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The Breastfeeding Factor: Using Drugs While Breastfeeding

A big part of the postpartum experience for most women is that of becoming a breastfeeding mother. Breastfeeding can simultaneously be one of the most challenging and rewarding parts of being a new mother. It both affects and is affected by your quality of life postpartum, and raises entirely new issues and concerns about how you take care of yourself. We will examine some of these issues, and offer advice on how to deal with some of the problems that can arise.

Using Drugs While Breastfeeding
After nine or more months of carefully avoiding so much as an aspirin, you may feel relieved at having your body back to yourself. Now, you think, if I have a headache or a cold I can take something for it. But then, as you offer your breast to your baby or pump milk for him, you are reminded that in many ways, the two of you are still sharing the same body. Virtually all foods, herbs, drugs, and hormones that enter your body have the potential to enter your breast milk and affect your baby.

Much conflicting information exists about the safety of using different medications and herbs during breastfeeding. Not long ago, new mothers were told that they must wean their babies in order to treat a health condition with drugs. Some mothers never even started to breastfeed because of medications they were told they needed during pregnancy or immediately postpartum. Today, mothers are advised to switch to formula temporarily and "pump and dump" their milk during that time if they want to continue to breastfeed after using a medication, but this is often impractical and leads to engorgement and breast infections in many women who are accustomed to nursing their babies on demand. If a baby is less than six weeks old, giving her an artificial nipple can cause her to reject the breast when it's time to go back.

Today, the typical conventional health-care model advises against the use of any and all herbs and drugs during nursing, choosing a "better safe than sorry" approach. While this approach makes good sense when the health of a baby hangs in the balance, scientific research into the effects of various drugs and herbs on the composition of mother's milk and the potential for harm to the baby now allows us to make more specific recommendations. The enormous benefits of breastfeeding over formula feeding make it worth considering even if drugs or herbs are being used to support the health of the mother.

Ideally, you will remain well enough during your breastfeeding months or years to avoid having to use prescription or over-the-counter drugs. Even if you don't, take heart: There are few drugs that you absolutely cannot take while breastfeeding. Most drugs do pass into your milk and into your baby's body, but in most instances the amount of drug that actually gets to your baby is around 1 percent of what you have taken. Most experts agree that, in almost every case, having breast milk with a minuscule amount of medication in it is better for a baby than switching to formula feeding. The general cautiousness toward drugs and nursing has much to do with the litigious age we live in; physicians and drug companies don't want to be held responsible for any harm that could come to an infant due to drug exposure.

We are certainly not encouraging you to swallow a pill for every ill you experience. It is almost always better to try nutritional, herbal, and lifestyle adjustments to allow your body to heal itself before you introduce foreign chemical substances into your body and into your milk. This is especially true during the first six weeks of your baby's life, when the cells that line her intestines are loosely knit to allow large immune system factors from your milk into her bloodstream. During these early weeks, drugs that would otherwise not pass into baby's circulation can float through easily. If at all possible, avoid taking any medications until your baby has been in the world for six weeks. If you cannot do so, you may be able to work with your doctor to time your drug dosages so that your baby's exposure is minimized.

Factors Affecting Drug Safety
What makes one drug safer than another for a breastfeeding pair? Several different factors come into play here. Among them are characteristics of the drug, such as the drug's half-life, its protein-binding capacity, its lipid solubility, and its oral bioavailability.

A drug's half-life is the measure of how long the drug stays in your system. Different drugs are cleared from your body at different rates. The longer a drug lingers in your circulation before being processed by your liver and completely eliminated, the greater your baby's exposure will be through your milk. A drug with a shorter half-life is better for a nursing mother than one with a longer half-life. A drug with a longer half-life will actually build up in a baby's bloodstream over time. If a drug has a short half-life, you can schedule your dosages so that levels of the drug fall significantly in your body before your baby feeds again.

Protein-binding capacity is the degree to which the active ingredient in the drug joins with proteins in the body on a molecular level. A drug with a high protein-binding capacity – one that binds well with proteins in the mother's body – is safer, because only non-protein-bound drugs can pass into milk.

