Medicines For Two:

At some time during lactation, most mothers will need medicines to deal with an illness. Besides wondering how the drug will behave in your own body, you now have another body to consider. Most drugs taken by the mother enter her milk, but usually only around 1 percent of the dose appears in the milk. Here's how to safely take medicines while breastfeeding.

General Considerations
Before taking any medication during breastfeeding, consider the following:

* Will the medicine harm your baby?
* Will the medicine diminish milk production?
* Are there safer but equally effective alternative treatments?
* Are there ways to juggle medicine taking and breastfeeding to lessen how much of the drug gets into your baby?

You should be aware that advice for a mother about a medication is sometimes based more on legal considerations that on scientific knowledge. A physician who does not know if a drug is safe may tell the mother not to breastfeed. Pharmaceutical companies also legally protect themselves (with package inserts and in the drug reference book 'Physicians' Desk Reference') by advising a mother not to breastfeed while taking a certain drug. This precautionary advice is usually less expensive than researching how much of the medicine enters breast milk and its effect on the baby. As a result of erroneous advice given about a harmless medication, babies are often weaned prematurely, abruptly, and unnecessarily.

Juggling Medicine Taking and Breastfeeding
If you need to take a medicine, here's how to reduce the amount that gets into your baby.

Ask yourself if you really need the medicine. If you have a cold, can you achieve the same benefits by steam, extra fluids, and a tincture of time? Can you get by with a single-ingredient rather than a multiple-ingredient cold medicine?

Find out if you can delay your treatment. If you need a diagnostic procedure (for example, X-ray studies with a radioactive material) or elective surgery, can you wait until baby is a few weeks or months older? The drug may affect exclusively breastfed newborns more than an older infant who has alternative sources of nutrition and whose more-mature systems are better able to handle the drug.
Choose a medicine that passes poorly into your milk. Let your doctor know how important breastfeeding is to you and your baby and that you don't want to stop unless medically necessary. Your doctor can choose a medicine (such as an antibiotic) that passes poorly into your milk. Also, your doctor can choose an alternative route of administration so that more of the medicine gets directly to the site of the problem and less gets into your bloodstream. For example, instead of pills try locally applied creams for skin infections, inhalant medications for asthma or bronchitis, and decongestants sprayed into the nose instead of taken orally. Because they clear more quickly from your milk, short-acting medicines (taken three to four times a day) are generally regarded as safer during breastfeeding than long-acting drugs (taken once or twice a day).

Juggle feeding and medicine times. Ask your doctor when the time of peak concentrations is. (This is when the medicine reaches the highest level in your blood -- usually the same time that it's highest in your milk). Most drugs reach their peak concentration one to three hours after you take the medicine and are nearly cleared from the milk after six hours. If there is doubt about the safety of a drug, try these tactics:

1. If possible, before beginning the medicine, pump and store a few feedings' worth of milk.
2. Breastfeed just before taking the medicine.
3. Take the medicine just prior to baby's longest sleep period, usually after the last feeding at night.
4. If baby requires a feeding within the next three to six hours, use the "safe" milk from your storage supply, or use formula.
5. Pump and dump. Because most drugs leave the breast milk as quickly as they enter it, some authorities feel that waiting six hours is just as effective as pumping and discarding the milk, but pumping my help prevent engorgement. In addition, some fat-soluble drugs are stored in the fat of breast milk, so it may be helpful to pump and discard a feeding's worth of milk up to three or four hours after taking the medication.

This timing of the sequence is a general guide and may vary according to the type of medication and the feeding pattern of your baby. (Some radioactive medications may take twenty-four hours to clear your system, for example.) Check with your doctor on the best juggling schedule.

If the safety of a drug you must take is questionable, but medically your baby must breastfeed (for example, baby is allergic to formula), besides observing the preceding juggling tips, consult your doctor about monitoring the amount of drug that enters your milk or baby's blood.

