breastfeeding, maternal medications, and substance use new mexico breastfeeding task force 21 st...

Breastfeeding, Maternal Medications, and Substance Use

New Mexico Breastfeeding Task Force 21st Annual Conference: Innovative Approaches to Lactation Management

March 4-7, 2015

Emilie Sebesta, MD

Objectives

(1) Understand the basics of drug transfer into human milk

(2) Know where to look or whom to contact with questions about a particular drug and breastfeeding

(3) Be familiar with one hospital’s breastfeeding and substance abuse guidelines

AAP Clinical Report: The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics

Few medications contraindicated or with adverse effects on infants

Information for providers is needed but may not be available.

Proposed new FDA rules will create a section called Lactation with subsections:

1. Risk Summary2. Clinical Considerations3. Data

AAP Committee on Drugs, “The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics,” http://pediatrics.aappublications.org/content/early/2013/08/20/peds.2013-1985

http://pediatrics.aappublications.org/content/early/2013/08/20/peds.2013-1985

Transfer of Drugs into Human Milk

When determining if a maternal drug is safe for breastfeeding, the 3 most important factors are

the volume of distribution (Vd)

the percentage of maternal protein binding (PB)

the molecular weight (MW)

Nice, FJ, Luo, AC, “Medications and Breast-feeding: Current Concepts,” JAPhA, 52:1, 86-94 (2012).

Volume of Distribution (Vd)

distribution milk levels

Vd of 1-20 L/kg generally compatible


Protein Binding

Protein Milk Binding levels

PB >90% usually compatible


Molecular Weight

Molecular Milk Weight levels

Drugs with MWs <200 pass easily into the milk. Drugs with MWs >800 are more compatible with breast-feeding (e.g., insulin)



Other pharmacokinetic factors that influence if a maternal drug is safe for breastfeeding include: pH: Because breast milk is more acidic than plasma, drugs with a

high pH may concentrate more in breast milk than plasma.

logP: Drug molecules that are water soluble are less likely to concentrate in the breast milk.

t ½ : drugs with shorter half-life reach a low plasma concentration more frequently and allow the mother to time her feedings to correspond to trough levels. (Cocaine & PCP and their metabolites have very long half-lives and are particularly dangerous to infants.)



Tmax: time from administration when drug level is highest in mother’s plasma.

Milk-to-plasma ratio (M/P) of less than 1 is usually safe to breastfeed.

Relative infant dose (RID) infant weight–adjusted dose supplied via breast milk divided by maternal weight–adjusted dose. RID < 10% of maternal dose generally safe for breast-feeding


The special case of codeine and hydrocodone

Codeine and hydrocodone should be avoided by nursing mothers

A fatality has been noted in an infant of a mother with ultrarapid metabolism

Unexplained apnea, bradycardia, cyanosis, and sedation have been reported in nursing infants of mothers receiving codeine.

Given the reduced clearance of hydrocodone in neonates and the adverse events observed in ultrarapid metabolizers of codeine, caution is advised for use of codeine and hydrocodone in both the mother and nursing infant.



Tips for reducing a baby’s exposure

Avoid nursing at times of peak drug concentrations in milk. Nursing before a dose may avoid peak drug concentrations. This works best for drugs with short half-lives.

Administer the drug before the infant’s longest sleep period. This will minimize the infant’s dose and is useful for long-acting drugs that can be given once daily.

Medications with Absolute Contraindication for Breastfeeding

Radioactive Iodine (131I) May increase baby’s risk of thyroid cancer later in life Mom should wean several weeks before receiving

because iodine will preferentially deposit in active breast tissue increasing mother’s risk of breast cancer

Most chemotherapyBUT radiation therapy is okay though if being

directed at a breast for breast cancer, milk production may decrease in that breast.

Resources to Look up Drugs/Medications

Best! Drugs and Lactation Database (LactMed) - A peer-reviewed and fully

referenced database of drugs to which breastfeeding mothers may be exposed. Among the data included are maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider. http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT

Hale’s Medication and Mothers’ Milk, 2014 – An excellent book and app may be purchased. Has great tables/appendices looking at contrast materials, vaccines, chemotherapeutic agents, and OTC medications.

