Medication use in lactation: evaluating safety concerns

Breastfeeding and medication can often be a concerning combination for mothers, due to the possible impacts of drug diffusion through maternal milk. MIMS Doctor received feedback from Sharmila Sathianathan, neonatal intensive care unit (NICU) pharmacist at Hospital Tengku Ampuan Rahimah, Klang, on considerations for medication safety in breastfeeding mothers. The following is an edited version of her commentary on the issue.

As a pharmacist, I receive frequent enquiries from healthcare professionals (HCPs) and patients on the safety of medications consumed during lactation. As many are fearful of the effects of a medication towards a child, some choose the easier option of stopping lactation while consuming medications in general. This is not only wrong, but it prevents a child from receiving optimal nutrition from breast milk.

HCPs can refer to resources such as the Drugs and Lactation Database (LactMed®)—part of the US National Library of Medicine (NLM) Toxicology Data Network—which is a database on the safety of medication consumption during breastfeeding and is referenced from scientific literature. The database provides information on safe levels (if any) of medication content in infant blood, adverse effects, alternative medication suggestions, and monitoring parameters.

Besides that, one can refer to books on neonatal medicine that provide information on safety of medication in breastfeeding such as Gomella’s Neonatology (Lange Medical Books/McGraw-Hill Education). Quick references may be sought from drug information databases such as Lexicomp’s breastfeeding section for detailed descriptions on medications.

According to the US Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP), necessary considerations include the mother’s medication use, effects of medication consumption on breast milk production levels, amount of medication content in breast milk, the child’s age, amount of breast milk consumed, amount of medication absorbed orally by the child, and potential side effects from the medication. [Available at: https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/vaccinations-medications-drugs/prescription-medication-use.html]

In general, HCPs should opt for drugs with a short half-life and the lowest effective dose while breastfeeding.

An article by Neil Hotham and Elizabeth Hotham published in Australian Prescriber highlighted several medications contraindicated to breastfeeding including amiodarone, antineoplastics, gold salts, iodine, lithium, radiopharmaceuticals, and oral retinoids. Other key points are summarized in Table 1. [Aust Prescr 2015;38(5):156–159; 2016;39(1):27 (published correction)]

Table 1: Factors for consideration in medication use during lactation.

To conclude, many medications consumed by mothers are safe with breastfeeding as the amount excreted into the breast milk is small. HCPs can refer to a wide range of resources to ensure medication safety prior to advising mothers. By sharing the evidence from literature with mothers, HCPs may be able to alleviate their anxiety as well as prevent nonadherence to medication and/ or breastfeeding discontinuation.