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Questions on Using Medications

Susan Buckley
West Hartford Connecticut, USA
From: LEAVEN, Vol. 35 No. 4 August-September 1999 pp. 89-90

We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time

Leaders often receive calls from mothers with questions about taking medications while breastfeeding. The circumstances prompting such calls can be disconcerting for everyone involved. The mother may feel ill. Her stress, compounded by family responsibilities, may push her beyond her ability to cope. The baby, sensing a change in the familiar routine, may seek reassurance by asking to nurse more frequently than usual. The family wants mother to get well quickly so life at home can return to normal. The doctor, perhaps unfamiliar with medications and breastfeeding, may suggest weaning while taking the prescribed drug.

Leaders who answer drug calls often feel anxiety, too. We want the breastfeeding relationship to continue but at the same time, we want to assure the health and safety of the baby and mother. It can be tempting to refer these calls to a more experienced Leader, yet "learning by doing" is the best way to gain experience helping a nursing mother with a question about a medication.

"What did your doctor say?" is a good first question to ask a mother, perhaps followed by, "Why do you think your doctor said that?" Sometimes a mother assumes her doctor knows she is nursing. Occasionally a mother will hesitate to tell her doctor that she is breastfeeding because she fears that the doctor will not be supportive of her choice. If she hasn't already done so, encourage the mother to tell her health care provider that she is breastfeeding.

A mother may prefer to bring her question to an LLL Leader where she knows she will find support. Keep in mind, however, that when a mother does not mention breastfeeding to her health care provider, she misses an opportunity to build a rapport as well as educate him or her about breastfeeding. A failed attempt to work out a satisfactory solution may lead a mother to realize that she must find a practitioner who is more suited to her needs. All doctors do not evaluate a drug's compatibility with breastfeeding in the same way so the mother may need to contact more than one doctor before she finds the support she seeks.

Some health care providers will prescribe a treatment without asking the mother how she feels about the recommendation. Leaders can provide a valuable service by encouraging the mother to request treatment options. We can then help the mother sort her options into risk/benefit categories. We can suggest that she talk to her doctor on a feeling level with phrases such as "I feel very uncomfortable about trying..." or by stating "Breastfeeding is very important to me." Offering a mother the skills and moral support she needs to converse with her medical practitioner is as vital as providing her with specifics about a given drug.

The most important point to remember is that Leaders cannot diagnose, prescribe or advise. We can certainly give the mother the information we have but we can not offer advice about a particular medication. It is much more appropriate to say, "How upset you must be feeling. Being sick and having decisions to make can't be easy. Let me read to you what it says here on page___ in this book called ___. I can't tell you whether or not to take this medication because I'm not qualified to prescribe, but if you would like, I can give you a reference to share with your health care provider so the two of you can talk about it."

Remember that the reference or citation is only a beginning. The mother needs the information interpreted and applied to her own situation by her physician. These tasks fall outside the scope of a Leader's responsibility and expertise.

Sometimes a mother has a difficult time making a decision about a medication, even though her health care provider, the baby's health care provider and our LLL-approved resources indicate that it is compatible with breastfeeding. We can dialogue with a mother to help her identify her concerns. it may be helpful to share the tried and true statement, "Many mothers have found..." along with an example. It can also be helpful to give the mother a better understanding of how a medication works in the body. Some seemingly benign medications easily pass into human milk while other more powerful medications may pass less readily or not at all. An Area Professional Liaison Leader can usually supply this type of information to Leaders who request it.

A mother who responds with "Yes, but..." may be overwhelmed with the responsibility of making a decision. She may be waiting for someone else to make it for her. As another mother, our heart certainly goes out to her. As a Leader, we cannot make a decision for her.

Several commonly held misconceptions concern the compatibility of a Mother's treatment with her desire to breastfeed her infant.

Misconception: Medications prescribed for pregnant women are also appropriate for breastfeeding women.

Whether or not a medication can be taken during pregnancy is not a means of determining if the drug is compatible with breastfeeding. Medications taken during pregnancy are potentially transferred directly to the bloodstream of the fetus through the mother's blood. Medications taken by the mother during lactation are potentially transferred to the baby via her milk and may be absorbed through the infant's digestive tract. Each medication, therefore, needs to be examined individually to determine how it is present in the mother and how it could affect the infant.

The baby's physical development is an area of concern. The vulnerability of different systems and organs varies during the pregnancy, so some medications are not used during certain trimesters. After a critical stage of development has passed, possible exposure to the mother's medication may be less of a concern. A premature infant might be more at risk than a full-term infant or older baby because the premature nursling lacks physical maturity. An older baby or toddler who receives solids or supplements receives less of a drug relative to his body size than does a baby who is exclusively breastfed.

During pregnancy, the fetus relies upon the mother's body to help excrete toxins. After birth the baby must excrete toxins on his own even though a newborn kidney and liver functions are not fully mature. For this reason some substances can build up in a newborn's body even though the effects are short-lived in the mother.

In short, while most medications do not require the mother to wean, one cannot look at the drug's use during pregnancy to determine compatibility with breastfeeding.

Misconception: Over-the-counter medications are safe to take while breastfeeding.

Over-the-counter medications (OTCs) should be looked at with the same consideration as prescribed medications. Are they necessary? Are there other treatments available? Do they cross into human milk? Will they have any effect on the quality or quantity of the mother's milk? What is the age and health of the nursing infant? Are there known side- effects? If so, what are they?

