When counseling breastfeeding mothers who intend to take or are taking medications (prescription, over-the-counter, and/or herbal), the questions below should be considered and asked. The provided answers are necessary to properly counsel mothers on the safe and effective use of medications while breastfeeding. A stepwise approach based upon these answers can then be used to minimize infant drug exposure while breastfeeding. The steps evolve from not taking a medication to discontinuing breastfeeding. Steps can be skipped or combined as appropriate. Following this approach almost always allows the nursing infant to continue to breastfeed safely.
Asking this question helps get the proper perspective as to the stage of the drug / breastfeeding situation that is being evaluated. The mother may be seeking advice on whether to continue breastfeeding, if and when she takes the drug. She may be questioning whether she is acting correctly by taking the drug and continuing to breastfeed. And she may have concerns about possible adverse effects on her infant.
- Withhold the Drug Avoid the use of non-essential medications by enlisting the mother’s cooperation.
- Try Non-Drug Therapies Suggested therapies include: Analgesics: relaxation techniques, massage, warm baths. Cough, cold, allergy products: saline nose drops, cool mist, steam. Anti-asthmatics: avoid known allergens, particularly animals. Antacids: eat small meals, sleep with head propped, avoid head-bending activities, avoid gas-forming foods. Laxatives: eat high fiber cereal, prunes, or hot liquids with breakfast. Anti-diarrheals: discontinue solids 12-24 hours, increase fluids, eat toast / saltine crackers.
- Delay Therapy Mothers who are ready to wean the infant might be able to delay elective drug therapy or elective surgery.
- Choose Drugs That Pass Poorly Into Milk Within some drug classes there are large differences among class members in drug distribution into milk.
- Choose More Breastfeeding Compatible Dosage Forms Take lowest recommended dose, avoid extra-strength and long acting preparations, avoid combination ingredient products.
- Choose an Alternative Route of Administration Local application of drugs to the affected maternal site may minimize drug concentrations in milk and subsequently the infant’s dose.
- Avoid Nursing at Times of Peak Drug Concentrations in Milk Nursing before a dose is given may avoid the peak drug concentrations in milk that occur about 1-3 hours after an oral dose. 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.
- Temporarily Withhold Breastfeeding Depending on the estimated length of drug therapy, nursing can be temporarily withheld. Mothers may be able to pump a sufficient quantity of milk beforehand for use during therapy. The pharmacokinetics of the drug must be examined to determine when the resumption of breastfeeding is advisable.
- Discontinue Nursing A few drugs are too toxic to allow nursing and may be necessary for the mother’s health.
- Penicillinase-Resistant Penicillins: dicloxacillin (first choice), cloxacillin, methicillin, nafcillin
- Macrolides (if allergic to penicillins): azithromycin (first choice), clarithromycin
- Aminoglycosides: clindamycin, vancomycin (IV) (if incision and drainage necessary)
- Sulfamethoxazole/trimethoprim (oral): (if incision and drainage necessary)
- Linezolid (high rate of thromboplastinemia)
- Chloramphenicol (do not breastfeed if this drug is necessary)