Keeping up to date on safe prescribing in breast-feeding
The Government's National Breast-feeding Awareness Week this week aims to reinforce its benefits to mother and child. With a national shortage of midwives to give advice, it is more important than ever for younger GPs to ensure they are informed on breast-feeding so they can offer support. Dr Morag Martindale explains how GPs can reassure mothers taking medication that it is safe to continue breast-feeding.
With a national shortage of midwives to give advice, it is more important than ever for younger GPs to ensure they are informed on breast-feeding so they can offer support.
Dr Morag Martindale explains how GPs can reassure mothers taking medication that it is safe to continue breast-feeding.
GPs are understandably cautious when prescribing for women who are breast-feeding. Many drugs are excreted in breast milk and there are concerns about the possible effects on the infant. The BNF is equally cautious in its advice in the appendix on prescribing in lactation and since many pharmaceutical companies have not conducted clinical trials on drugs in lactation, many drugs remain off licence for breast-feeding mothers.
But it is possible to prescribe safely in the most common conditions that present to GPs. It should only very rarely be necessary to advise a woman to stop breast-feeding to allow her to take medication.
Some of the texts used by our hospital and community pharmacists have more detailed advice on drugs, which can be used in lactating women. Drugs in Pregnancy and Lactation by Briggs, Freeman and Yaffe is used by many pharmacists in the UK and by doctors and pharmacists in the US. Its advice tends to be more liberal than the BNF.
Guidelines, such as from SIGN on postnatal depression, are also helpful. The general advice on prescribing in lactation is as follows:
lEstablish a clear indication for drug treatment
lUse treatments in the lowest effective dose for the shortest period necessary
lDrugs with a better evidence base are preferable
lAssess the benefit/risk ratio of the illness and treatment for both mother and baby/fetus.
Advice is also given on dosing. It is recommended that medication prescribed to a breast-feeding mother is best taken as a single dose administered before the longest sleep period. This can be difficult to organise in the very early weeks of an infant's life but most babies will begin, within four to six weeks, to have a regular, longer feeding gap at some point in the day. Breast-feeding should therefore be done just before this gap and, if possible, avoided for one to two hours after a dose (the time of highest plasma concentrations).
There is no clinical indication for women treated with paroxetine, sertraline, fluoxetine or tricyclic antidepressants to stop breast-feeding provided the infant is healthy and his/her progress is monitored. However, paroxetine has the lowest half-life of the SSRIs above and has the lowest plasma/milk ratio.
The guidelines also state lithium should never be prescribed for a breast-feeding mother and new prescriptions for benzodiazepines should be avoided.
With regard to infections, penicillins, cephalosporins and macrolides are safe but ciprofloxacin should be avoided. Metronidazole should be used with caution. In general, if a woman requires an antibiotic for mastitis a broad spectrum one is ideal. It should be noted that prompt referral to a midwife/health visitor is vital for help with engorgement and correct attachment of the baby. This may be all that is needed in the mild cases and antibiotics are not always necessary. The same advice applies to women with cracked nipples.
Paracetamol and ibuprofen can be given for pain and fever. Women should try if at all possible to keep feeding to empty the breast and avoid the complication of breast abscess.
Aciclovir can be used for herpes infections.
One slightly contentious area is the subject of breast thrush. This results in nipple and/or deep breast pain, which can often start after weeks of problem-free feeding. It can be associated with oral thrush in the baby and flaky nipples in the mother.
The BNF advises avoiding fluconazole and yet, somewhat illogically, fluconazole is licensed for neonates at doses higher than those found in breast milk. Many GPs are prescribing fluconazole and as a result there is an increasing body of evidence for its safety.
Mother and baby should be treated simultaneously. Recommended treatments are:
lBaby Nystatin drops
or Miconazole oral gel to start
lMother Fluconazole orally 150mg
to start followed by 50mg BD
for 10 days
or Nystatin tabs 500,00 units QDS for 14 days
Terbinafine should not be prescribed.
Analgesics and antihistamines
Analgesics such as paracetamol and codeine are safe as is ibuprofen. Aspirin is to be used with caution and tramadol and Cox 2 inhibitors should not be used. Antihistamines such as loratadine and trimeprazine can be prescribed.
Women who remain hypertensive after delivery are often treated with labetalol. There is no reason for these women to stop breast-feeding and other antihypertensives such as diltiazem, ACE inhibitors and bendrofluazide can also be used.
Salbutamol and terbutaline are safe to continue in patients with asthma. There is no data available on beclomethasone and budesonide.
Women requiring treatment for dyspepsia and related conditions can have ranitidine or cimetidine as well as antacids but PPIs should be avoided until breast-feeding is finished. Loperamide and codeine are safe to be used if necessary for diarrhoea but metoclopramide and prochlorperazine should be used with caution.
In conclusion, the benefits of breast-feeding to babies and mothers are well documented. Midwives and health visitors provide most of the support required by mothers but GPs also have an important role to play by providing up-to-date knowledge on the conditions that present to them. As a general rule women who are breast-feeding should avoid taking medication where possible to avoid unwanted effects on their infants. But where medication is necessary it should be possible in almost all cases to find a medication that is suitable. In particular, in the case of postnatal depression, the SIGN guidelines have been enormously helpful in giving GPs the confidence to prescribe without advising women to give up breast-feeding.
Morag Martindale is a partner in Blairgowrie, Tayside, and has recently compiled an information pack on breast-feeding for GPs
in the area. She is on the policy, research and campaigns committee of the National Childbirth Trust
Information and support
•The National Childbirth Trust , Alexandra House, Oldham terrace, Acton, LondonW3 6NH www.nct-online.org
•NCT Breast-feeding Line 0870 444 8708
•Breast-feeding Network, PO Box 11126, Paisley PA2 8YB www.breastfeedingnetwork.org.uk.
•Breastfeeding Network Supporterline 0870 900 8787 and Drugs in Breastmilk Helpline 02392 598604
•SIGN guidelines on postnatal depression and puerperal psychosis. 2002. www.sign.ac.uk
•Antidepressant Medication and Breast-feeding. Wendy Jones PhD MRPharmS. Community Pharmacist. The Breastfeeding Network. www.breastfeedingnetwork.org.uk
•BNF, BMJ Books. London
•Hale T. Medications in Mother's Milk. 2002 Pharmasoft Medical Publishing. Texas