The Pharmaceutical Care of the Breastfeeding Mother

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The Pharmaceutical Care of the Breastfeeding
Mother

• NES 25th February 2007

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The Pharmaceutical Care ofBreastfeeding Mothers

• Wendy Jones
• Primary Care Pharmacist,
• Supplementary Prescriber
• Breastfeeding Network Supporter
• BfN Drugs in Breastmilk Helpline

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The aim of the pack

• To enable pharmacists to promote breastfeeding in
  their normal everyday working practice
• taking into account common breastfeeding problems
  
• the use of medicines for breastfeeding mothers
• encompassing multi-disciplinary team working
• using evidence based information to reduce
  conflicting advice

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Why do we need the training pack?

• Human milk is the most appropriate of all milks
  for the human neonate because of its nutritional
  and immunological advantages

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Advantages of breastmilk

• Sudden infant death
• Gastro-intestinal diseases
• Asthma and eczema
• Respiratory infections
• Wheeze
• Otitis media
• UTI
• Increased IQ
• Diabetes
• CHD

• Neo-natal enterocolitis
• MS
• Dental malocclusions
• Enhanced immunity
• Crohns disease
• maternal advantages
• Breast cancer in mother
• Ovarian cancer in mother
• Weight loss in mother

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NSF for Children, Young People and Maternity
Services Infant Feeding 10.3 (2005)

• There is clear evidence that breastfeeding
• has positive health benefits for both mother and
  baby in the short and longer term.
• has an important contribution to make towards
  meeting the national target to reduce infant
  mortality and health inequalities

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When not to breastfeed?

• A few metabolic diseases
• eg Galactosaemia, Maple syrup urine disease,
  Phenylketonuria, Lactose intolerance
• Mother being HIV positive - ?-
• Certain drugs - gold, iodides, ergot
  preparations, chemotherapy
• Mothers wishes - or influence of others????

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Why should pharmacists promote breastfeeding?

• Prevention of illness for child
• Prevention of illness for mother
• Governmental initiatives
• The health promotion role of pharmacists should
  be foremost amongst all activities
• It should not be replaced by commercial pressures

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Are mums happy with duration of breastfeeding?
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What can pharmacists do to help breastfeeding
mothers?

• Know that breastfeeding has positive health
  benefits
• Be alert for opportunities to discuss infant
  feeding non judgementally
• Signposting if mother mentions sore nipples,
  inadequate weight gain, frequent waking, hungry
  baby
• Be positive and encouraging

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What breastfeeding problems might you be asked
about?

• Sore nipples
• Mastitis
• Thrush
• Not enough milk
• Weight gain
• Weaning
• Conflicting information
• GP/Mum asking about safety of drugs

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Problems

• What not to sell
• nipple shields, shells, breast relievers
• Kamillosan type products
• Who to refer to
• local health visitor
• sure start groups
• voluntary groups
• National Support numbers

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WHO and DoH recommendations on introduction of
solids

• Breastfeed exclusively for 6 months
• Continue to breastfeed during introduction of
  solid foods
• Continued antibody and immunological protection
• What do commercial packet labels suggest as time
  to wean?
• Are pharmacists and staff in a good position to
  intervene when women begin weaning?

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How do GPs/Pharmacists know if a mother is
breastfeeding?

• Talk to patients and customers
• Train staff to ask about breastfeeding as part of
  2WHAM interventions
• Health displays
• Welcome breastfeeding
• Show your knowledge
• Use appropriate, up-to-date resources

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Advertising

• The RPSOGB MEP prohibits
• advertising
• special displays of free samples and discounting
• any other promotional activity to induce the sale
  of an infant formula
• Infant Formula and Follow-on Formula Regulations
• 1995.

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NSF 10.5

• Mothers who are taking medicines need particular
  advice about breastfeeding.
• Current sources available to healthcare
  professionals may lead to women being advised,
  unnecessarily, not to breastfeed, because of the
  medicines which they are taking.

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Why do drugs and breastfeeding not mix?

• Lack of readily available information?
• Lack of time to look?
• Lack of belief in importance of breastfeeding?
• Fear of litigation?
• Lack of promotion of breastfeeding by reps?

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What do prescribers think?

• I have a mum who needs treatment
• The BNF says the manufacturer advises against
  breastfeeding with this drug
• I havent got time to find out any more
  information
• I have 6 more patients and my clinic is already
  running 20 minutes late

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The Prescribers dilemma

• If I prescribe outside of license I have to take
  responsibility
• What if something goes wrong?
• Surely its safer to tell mum to stop
  breastfeeding?
• I believe breastfeeding is the best for mothers
  and babies but what do I do now?