Lipid solubility is just what it sounds like: the ease with which a drug is absorbed into fats in the body. A drug that is more lipid-soluble is better absorbed into fats, so more of it can pass into a mother's milk.

A drug's oral bioavailability is its potential to be absorbed through the walls of the baby's gastrointestinal tract. This also is an important factor in the safety of a medication. Drugs with low oral bioavailability cannot pass through the intestinal walls into the baby's bloodstream, and just pass right out into the baby's diaper.

Occasional use of medications, when you really need them, should not stop you from breastfeeding your baby. If you have a chronic disease, such as rheumatoid arthritis, Graves' disease (an autoimmune disease that affects the thyroid), or epilepsy, and you have no choice but to use medications every day, you will need to work closely with your physician and your baby's pediatrician, but you should still be able to breastfeed for at least a few weeks. Even a few weeks' worth of mother's milk is better than none.

Drugs to Avoid
There are some drugs that should never be taken by nursing mothers. For example, absolutely avoid radioactive compounds while breastfeeding. Radioactive compounds are used for diagnostic testing and some treatments for serious conditions, such as Graves' disease. If you are being tested for a thyroid hormone imbalance, you may be told you need to take a test that uses radioactive iodine. The radioactive iodine can accumulate in your baby's thyroid and cause permanent damage. Tell your physician that you would prefer to skip the thyroid scan. If the test must be done, it can be performed with technetium – a radioactive compound that clears from the body within thirty hours. You can formula feed and pump and dump your breast milk for that period.

If you are tempted to indulge in marijuana while you are nursing, please don't. It will decrease your production of prolactin, which will in turn diminish your milk supply and your maternal urges. Alcohol, however, is fine – in moderation. Limit your alcohol intake to a single glass of wine or beer a day. Caffeine should not hurt your baby either, in small amounts, but if it seems to make your baby jittery, you may want to avoid it while you are nursing.

All antihistamine drugs – both prescription and over-the-counter – should be avoided during pregnancy and while nursing. Most pass readily into breast milk and show up in high concentrations in the baby's bloodstream. Avoid the following allergy-type medications (the following include both generic and popular brand names):

• Astemizole (Hismanal).
• Azatadine (Optimine, Trinalin).
• Azelastine (Astelin).
• Brompheniramine (in Allerhist, Dimetane, and others).
• Cetirizine (Zyrtec).
• Chlorpheniramine (in Chlor-Trimeton and others).
• Clemastine (Tavist).
• Cyproheptdine (Periactin).
• Dexchlorpheniramine (Mylaramine, Polaramine).
• Diphenhydramine (in Allerdryl, Benadryl, Dramamine, Dytuss, and many other over-the-counter cold and allergy products).
• Fexofenadine (Allegra).
• Loratidine (Claritin).
• Methdilazine (Tacaryl).
• Phenindamine (Nolahist).
• Promethazine (Phenergan).
• Pyrilamine.
• Trimeprazine (Temaril).
• Tripelennamine (PBZ).

Be careful to read labels of any over-the-counter medicine you choose to take; there may be an antihistamine hidden away in there – even if the medication isn't labeled as an antihistamine. Fortunately, having to forgo antihistamines rarely involves anything more than some sneezy, itchy discomfort for mom, and these discomforts usually diminish or disappear with the right nutrient and diet prescription.

Other medications and types of medications that don't mix with nursing include the following:

• Amphetamines, stimulants that are prescribed to treat attention deficit hyperactivity disorder, narcolepsy, and other conditions.

• Antithyroid drugs, used to control Graves' disease (hyperthyroidism).

• Aspirin and other salicylates. These may cause Reye's syndrome, a severe illness, if an infant with any kind of viral infection is exposed to it. Ask your pharmacist if you aren't sure whether any over-the-counter or prescription drug contains salicylates.

• Atropine, which is used to dilate the pupils during eye examinations, and to treat certain eye disorders. It is also an ingredient in a medication sometimes prescribed to relieve the discomfort of urinary tract infection.