Because OTCs are available without consulting a doctor or pharmacist, some women believe that they are not "real" medications. When a mother chooses to use an OTC, it becomes her responsibility to check with her health care provider as well as other resources and watch the nursing baby for any possible effects. Most OTCs or the ingredients from which they are made are listed in the American Academy of Pediatrics "The Transfer of Drugs and Other Chemicals Into Human Milk" on pages 525-538 of the BREASTFEEDING ANSWER BOOK, 1997 edition. When necessary, Leaders can contact a Professional Liaison (PL) Leader for access to other appropriate references.

It is important for the mother to provide accurate information on the OTC she is considering using. Some products have similar names yet vary widely in dosage, strength and duration. There is a tendency for a mother to want to take the strongest and longest-lasting medication available. When a woman is breastfeeding, however, the smallest effective dose and the shorter-acting preparations are usually better choices. Remember that we, as Leaders, never recommend a medication or say it is safe.

Misconception: Herbal remedies are compatible with breastfeeding.

A mother may believe that a medication derived from herbs is natural and, therefore, safe. She might not even mention that she is taking an herbal remedy when asked if she is taking any medication. Herbal remedies are far from benign. Some can increase or decrease the milk supply; others can cause babies to be sleepy or show symptoms of colic. Most important, some are contraindicated when breastfeeding. Since herbs are not regulated in the same way that other drugs are, it is important for a mother to have a good resource person or trustworthy source to ascertain purity, strength, uses and contraindications. PL Leaders can help Leaders with specific herbal questions. (See also LEAVEN Jun/Jul 1998, pages 43-47.)

Misconception: A PL Leader will be able to provide a definitive answer to a drug 's compatibility.

While PL Leaders have access to the most recent and reliable information that is published on most medications, there are some medications about which safety during lactation is unknown. Especially for new drugs, information is frequently lacking or incomplete. Drugs are not routinely tested on breastfeeding women and their babies; most of the available information is based on case studies, individual instances when a woman and her doctor decided to use the medication and report the outcome. The more information a Leader can provide about the mother's and baby's health, the age and feeding patterns of the baby, the dose and the duration of the medication, the better able the PL Leader will be to provide helpful information to assist the mother to make her own decision.

In very few instances a prescribed medication is not compatible with breastfeeding, yet it is the best medication for the situation. A mother faced with the necessity of weaning is often relieved to find out that she may need to wean only temporarily. It can be quite comforting to learn that she can keep up her milk supply through hand-expression or pumping and that the Leader will be there to help her re-establish breastfeeding when the course of the medication is completed.

It is possible that weaning must be permanent, though this is quite rare. When this is the case, the mother needs to be reassured that she has given her baby the best possible nutrition for however long she has been nursing. She can be encouraged to remember that above all else, she is important to her baby. Her ability to be available to carry on her relationship with her baby supersedes her feeding method.

Although Leaders may still feel some anxiety when a mother calls asking about the compatibility of a medication with breastfeeding, it is helpful to relax and remember that LLL provides resources for answering such questions. PL Leaders are available to provide information and support to Leaders when medical questions arise. Remember, however, that the skills Leaders use in any helping situation-active listening, asking the mother to identify the problem, helping her sort through multiple concerns, discussing options and sharing information but not advice-are also the keys to helping a mother with a drug-related question.

Bibliography

Leader's Handbook. Schaumburg, Illinois: LLLI, 1998; 208-13.

Mohrbacher, N. and Stock, J. Breastfeeding Answer Book. Schaumburg, Illinois: LLLI, 1997; 500-13.

Publications for Parents

Mohrbacher, N. When a Nursing Mother Gets Sick. Schaumburg, Illinois: LLLI, 1996. Publication No. 21a.

THE WOMANLY ART OF BREASTFEEDING, 6th edition. Schaumburg, Illinois: LLLI, 1997; 312-14.

Publications for Leaders

Briggs, G., Freeman, R. and Yaffe, S. Drugs in Pregnancy and Lactation, 5th edition. Baltimore: Williams and Wilkins, 1998.

Hale, T. Medications and Mothers' Milk, 1998-99, 7th edition. Amarillo, Texas: Pharmasoft Medical Publishing, 1998. (See guidelines in the review of the 6th edition in LEAVEN, Feb/Mar 1998, page 13.)

Humphrey, S. Sage Advice on Herbs and Breastfeeding. LEAVEN Jun/JuI 1998; 43-47.

Lawrence, R. Breastfeeding.A Guide for the Medical Profession, 5th edition, St. Louis: Mosby, 1998; 351-93; 744-867.

Riordan, J. and Auerbach, K.G. Breastfeeding and Human Lactation, 2nd edition. Boston: Jones and Bartlett, 1998; 163-89; 190-219.

This article was adapted from three sources: "Answering the Drug-Related Call " by Jeanne Amaral-Silva of Billerica, Massachusetts, USA and published in LLL of Massachusetts/Rhode Island/Vermont's Yankee Wellspring, Winter 1999; "A Difficult Question About a Medication " by Sarah Chaikin of Brigantine, New Jersey, USA and published in LLL of New Jersey's Nursery Notes, Fall 1998; "Medical Misconceptions" by Sandee Luttkus of Westhope, North Dakota, USA and published in LLL of Minnesota/Dakotas' Northern LLLights, Winter 1998.

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