are some common medications that cause adverse drug reaction in breast milk in infants?

A

Opioids 25%

Antidepressants 15%

Multiple drug classes 11%

Anticonvulsants 11%

Iodine 6%

Antimicrobials 6%

Antipsychotics 4%

Cardiovascular drugs 4%

Sedatives 4%

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6
Q

What to do when treating breastfeeding mother?

A
  • Treat mother effectively
  • Minimise infant exposure
  • Minimially disrupt nursing

Witholding breastfeeding is NOT a risk free option as mother and baby will be deprived of benefits

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7
Q

How does drug transfer into milk occur?

A
  • Mainly - passive diffusion
  • Gaps between alveolar cells

> early post natal period

> passage of immunoglobulins, maternal proteins

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8
Q

Factors affecting infant exposure?

A
  1. Drug properties
  2. Maternal facotrs
  3. Infant factors
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9
Q

Outline how the below drug properties affect infant exposure:

A) Protein binding

B) Molecular weight

C) Lipid solubility

D) Volume of distribution

E) Ionisation

A

A)

high (>90%)→ unable to diffuse into milk (ibuprofen, warfarin)

B)

<200da cross readily, 800-1000da may cross, >1000da unlikely

C)

Milk more lipophilic (benzodiazepines) cross more easily

D)

Drugs with high volumes of distribution (Vd) (1-20 L/kg) are distributed in higher concentrations in remote compartments of the body, and may not stay in the blood

E)

pKa measures pH at which drug is equally ionic and nonionic

The more ionic a drug, the less it can transfer from the milk to the plasma, so pKa>7.2 can be ion trapped in milk.

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10
Q

Outline how the below maternal factors affect infant exposure

A) Pharmacogenomics

B) Maternal bioavailability

C) Maternal plasma concentration

A

A)

Influenced by metabolism differences (codeine)

B)

Low bioavailability –> low plasma levels (pyrantel)

D)

Via passive diffusion (how drug gets into breast milk)

High plasma concentration = cross into breast milk more likely

E.g. sertraline has lower maternal plasma and high volume of distribution = lower in milk (sertraline)

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11
Q

Outline how the below infant factors affect infant exposure

A) Amount of drug ingested by infant

B) Oral bioavaliablilty in infant

C) Age of infant

D) Use in infants

A

A)

  • Milk concentration
  • Daily milk intake (150mL/kg/day)

B)

  • Infant’s stomach acidity denatures many drugs (aminoglycosides, omeprazole)

C)

  • Immature metabolism in preterm infants

D)

  • If used therapeutically unlikely to be toxic via breastmilk
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12
Q

Clearance values (hepatic and renal) as baby ages

A
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13
Q

What is the formula for relative infant dose (RID)?

> better than M/P

A

Infant dose(mg/kg/day) / Maternal dose (mg/kg/day) x 100

< 10% is safe

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14
Q

What is the milk/plasma ratio (M/P)?

A

Use to calculate milk concentration if maternal plasma concentration known

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15
Q

How to do risk assessment of the infant through:

A) infant

B) drug

C) dose based on milk transfer

A

A)
age = premature and newborn at greater risk

size = calculate dose

stability = unstable infants may increase risk

B)

Paediatric use

Inherent toxicity

C)

What is the relative infant dose (RID). Less or more than 10%.

Infant dose –> compare this to therapeutic use

M/P

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16
Q

What is a safe dose?

A
  • Relative infant dose (RID) <10%
  • Lower dose if infant preterm or in first month of life
  • Less if drug is inherently toxic
  • Less where doses are uncontrolled –> prn dosage
  • Check literature for reports of adverse effects in infants
17
Q

What must be done in all cases when it comes to giving a mother a drug?

A

An individual risk versus benefit assessment is necessary to evaluate safety of breastfeeding when a mother is taking medication

18
Q

Risk-benefit analysis of a breastfeeding mother taking medication?

A
19
Q

How to minimise drug exposure to infant?

