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DRUGS AND NURSING

A typical summary comment to be found about drugs and breastfeeding is: "Most medications are safe to take during breastfeeding, but there are a few that can be dangerous for the baby." Examples of commonly consumed substances that can pass through the milk are alcohol and caffeine. These can affect the nervous system of the infant (in the same manner as it can affect adults, with caffeine causing stimulation and alcohol causing sedation), so consumption of beverages containing these substances should be limited (but need not be completely avoided). Food substances that can produce allergic reactions may also affect the infant, potentially causing a rash or other histamine-type response. For drugs, there are lists of substances that are currently considered safe and one or more other lists of substances that are potentially harmful (see Appendix 1). The drugs listed as safe include: the common pain-relievers and anti-inflammatories acetaminophen and ibuprofen; many antibiotics; most antiepileptics; most antihistamines; most antihypertensives; and miscellaneous drugs with specific mention of codeine, decongestants, insulin, quinine, and thyroid medications.

Drugs that are of concern include: 

• any radioactive substances used for diagnostic or therapeutic purposes; 
• chemotherapy drugs for cancer; 
• ergotamine (a powerful alkaloid used for migraines); 
• lithium (for manic-depressive syndrome); 
• methotrexate (a powerful anti-inflammatory used for arthritis); 
• cyclosporine (a powerful immune suppressant used for autoimmune diseases); and 
• some drugs that strongly affect brain functions such as antianxiety drugs, antidepressant drugs, and antipsychotic drugs.

Clearly, the list of drugs of concern involves substances that are not similar to those found in commonly prescribed herbs. Rather, these are powerful agents that have significant effects on the nervous system or immune system, mainly suppressive actions.

Although there is little data from human studies on the use of drugs during breastfeeding, it has been shown that small amounts of most of the tested drugs reach the breastfed infant. However, the AAP has found that most of the drugs are acceptable for infant exposure at those levels, including the powerful alkaloid codeine and nervous system inhibiting antihypertensives and antiepileptics. 

As an example of a careful evaluation for a drug of concern, citalopram (an antidepressant) was given to a mother at 40 milligrams per day. The concentration of the drug in the breast milk was found to reach about 0.2 micrograms/ml (a microgram is one-thousandth of a milligram). A feeding of 6-7 fluid ounces (about 200 ml) provides the infant with 0.04 milligram of the drug, or about 1/1000 of the mother's daily drug dose in one feeding. The infant's blood serum was tested and found to contain about 0.013 micrograms/ml of the drug as a result of regular feeding; this compares with the maternal serum drug level of about 0.10 micrograms/ml, so that the infant's blood serum drug concentration was 1/8 that of its mother's serum drug concentration. This drug level in the infant was associated with "uneasy sleep," a condition that was then alleviated by reducing the infant's exposure to the drug. 

HERBS AND NURSING

Based on the potential for some drugs to have an effect on nursing infants, certain herbs that might have a strong effect should be used minimally or avoided. In particular, one should be cautious about using high doses of herbs that contain alkaloids, particularly those that affect the nervous system. Examples of Chinese herbs that would fit this category include coptis and phellodendron (berberine alkaloids), sophora root (contains oxymatrine), ma-huang (contains ephedrine), and evodia (contains rutecarpine). One should be cautious also about herbs that have a potent hormonal effect, such as fennel and anise, at least if they are used in large amounts over an extended period of time. Such herbs are most often used in small quantities as digestive aids or tonics, which is not of concern; they are sometimes used in large amounts to stimulate milk production over a period of several months (licorice has been listed as an herb to avoid for the same reasons). Herbs that contain pyrolizidine alkaloids, which can accumulate in the liver if taken daily, are also to be avoided (e.g., comfrey and coltsfoot), as are strong purgatives (e.g., aloe, senna, rhubarb root) that might cause colic or diarrhea in the infant Powerful immunosupressive herbs, such as tripterygium, are not used by Western practitioners. A list of herbs that have appeared in the literature as being of concern in relation to nursing appear in Appendix 2. 

STEPS TO TAKE

Mothers can watch for possible infant reactions to drugs, herbs, foods, and beverages. Although reactions are rare overall, the most common reactions are related to nervous system effects (e.g., irritability, insomnia, somnolence), digestive system reactions (e.g., colic, diarrhea), or allergic skin reactions (e.g., rash). Since all of these possible reactions are also consistent with normal infant experiences, it is not always possible to make a direct correlation between drug (or herb) ingestion and infant responses.

The level of drug or herb ingredients increase in the milk as the blood concentrations rise, but also leave the unexpressed breast milk as the mother's blood concentrations of the drug decline. It is common for drug concentrations in the serum to peak about 45-90 minutes after ingestion and to peak in the breast milk about 15 minutes later. Therefore, in order to minimize infant exposure to maternal drugs via breastfeeding, it is recommended that women take the drugs immediately after breastfeeding so that the drug concentration peak is passed by the time the next feeding session begins. During early infancy, some babies may feed every hour or so, in which case, this advice is not relevant. Once the feeding frequency declines to an interval greater than 2 hours, this suggestion makes sense. 

Women who are taking drugs and breastfeeding are advised to use the lowest dose of the drug that can provide the desired results. In this way, infant exposure is kept at the lowest possible level without interfering with the maternal drug benefits. Many times, standard drug dosing is slightly higher than is essential because there is a range of acceptable dosage and one has to recommend a level that will be effective for most users. Some users can get by with less. The same consideration applies to herb dosing.

For those who wish to be especially careful, there are information sources that take a highly conservative viewpoint and recommend that certain herbs be avoided simply because not enough is known. Many times, if there is a potential for any kind of harm or reaction in an adult, it is assumed that the herb should be avoided by nursing mothers. As an example, in the journal U.S. Pharmacist, there was an article titled "Herbals and breastfeeding" (September, 2000), which suggests avoiding tang-kuei (because it can stimulate the nervous system and make the skin more sensitive to light), ginseng (because of estrogenic effects and platelet changes), eleuthero (because little is known), and ginkgo leaf (because it is known to be a platelet inhibitor). This article can be accessed through the U.S. Pharmacist web site ( http://www.uspharmacist.com). 

In sum, as with drugs, most herbs are acceptable for use during breastfeeding, but one should be cautious about herbs that contain alkaloids with strong nervous system effects or herbs that have strong hormonal effects. One can minimize infant exposure to herbs by consuming them around the time of breastfeeding and by using the lowest effective dosage.

APPENDIX 1: Lists of Drugs in Relation to Safety for Breast Feeding.

Table 1: Common medications that are said to be safe to use while breastfeeding. The safety of the following medications is established for short-term use only. Vitamins and minerals taken in the normal dosage range are also considered safe.

Table 2: Drugs that require careful monitoring by a physician when taken while breastfeeding. Whether these drugs and medications are safe to take while breastfeeding depends on many factors: the dosage, age of infant, duration of therapy, and timing of dosage and breastfeeding. Alcohol use is also to be monitored.

Table 3: Drugs that should not be used while breastfeeding. In addition to the drugs listed here, all illicit drugs, such as heroin, cocaine, marijuana, PCP, halucinogens, etc., must be avoided.

Herbs to Avoid While Nursing

Most of these are "Western herbs," but a few appear in Chinese medicine, including aloe, coltsfoot (tussilago), ephedra, garlic, licorice, and rhubarb. Some herbs are suggested to be avoided because they "dry up milk:" sage and parsley are examples. Garlic can flavor the milk and cause some infants to consume less than they normally would. In most cases, the concern is related to using large doses regularly rather than avoiding any exposure.