Most Common Medications
The following guidelines will help you when dealing with some of the most frequently used drugs.

Pain and fever relievers. Acetaminophen is the safest analgesic to use during breastfeeding; only 0.1-0.2 percent of the maternal dose enters the milk. Several doses of narcotic analgesics (Demerol, codeine, and morphine) after delivery or surgery may cause baby to be temporarily sleepy, but not enough to discourage breastfeeding. Prolonged use of narcotic pain relievers may not e safe during breastfeeding.

Cold, cough, and allergy remedies. These nonprescription medicines are safe to take while breastfeeding, but observe the following precautions: Try single-ingredient medications (either decongestant or antihistamine, for example) before using combinations; short-acting medicines are usually safer than long-acting ones. Before bedtime, cough syrup containing codeine is all right; dextromethorphan (DM) is preferable. It is best to take these remedies after breastfeeding and before bedtime. Watch baby for hyperirritability following your taking decongestant medications or for excessive sleepiness after an antihistamine, and adjust the medicines accordingly. Nasal sprays (cromolyn, steroids, decongestants) are safer than oral medications while breastfeeding.

Antibiotics. Nearly all antibiotics are safe to take while breastfeeding, especially if taken for the usual one- to two-week course for common infections. Even though only a trace amount of the most commonly used antibiotics (penicillin's and cephalosporin's) enter the milk, baby may be allergic to the antibiotic (allergy-type rash) or develop oral thrush or diarrhea from a prolonged effect of the antibiotic on the intestines. Sulfa antibiotics should be used with caution during the newborn period. Your doctor may take special precautions with the prolonged use of any antibiotic such as tetracycline, with some high-dose intravenous antibiotics, or with special antibiotics like Flagyl.

Caffeine and chocolate. No, you don't have to give up your coffee, tea, soft drinks, or chocolate candy during breastfeeding. Studies show that only 0.5-1 percent of the maternal dose of caffeine or chocolate enters the breast milk. The occasional baby may become irritable, showing a hypersensitivity to caffeine or the theobromine in chocolate.

Oral contraceptives. Most authorities believe the low-dose progestin-only pill (the "minipill") is safe while breastfeeding. And for mothers who exclusively breastfeed, the minipill is as protective as the older progestin-estrogen combination, which decreases the quality and quantity of milk and is not safe. Studies have shown the progestin-only pill does not alter the quantity or quality of breast milk or interfere with infant growth, and some studies show that this type of pill may even enhance milk production. An occasional mother, however, may report a decreasing milk supply even with the minipill. Although an eight-year follow-up of breastfed infants of mothers taking a fifty-microgram progestin pill showed no harmful development or effects, the primary concern is the possible long-term effects when these babies begin to procreate. Like the progestin-only pill, levonorgestrel implants are generally regarded as safe, but their long-term effects are also unknown. Because longer-term effects of oral contraceptives on breastfed infants are being studied, consult your gynecologist for the latest information on the safety of oral contraceptives while breastfeeding.

Antidepressants and other psychiatric medications. These drugs are in the use-with-caution category. Most of these drugs appear in breast milk in greater or lesser amounts, and there is little information available about long-term effects on infants. However, a mother who is suffering from serious postpartum depression may benefit from medication, and treating the mother's depression will indirectly benefit the baby.

The most commonly used antidepressants are collectively known as SSRI's (selective serotonin reuptake inhibitors). They boost the brain's levels of serotonin, a mood-elevating neurochemical. Zoloft (sertraline) seems to be the safest SSRI to use while breastfeeding. Studies of infants whose mothers are taking Zoloft have found either insignificant amounts of the drug in the infant's blood, or the drug has been undetectable. Paxil (paroxetine) is the next best choice, and Prozac (fluoxetine) is also considered compatible with breastfeeding.