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What do mothers think?

• I want my baby to be safe
• I want to feel better
• I want to carry on breastfeeding
• Why do the leaflets in the box say I cant
  breastfeed?
• Please explain in terms I can understand

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The mothers dilemma

• My GP says he will only prescribe if I stop
  breastfeeding,
• The pharmacist has queried whether I am
  breastfeeding and says it isnt advised with this
  drug
• How can I best protect my baby?
• Why can no-one give me a straight answer

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Adverse drug reactions in breastfed infantsless
than imagined

• Clinical Paed 200342325-340
• Medication shortens duration because of specific
  advice or subtle cues by HCP.
• 100 possible individual reports of adverse events
  
• none definite
• 53 possible
• 47 probable

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Adverse events

• 37 cases of AE in newborn
• 63 lt 1 month
• only 22 in babies gt 2 months
• Most involved CNS drugs - 3 deaths
• 1 previous near miss SID
• 1 overlaid in parents bed phenobarb
• 1 methadone with obvious neglect

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Theory of Drugs in Breastmilk

Milk-Plasma Ratio - the higher the M/P ratio, the
more drug is found in breastmilk Molecular Weight
the lower the molecular weight, the more easily
the drug passes into breastmilk Plasma Protein
binding - the more highly bound the drug the less
can pass into breastmilk Oral Bio-availability if
it isnt absorbed from the gut, baby wont absorb
any Use your professional knowledge - dont just
pass the buck or rely on the BNF/ABPI
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Examples

• Flu vaccine - poor bio availability
• Ibuprofen gt99 plasma protein bound
• Amoxycillin - licensed in children
• Levothyroxine - replacing natural levels
• NRT - safer than smoking
• Domperidone - stimulates milk supply as dopamine
  antagonist stimulates prolactin
• Warfarin - large molecular weight

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Example of how to decide on safety

• Sertraline (Lustral)
• half life 26-65 hours
• peak 7-8 hours
• MP ratio 0.89
• Plasma binding 98
• Maternal dose 25-150mg/day - infant levels
  undetectable in 7/11, maximum of 3ng/ml in
  others, no untoward effects

• Fluoxetine (Prozac)
• half life 2-3 days
• peak 1.5 - 12 hours
• MP ratio 0.286-0.67
• Plasma binding 94.5
• Theoretical infant dose 9.3-57 ug/kg/day
• Some adverse reports- depends on age of child.
  colic, crying has been reported in one case study

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Drugs to avoid in a breastfeeding mother

• Cabergoline and bromocriptine
• Loop diuretic and thiazide diuretic
• Pseudoephedrine
• Combined oral contraceptive pill
• Sedating antihistamines - long term use
• Sedatives - long term use
• Drugs of misuse ? - methadone is safe

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Drugs which breastfeeding mothers can take

• Alcohol - within reason
• Corticosteroids eg prednisolone lt40mg/day
• Codeine - beware of drowsiness
• Anthelmintics
• Progesterone only pill and EHC
• Antibiotics, anti-inflammatories, herbal
  remedies, cough and cold remedies, vitamins, PPIs
  and MOST other drugs

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Quick guidelines

• If a drug is licensed to be given directly to
  children levels passing through breastmilk are
  unlikely to cause harm
• Drugs with high levels of plasma protein binding
  and large molecular weight are unlikely to
  penetrate breastmilk in high levels
• Drugs with low milk plasma ratios are likely to
  be safer

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Stop breastfeeding and take this medicine?

• Advising a mother to stop breastfeeding to take
  medication should be the final resort having
  taken into account the risk of denying the baby
  the right to continued breastfeeding balanced
  against the need for any particular drug, given
  full, quantitative
• data

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Multi disciplinary team working

• Talk to other members of the primary and
  secondary care team
• Use evidence based information
• Signposting - works both ways!
• Dont dismiss the input of others
• Counselling skills - LISTEN
• Consider the problems of mums with contradictory
  information

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The Drugs in Breastmilk Helpline

• Who can access the helpline?
• When is it available?
• What sort of questions are asked?
• Who will I speak to?
• 08700 604233
• www.breastfeedingnetwork.org.uk

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Resources

• www.nes.scot.nhs.uk/pharmacy/breastfeeding/index.h
  tml
• www.ukmicentral.nhs.uk/drugpreg/qrg_p1.htm
• Hale T Medications and Mothers Milk Pharmasoft)
  available from UNICEF www.babyfriendly.org.uk/item
  s/resource_detail.asp?item228
• www.Breastfeedingnetwork.org.uk
• Local DI centres

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Good attachment - the key to success