• Bromides (for example, Bromo-Seltzer).

• Cancer chemotherapy drugs.

• Cathartic drugs, which are drugs that cause diarrhea, and are sometimes used to evacuate the colon for diagnostic testing.

• Diet drugs.

• Ergot and related compounds, which can be used to treat a variety of disorders, including migraine and cluster headaches and menopausal discomforts such as hot flashes and excessive sweating.

• Iodides.

• Mercury-based drugs.

• Metronidazole (Flagyl, Metric, Protostat), an antifungal.

• Oral anticoagulants (blood-thinners).

• Tetracycline, an antibiotic also sold under the brand name Achromycin.

Most topical medications (those applied to the skin) and inhaled medications pass into the milk in even smaller quantities than oral ones do. If you have problems with allergies, asthma, or eczema – the usual reasons for long-term use of inhaled or topical medications – we hope that you will be able to stop using these drugs once you are using our postpartum program. Eliminating food allergens and improving digestive health have cleared up these problems for many of our patients. While using the medications isn't the worst thing in the world, you are better off not needing them. Consider that inhaled steroids, used for years at a time, cause bones to thin and increase the risk of developing osteoporosis later in life and also increase the risk of developing glaucoma. Quick-acting bronchodilating asthma inhalers may relieve attacks in the short term, but, according to the U.S. Centers for Disease Control and Prevention (CDC), if used too often, especially over long periods of time, can lead to worsening of the disease and even increase your risk of dying of asthma.

Drugs that May Be Unsafe
It is common sense to avoid taking several medications at once while you are breastfeeding. If you use more than one medication at a time and your baby develops symptoms that you think might be related to the drugs, you will not be able to tell which drug is affecting her. Once you combine more than two drugs, the side effects can be unpredictable and may include problems not noted on a patient information insert. This applies to both pharmaceuticals and herbs, which can be as potent as drugs. Take any new drug or herb alone for the first few days to be certain that it isn't causing problems. Stick to the lowest possible effective dose and avoid extra-strength or long-acting medications. If possible, take medications after nursing or before your baby's longest period of sleep, so that your body has time to process the drug before the next feeding.

We have already discussed some of the possible dangers of selective serotonin reuptake inhibitors (SSRIs) such as Paxil, Prozac, and Zoloft for nursing mothers. They may be linked to colic, and despite the fact that some are eliminated from the body more rapidly than others, they are all removed from the circulation relatively slowly. Because of the chemical composition of drugs that affect the central nervous system – including SSRIs, other antidepressants, and antianxiety drugs – they enter the milk in higher concentrations than other types of drugs. No research exists on the long-term nervous-system effects of these medications on babies exposed to them through their mothers' milk. Some medical organizations maintain that it is all right for nursing mothers to use SSRI antidepressants, and this approach is becoming an increasingly popular one for treating postpartum depression. We disagree. We feel that it is terribly premature and careless to widely prescribe these drugs at this time. However, there are exceptions. If you and your doctor perceive that you are in immediate and serious trouble and need quick short-term pharmaceutical help getting back on your feet, you don't necessarily have to stop breastfeeding. The benefits of nursing to your baby and to you probably outweigh the risks of exposing your baby to SSRIs for a few weeks. If you must take SSRIs, carefully watch your baby for any signs of increased sleepiness and consider stopping if your baby becomes so somnolent that you have to wake her up to nurse.

We advise against the use of low-dose minor tranquilizers, such as alprazolam (Xanax), in most cases. Very little is known about the effects they can have on a baby's developing nervous system, and they are addictive. There are many safe natural alternatives to these drugs that can help you relax during the day and sleep at night. Calcium and magnesium, taken at bedtime, can help relax your body into sleep. Mild to moderate exercise, meditation, yoga, and deep breathing are just as effective as minor tranquilizers. Herbs such as chamomile, passionflower, and valerian are safe natural relaxants that are safe for your baby.