In addition to medication, consider professional counseling and peer support. Getting help at home, regular exercise, and the relaxing effects of breastfeeding can also help mothers weather a mild depression. Life-style changes are important, even if you are also taking medication.

Other psychiatric medications that are sometimes prescribed for mothers include antidepressants from the tricyclic category. Your doctor can choose one of these that is safe to take while breastfeeding. An occasional dose of Valium (diazepam) is considered safe while breastfeeding, but prolonged use is not advisable. Lithium, used to treat bipolar disorder, is in the yellow-light category (that is, use it with caution) for mothers who are breastfeeding. If treatment with lithium is necessary for mother and premature weaning is undesirable, the levels of lithium in the baby's blood should be closely monitored, approximately every two to four weeks.

Herbs and vitamin supplements.
Herbs and dietary supplements are drugs. Use the same caution about taking these as you would about taking any over-the-counter medication. Prenatal vitamins are fine to take while breastfeeding, but mega doses of vitamins may not be a good idea while breastfeeding. Herbal teas promoted as galactagogues (substances that increase your milk supply) are harmless and may work, though there are not scientific studies that confirm this. Herbs to be avoided or used with caution during lactation include comfrey, sassafras, ginseng, and licorice.

Alcohol. New research is questioning the wisdom of traditional breastfeeding folklore that wine is good for relaxing the breastfeeding mother and beer is good for increasing milk supply. Studies suggest two major concerns when a mother drinks alcohol while breastfeeding. First, alcohol enters breast milk very rapidly and in concentrations nearly equal to that in the maternal blood. Second, the tiny infant may have a limited ability to detoxify the alcohol from his or her system. Alcohol has also been shown to inhibit the milk-ejection reflex, and the higher the dose the greater the effect. Studies in animals show that alcohol reduces milk production. A study in humans has shown that infants take less milk from the breast in feedings following their mother's consumption of alcohol. It's possible that alcohol alters the flavor of human milk, making it less appealing to babies. In another study, the infants of breastfeeding mothers who regularly consumed two or more alcoholic drinks daily scored slightly lower on tests of motor development at one year. For these reasons mothers would be wise to limit their alcohol consumption during breastfeeding or eliminate alcohol altogether. The occasional glass of wine with a special dinner should not be a problem. Sip it slowly with food, and, if possible, wait an hour or two before breastfeeding your baby.

Smoking. Nicotine passes into mother's milk, into the baby, and causes colicky symptoms. Secondhand smoke irritates a baby's nasal and respiratory passages, causing frequent colds, runny noses, and difficulty breathing. Studies show that mothers who smoke have a delayed milk-ejection reflex and a decreased milk supply, and they tend to wean earlier than nonsmoking women. Mothers who smoke also have lower prolactin levels.

Clearly, there are plenty of reasons to quit smoking before you become a parent and even more reasons not smoke around your baby. If you smoke, you are encouraged to seek help if quitting is difficult for you. If you cannot quit, do not smoke around your baby and do not smoke while breastfeeding. If you must smoke, have one cigarette immediately after feeding your baby, allowing the nicotine to clear from your body before the next feeding.

Recreational drugs. Research on the effects of some recreational drugs on the breastfeeding infant is inconclusive at this time. The problem chemical in marijuana, THC, appears in the breast milk of users, and marijuana has been found to lower the levels of prolactin in the mother. Animal studies have shown structural changes in brain cells of breastfeeding infants after their mothers were exposed to marijuana. These experimental hazards, in additional to the possibility that marijuana may lower a mother's attentiveness to her baby, dictate, by common sense, that mothers avoid marijuana if breastfeeding.

Cocaine, a more dangerous and powerful drug, enters the milk of the breastfeeding mother and agitates the baby's nervous system, causing irritability, sleeplessness, and colicky symptoms. This drug, as well as depressing addicting drugs such as heroin, should obviously be completely avoided.

There will be more articles on breastfeeding, raising baby and other related topics so be sure to keep an eye out for my articles.