Also AAP Committee on Drugs, “The Transfer of Drugs and Other Chemicals

Into Human Milk” Pediatrics 2001; 108; 776.


http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT

Example: Bipolar Mother on Effexor (Venlafaxine)

Pros:-Volume of

Distribution 3.8-11.2 L/kg(1-20 L/kg

generally compatible)-Relative Infant Dose

3-11% (<10% generally safe)

Cons:-Protein Binding 27%-30%

(>90% safe)-Relative Infant Dose 3-11%

(<10% generally safe-Half life 3-7 hrs & 9-13 hrs

for active metabolite-Milk to Plasma Ratio 2.75

(<1 generally considered safe)

Example: Effexor (venlafaxine)

LactMed “[N]o proven drug-related side effects have been reported. Breastfed infants, especially

newborn or preterm infants, should be monitored for excessive sedation and adequate weight gain if this drug is used during lactation”

“[N]ewborn infants of mothers who took the drug during pregnancy may experience poor neonatal adaptation syndrome as seen with other antidepressants such as SSRIs or SNRIs. Use of venlafaxine during breastfeeding has been proposed as a method of mitigating infant venlafaxine withdrawal symptoms,[1] but only one apparently successful case of this use has been reported.”

Hale Rated “L3” = moderately safe

Reference Information from Insert Newborns whose mothers took during pregnancy may experience

Respiratory difficulty Poor feeding Temperature instability Vomiting Hypo or hypertonia Apnea Seizures Crying

Example: . . . And on Abilify (aripiprazole)

Pros:-Volume of Distribution

4.9 L/kg(1-20 L/kg generally compatible)-Protein Binding >99%

(>90% safe)-Relative Infant Dose 0.9%

(<10% generally safe)

Cons:--Half life 75 hours

Example: Abilify (aripiprazole)

LactMed “Limited information indicates that maternal doses of aripiprazole up to 15 mg daily produce

low levels in milk” Hale

Rated “L3” = moderately safe “Several reports (personal communications) of somnolence have been reported to this author.

The infant should be monitored for somnolence.” Reference Information from Insert

Newborns whose mothers took during pregnancy may experience Agitation Hper or hypotonia Somnolence Respiratory distress Feeding disorders

Example: Bipolar Mother on Effexor & Abilify

Decision made to allow baby to breastfeedBaby seen in Newborn Clinic on DOL 5

Mom feeding baby every 4-5 hours Weight down 15% Jaundiced, but not yet at light level Readmitted to hospital

Lesson: More counseling Follow up sooner

Example: Mother with long history of depression on Sertraline throughout pregnancy

Cons:-Long Half life 13-45

hours-Milk to Plasma Ratio

0.42-4.81 (<1 generally considered

safe)-Molecular Weight

342.7 (<200 likely to pass easily into milk,

>800 very safe)

Example: Sertraline

Depression is common with a lifetime prevalence rate of 16.2%.

Women are 1.7–2.7 times more likely to suffer from depression than men.

Estimates for rates of depression in pregnancy range from 1% to 20%, depending on the classification used.

Selective Serotonin Reuptake Inhibitors (SSRIs) are the most common medications used for depression (and anxiety) with an estimated use in 1.8-2.8% of pregnancies.

Maternal use of SSRIs, SNRIs, and NaSSAs: practical recommendations during pregnancy and lactation, Table 2, Arch Dis Child Fetal Neonatal Ed 2012;97:F472-F476 doi:10.1136/archdischild-2011-214239

Example: Sertraline

According to a 2014 Cochrane Review looking at treatment of postpartum depression:

There were very limited data on adverse effects experienced by breastfed infants, with no long-term follow-up.

Antidepressant treatment for postnatal depression, Molyneaux, E, et al., Editorial Group: Cochrane Depression, Anxiety and Neurosis Group,http://onlinelibrary.wiley.com.libproxy.unm.edu/doi/10.1002/14651858.CD002018.pub2/full, 11 SEP 2014

http://onlinelibrary.wiley.com.libproxy.unm.edu/doi/10.1002/14651858.CD002018.pub2/full

http://onlinelibrary.wiley.com.libproxy.unm.edu/doi/10.1002/14651858.CD002018.pub2/full

Example: Sertraline

According to the AAP:

Most publications regarding psychoactive drugs describe the pharmacokinetics in small numbers of lactating women with short-term observational studies of their infants. In addition, interpretation of the effects on the infant from the small number of longer-term studies is confounded by prenatal treatment or exposure to multiple therapies. For these reasons, the long-term effect on the developing infant is still largely unknown. (2013)

Among the agents considered to be least problematic were the tricyclic antidepressants amitriptyline and clomipramine and the selective serotonin-reuptake inhibitors paroxetine and sertraline. (2012)

The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected TopicsHari Cheryl Sachs & COMMITTEE ON DRUGS, http://pediatrics.aappublications.org/content/early/2013/08/20/peds.2013-1985