Women who suffer from severe psychological disorders, such as suicidal depression, obsessive-compulsive disorder (OCD), or bipolar mood disorder (manic depression), may experience a worsening of their symptoms in the postpartum period. Such women may need medication. While research indicates that the drugs used for these disorders can be used during breastfeeding, there is no sure guarantee that they are completely safe. If you are extremely depressed, bipolar, or obsessive-compulsive, consult with your doctor and get a few other opinions before you give up on nursing your child. We also recommend that you read Dr. Andrew L. Stoll's book, The Omega-3 Connection (Simon & Schuster, 2002). Dr. Stoll has done extensive research on the use of omega-3 fats for the relief of bipolar disorder. Trying his plan is a no-risk, all-gain proposition that will actually benefit a breastfeeding baby.

Commonly used over-the-counter cough and cold medicines, decongestants, indigestion and diarrhea remedies, laxatives, and nonaspirin pain medications may not pose a significant danger to your nursing infant, but you probably don't really need to use them, either. In our culture, over-the-counter medications are considered to be utterly benign, but the truth is that every one of them has a long list of potential side effects, and they can be dangerous if several are taken in the wrong combination. Drugs are synthetic molecules not found in nature, and are usually harder on your detoxification systems than natural substances are. You should not be surprised if any of these drugs significantly diminishes your milk supply, either.

In most cases, you are better off finding a natural remedy for most of these complaints. Besides, such drugs provide only short-term treatment of symptoms. They do nothing to address the root issue. If you are generally healthy and well-nourished, you will not need any of these drugs.

If you do need over-the-counter temporary relief, stick with drugs that are used for babies as well as for adults. Check the shelf for baby versions of the drug you would like to use. Acetaminophen (in Tylenol and many other over-the-counter products) is your best bet for pain relief, although it is hard on the liver, so think twice – or even three times – before using it for yourself or your baby. Herbs and nutrients are better medicine than over-the-counter drugs for colds and most digestive complaints.

What if you are struck with an illness that requires antibiotic treatment? Monitor your baby carefully if you must use antibiotics. They may affect your baby's digestive function, causing diarrhea, constipation, or even colitis (a painful inflammation of the colon). If you or baby needs to take antibiotics, you can help to support baby's digestive health by giving him baby acidophilus powder. You can mix this into a bottle of expressed breastmilk or dab some onto your nipple before baby starts a nursing session. If you do need an antibiotic, your doctor will probably recommend an older drug, such as penicillin. Some women experience a decrease in milk supply with this medication.

Other drugs that are not completely off-limits during breastfeeding, but that require close observation of effects on baby's health, include the following:

• Barbiturates, a class of tranquilizer.
• Chlorpromazine (Thorazine), which is used to treat certain psychiatric disorders.
• Corticosteroids, such as prednisone (Deltasone), which are used for inflammatory conditions.
• Diuretics (water pills).
• Nalidixic acid (NegGram), an antibiotic sometimes used to treat urinary tract infections.
• Phenytoin (Dilantin), an antiseizure medication.
• Reserpine, which is used to lower blood pressure.

If you find yourself needing to take medication and are faced with admonitions from your doctor to wean your baby as a result, call your local La Leche League leader. This organization keeps up-to-date drug information that will help you to make the right choice for you and your baby. It is possible that you may come to the conclusion that nursing simply isn't possible for you. It's true that some women simply cannot breastfeed for valid medical reasons. It is your decision, after all, and only you can make it. You can still have a wonderful, nurturing relationship with your baby – it just may take a bit more effort on your part. Fortunately, too, formulas are getting better all the time. American formula manufacturers are beginning to put the omega-3 fat docosahexaenoic acid (DHA) into their products (years after European companies mandated its addition), and finding a formula with DHA in it is easier than it has ever been. For excellent information on bottle-feeding, we recommend the books on baby care and breastfeeding by pediatrician William Sears, M.D.

Even if you decide to bottle-feed, try to nurse your baby – or pump your milk and feed it to your infant by bottle, if you'd rather – for at least the first six weeks. This gives your baby the benefit of your immune factors, which can be indispensable in keeping him healthy during the early years of his life.