A
  • Withhold drug þ
  • Delay treatment þ
  • Consider alternative routes of administration þ
  • Use lowest appropriate dose þ
  • Select drug within class having lowest RID þ
  • Avoid nursing when milk concentration is high þ
  • Withhold feeding temporarily þ
  • Discontinue feeding
20
Q

What are some examples of drugs contraindicated in breastfeeding?

A
  • Amiodarone: long half life, iodine containing, may affect infant thryoid function
  • Antineoplastics: leukopenia, bone marrow suppression
  • Gold salts: rash, nephritis, haemtaological abnormalities
  • Lithium: breastfeeding only with rigorous monitoring
  • Radio-pharmaceuticals: radiation exposure, often long e.g. iodide
  • Retinoids (oral): wide distribution, anaemias, LFTs raised
  • HIV medications: not recommended due to the condition being transferred
21
Q

True or false: Official CMI from drug manufacturers contraindicated breasfeeding for drugs such as antimicrobials while AMH, LactMed and PBMG specificy it can be used

A

True

> eMIMs recommendation which is conservative and on medicolegal based product information

22
Q

Analgesics in breastfeeding mothers? Which one AVOID?

A

CODEINE AVOID –> CI

Existing warnings contraindicating codeine use by breastfeeding mothers should be made consistent across all codeine – containing products, and warnings should be added to advise against using codeine if known to be an ultra-rapid metaboliser.

> CYP 2D6 catalyses codeine to morphine

> Number of populations have duplication of the gene

> Leads to ultrarapid metabolism of codeine and increased production of morphine

> Report of neonatal death with mother shown to be ultra rapid metaboliser

23
Q

What drugs increase milk production? (galactagogues)

A

Improve milk supply

More effective if commenced as soon as possible after delivery

Domperidone and metoclopramide block dopamine receptors in pituitary

Metoclopramide crosses BBB and not recommended due to dystonic reactions

> Use >4 weeks associated with low mood

> New TGA recommendation – maximum 30mg maximum 5 days

24
Q

Properties of domperidone?

A

Does not cross blood brain barrier n M

edicines safety update 2012 n

  • Doses > 30mg and > 60 years of age n

Recommended dose 10mg tds n Higher cardiac risk (QT prolongation) in women with history of ventricular arrhythmias n

Drug interactions CYP3A4 (azole antifungals, macrolide antibiotics) n

Take for 7 days - 6 weeks n

Taper dose at course completion

25
Q

Herbal preparations in breastfeeding mothers?

A

Used by majority of population n

Contain pharmacologically active components n

Use with caution n

Do not exceed recommended dose n

Use minimal amounts n

Avoid large mixtures of unknown herbal

26
Q

Questions to ask if patient wants to know if medication will have an effect on baby?

A

Age of baby ü

Full term or premature ü

Baby well ü

Indication - new or previous ü

Duration of treatment ü

Medication history ü

What happens if drug not taken ü

Has taken before or during pregnancy ü

Any other drugs tried in past

27
Q

Compare sertraline in eMIMS and AMH

A
28
Q

Reponse to sertraline?

A

Low amounts excreted. Probably not clinically relevant n

Adverse effects not noted in infants, but observe for restlessness, irritability, poor feeding n

Neurobehavioral development data limited n

Avoid feeding at peak levels if possible n

Manufacturers recommendation is conservative and based on medico legal considerations n

Effective drug. Benefits outweigh risks n

Give copy of MotherToBaby fact sheet or tell mother to download app

29
Q

What are some resources for lactation?

A
30
Q

Conclusions

A

Most drugs don’t enter milk in levels that are hazardous

Rarely does the amount transferred into human milk produce clinically relevant doses

Using the PB recognised resources is essential to ensure;

  • mother is not denied OPTIMAL treatment
  • treatment is based on TRUE estimation of RISK to the fetus and infant
  • Provision of up-to-date, evidence based, clinically relevant information

Bal (CPT) (27 decks)

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