AAP, Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3). Available at: www.pediatrics.org/cgi/content/full/129/3/e827

http://www.pediatrics.org/cgi/content/full/129/3/e827

http://www.pediatrics.org/cgi/content/full/129/3/e827

Example: Sertraline

According to LactMed, “most authoritative reviewers consider sertraline one of the preferred antidepressants during breastfeeding.”

http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/f?./temp/~lNb80V:1




Relative infant dose and available clinical data during lactation for SSRIs, SNRIs, and NaSSAs

RID (%) Available data (n) LactationSelective serotonin reuptake inhibitor Fluoxetin 6.5–11 116 200 Discourage Paroxetine 1.13–1.25 123 131 Preference Sertraline 0.2 146 143 Preference Fluvoxamine 1.34–1.38 13 14 Consider Citalopram 4.4–5.1 72 76 Consider Escitalopram 12 9 ConsiderSerotonin-noradrenalin reuptake inhibitor Venlafaxine 6.5 10 15 ConsiderNoradrenergic and specific serotonergic antidepressants Mirtazapine ±2 10 9 Consider


Serotonin Reuptake Inhibitor (SRI)-Related Symptoms

A variety of symptoms have been reported after prenatal exposure to SSRIs and to a lesser extent to SNRIs and NaSSAs: Tremors jitteriness irritability muscle tone regulation disorders excessive crying sleep disturbances tachypnoea and feeding problems


Date of download: 11/5/2014Copyright © 2014 American Medical Association.

All rights reserved.

From: Neonatal Abstinence Syndrome After In Utero Exposure to Selective Serotonin Reuptake Inhibitors in Term Infants

Arch Pediatr Adolesc Med. 2006;160(2):173-176. doi:10.1001/archpedi.160.2.173


Symptoms occur in approximately 30% of in utero exposed infants.

Factors that may contribute to the likelihood of symptoms developing include: maternal dose and metabolism specific SSRI use individual drug clearance genetic predisposition prematurity

Symptoms generally occur within 2 days after birth and are usually self-limiting.

Levinson-Castiel R, Merlob P, Linder N, et al. Neonatal abstinence syndrome after in utero exposure to selective serotonin reuptake inhibitors in term infants. Arch Pediatr Adolesc Med 2006;160:173–6.



Some now recommend monitoring all infants exposed to SSRIs

For a minimum of 48 hours Using Finnegan scoring (i.e., NAS scoring)

“Breastfeeding is not contraindicated for SSRI monotherapy, but follow-up for signs of NAS after discharge is recommended.” (Levinson-Castiel)

Levinson-Castiel R, Merlob P, Linder N, et al. Neonatal abstinence syndrome after in utero exposure to selective serotonin reuptake inhibitors in term infants. Arch Pediatr Adolesc Med 2006;160:173–6.


Example: Sertraline

Mom continued to take 100 mg of sertraline daily throughout pregnancy as discontinuing during prior pregnancy had resulted in relapse into severe depression and need to restart medicine.

Mother’s previous child experienced transient jitteriness immediately after birth but otherwise had a normal newborn course and normal development.

This baby latched well immediately after birth and breastfed exclusively without any SRI-related symptoms during 48 hour hospital stay.

Example: Marijuana

Pros:-Extensively bound to plasma proteins with a

PB of 99.9% (>90% safe)

Vd 4-19 L/kg (1-20 L/kg generally compatible)

-Predicted Relative Infant Dose of 0.8%

(<10% safe)

Cons:-Highly lipophilic

-Milk to plasma ratio may be up to 8:1 in

heavy users (<1 safe)-Long half-life 25-57

hours

Example: Marijuana

AAP Committee on Drugs, “The Transfer of Drugs and Other Chemicals Into Human Milk” “nursing mothers should not ingest drugs of abuse, because

they are hazardous to the nursing infant and to the health of the mother.”

only 1 report in literature of an adverse effect of marijuana on nursing infant but effect not mentioned.

2012 AAP Section on Breastfeeding Breastfeeding and the Use of Human Milk “Maternal substance abuse is not a categorical contraindication

to breastfeeding,“ but “Street drugs such as PCP (phencyclidine), cocaine, and

cannabis can be detected in human milk, and their use by breastfeeding mothers is of concern, particularly with regard to the infant’s long-term neurobehavioral development and thus are contraindicated.”

Example: Marijuana

LactMed Limited studies One study found daily use might result in motor delay Two studies found “occasional” use had no discernible effect Studies” inadequate to rule out all long-term harm.” “Marijuana use should be minimized or avoided by nursing mothers

because it may impair their judgment and child care abilities. “Because breastfeeding can mitigate some of the effects of smoking and

little evidence of serious infant harm has been seen, it appears preferable to encourage mothers who use marijuana to continue breastfeeding while minimizing infant exposure to marijuana smoke and reducing marijuana use.”

http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/f?./temp/~GaIbPm:1




Example: Marijuana

Medications & Mothers’ Milk 2014 L5 – Limited Data-Hazardous “Cannabis should not be used during pregnancy or breastfeeding.” “[T]here is increasing concern about the use of marijuana or other

cannabis products, in pregnant or breastfeeding mothers. Studies continue to suggest that cannabis may produce long-term sequelae, such as reduced cognition, and changes in mood and reward.”

“While the data on neurobehavioral effects of cannabis on infants from breastfeeding mothers is limited, cannabis use in breastfeeding mothers should be strongly discouraged.”

“For single or infrequent exposures, breastfeeding can continue after 24-48 hours. For daily continued use, mothers should be advised not to breastfeed.”

Hale, T.W. and Rowe, H.E., Medications & Mothers’ Milk, 16th Ed. (2014).

Example: Marijuana

University of California San Diego Policy “Mothers with known or suspected street drug or

alcohol use will be given the benefit of the doubt, educated about providing safe milk for their infant, and followed closely.”

There is “no need to discard milk, test the milk, or have the mother refrain from breastfeeding.”

Stanford No official policy. Their “practice tends to run along the

lines of [UNM’s], but each practitioner is left to decide for him/herself how to manage these patients.” (personal correspondence with medical director)

Example: Marijuana

Seton Hospital in Austin, TX Discourages breastfeeding when the mother has used

marijuana in the 12 weeks prior to birth. Quotes 2014 NEJM article on Adverse Effects of Marijuana:

“Marijuana use has been associated with substantial adverse effects, some of which have been determined with a high level of confidence; these include addiction to marijuana and other substances, abnormal brain development, progression to use of other drugs, schizophrenia, depression or anxiety, diminished lifetime achievement, and others.”

Denver Health Handout on “Marijuana and Your Baby” discusses potential

effects on mothers and their babies and “strongly advise[s] that marijuana not be mixed with pregnancy, breastfeeding, or parenting.”

Why do Hospitals Need a Breastfeeding & Substance Abuse Guideline?

Inconsistency between practitionersNurses ask for guidanceBabies of mothers with substance use may be at

increased risk for child abuse NAS babies more irritable Mothers often lack resources, support Breastfeeding shown to reduce risk of abuse

Babies of mothers with substance use may have increased risk of poorer neurodevelopmental outcomes Breastfeeding may improve neurodevelopmental outcomes

Breastfeeding Generally Supported

Mothers with a history of occasional use of alcohol or marijuana and who:

quit when they discovered they were pregnant in the first or second trimester or continued to use occasionally, i.e.., small amounts and not every day, and plan not to drink alcohol or smoke marijuana while they are breastfeeding or plan

only to use small amounts and not every day (i.e., occasional use vs. abuse).

Mothers with a known history of substance abuse during the current pregnancy and:

urine toxicology screen is negative at delivery & in 90 days prior to delivery, she indicates she does not intend to use while breastfeeding her baby, and she has received consistent prenatal care starting in the first half of her pregnancy.

Mothers using methadone or buprenorphine and Not using other drugs of abuse Enrolled in a substance abuse program

Marijuana

A maternal or infant urine toxicology screen positive for THC at delivery should not alone preclude breastfeeding if The provider has reason to believe the mother’s use is occasional, Documents reasons for believing the mother’s use is occasional and

therefore the benefits of breastfeeding outweigh the potential risks of the infant’s exposure to marijuana in the breast milk, and

Counsels mother regarding the potential effects of marijuana on her infant and her ability to care for her infant and encourages her to quit.

There is little evidence regarding the effect of maternal marijuana use and breastfeeding. What evidence there is suggests that the risk would only be significant when the mother is a “heavy user” of marijuana. See Djulus, et al., Nice & Luo, LactMed, ABM, and AAP Committee

on Drugs.

Marijuana

Approximately 2.5% of women admit to using marijuana during pregnancy.

Prenatal exposure to THC may effect endocannabinoid-mediated neuronal maturation, disrupt developing neurotransmitter systems, and interfere with maturation of the dopaminergic system and serotonin receptors, which could lead to an increased risk of neuropsychiatric disorders, such as drug addiction, schizophrenia and depression.

“Whether these changes are implicated in the future risk of addictive behaviours and depression in the human is as yet uncertain.”

Jaques, SC, “Cannabis, the pregnant woman and her child: Weeding out the myths,” J. Perinat. (2014), 1-8.

Marijuana

“[S]pecific recommendations with respect to breast feeding while using cannabis are hampered by the lack of substantial and definitive studies.”

“Depending on family circumstances, the benefits of breast feeding, even with continued cannabis use, may outweigh the negative side-effects, especially in infrequent cannabis users. Each institution should work towards a policy of ensuring best practices for their particular population of cannabis users.”


Volkow ND et al. N Engl J Med 2014;370:2219-2227.

Marijuana

“There is inadequate evidence to make a statement about the isolated use of marijuana in breast-feeding mothers. The studies that address this issue are confounded by the fact that few women have isolated use during breast-feeding in the absence of additional prenatal use of marijuana.”

Based on 2 large cohorts, “there may be some effects on visuoperceptual ability, reasoning and attention in older children, [but] the association was statistically significant only with prolonged, heavy maternal use (>5 joints per week throughout pregnancy and breast-feeding).”

“Based on these findings, mandatory reporting of marijuana use during [] or breast-feeding do not seem medically warranted. A consistent message of “breast is best” seems appropriate for mothers who continue to use marijuana while breast-feeding.”

Hill, M & Reed, K, “Pregnancy, Breast-feeding, and Marijuana: A Review Article,” Obstetrical & Gynecological Survey. 68(10):710-718, October 2013.

Breastfeeding Generally Discouraged

In a mother with a known history of substance abuse during the current pregnancy and Mother’s urine toxicology screen is positive at time of delivery

or in 30 days prior to delivery, or Mother admits to use of illicit substance or non-prescribed

opiate at the time of delivery or in 30 days prior to delivery, or Mother did not receive prenatal care during this pregnancy.

Exceptions permitted with chart documentation of the rationale for the exception and written order may be appropriate to “pump and dump” until the drugs are

cleared and to check weekly maternal UDMs over the first month or longer

Breastfeeding Discretionary

In the 30-90 day period prior to delivery mother admits to use or has a positive urine toxicology screen and provider believes this is

Limited relapse Mom not likely to use upon discharge

Mother only obtained sobriety in an inpatient setting, including incarceration

When deciding whether to encourage/support a mother’s decision to breastfeed in the hospital, providers should consider:

Mother’s history of drug use/abuse Mother’s participation in substance abuse treatment program Mother’s behavior in hospital

Providers should try to talk with mother’s prenatal providers regarding risk of continued abuse.

Provider Counseling

Whether a provider is encouraging or discouraging breastfeeding in a woman with a history of substance use or abuse, he or she must counsel the mother on the possible harm to her baby if she breastfeeds and continues to use illicit substances or non-prescribed opiates or is a heavy user of alcohol or marijuana, including but not necessarily limited to:

mother being impaired in her ability to care for her infant.

baby becoming sleepy or agitated or having difficulty sleeping depending on the drug.

the possibility of long-term effects on her baby’s neurobehavioral development.

the possibility of legal repercussions if baby is found to be positive for an illicit

substance or non-prescription opiate.

What to do if you’re not sure what to do

Err on the side of letting the mother breastfeed, let her know the plan might change, and document this, as well as the final decision by mother’s and/or baby’s providers, in the baby’s chart.

References


Volkow, ND, et al., “Adverse Health Effects of Marijuana Use,” N Engl J Med 2014; 370:2219-2227.

Hale, TW, Medications and Mothers’ Milk, 16th Edition, 2014.

Hill, M & Reed, K, “Pregnancy, Breast-feeding, and Marijuana: A Review Article,” Obstetrical & Gynecological Survey. 68(10):710-718, October 2013.


AAP Section on Breastfeeding, “Breastfeeding and the Use of Human Milk”, Pediatrics, 129:3 (2012).

The Academy of Breastfeeding Medicine Protocol Committee, “ABM Clinical Protocol #21: Guidelines for Breastfeeding and the Drug-Dependent Woman,” Breastfeeding Medicine, 4:4 (2009).


References


Garry, A, et al., “Cannabis and Breastfeeding,” J. Toxicol. 2009; 2009:596149. Djulus, J, Moretti, M, Koren, G, “Marijuana Use and Breastfeeding,”

Canadian Family Physician, 51:349-350 (2005). AAP Committee on Drugs, “The Transfer of Drugs and Other Chemicals Into

Human Milk” Pediatrics 2001; 108; 776. Sharma, P, Murthy, P, Bharath, MMS, “Chemistry, Metabolism, and

Toxicology of Cannabis: Clinical Implications,” Iran J Psychiatry. 2012 Fall; 7(4): 149–156.

Drugs and Lactation Database (LactMed),



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