Evaluating Infant Sensitivity to Medications
Of course, some infants are more sensitive than others to medications. Newborn and premature infants, those with poor liver or kidney functions, and those with specific pathologies, such as severe breathing difficulties, may be more sensitive. (Babies born to mothers who used SSRIs in pregnancy are actually more likely to be born with defects like lung problems, heart problems, or perhaps other problems listed here because of SSRI-induced preterm birth, and tragically, many infants will never survive a pregnancy if their mother is using SSRIs. Studies show twice the rate of miscarriage, and more preterm brths, stillbirths, and neonatal death with pregnancy exposure.) Infants subject to breathing difficulties should not be exposed to Valium-like drugs, beta-blocker high blood pressure medications, and sedating antihistamines without close monitoring. Neonates in the first month of life should not be exposed to sulfonamides or other drugs with high protein binding that might increase bilirubin levels. Ill or weakened infants should always be closely evaluated before a breastfeeding mother takes medication. But a big, healthy six month old can probably metabolize drugs as well as you can and is much less sensitive to the small amount of drugs present in your milk.

Ideal Drug Factors A nursing mother should choose drugs that have shorter half-lives. If possible, as noted above, she should not breastfeed when the drug peaks in her circulation. Although not contraindicated, she should be more cautious of medications with long half-lives. Certain drugs (Prozac and Demerol, for instance), when metabolized by the liver, produce active metabolites with incredibly long half-lives, which can build up over time in the infant and produce side effects. But even many medications with longer half-lives (phenobarbital, etc.) can be used safely, if the baby is observed closely. (As though observing a baby will prevent any ill effects from occurring - by the time you notice something is wrong, much damage has been done. It might even be too late - see below on comas caused by Prozac -The same argument is often used about how doctors need to observe and monitor patients on SSRIs. But that hasn't proven to show much benefit to patients at all.)

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Drugs That Directly Affect Milk Production
Quite apart from their ability to enter milk, some drugs have the potential to affect the production of breastmilk, either increasing or suppressing it. Early lactation is apparently highly sensitive to the level of circulating prolactin, the milk-producing hormone from the mother's pituitary. Drugs that stimulate prolactin early on, such as metoclopramide (Reglan), domperidone, and other dopamine antagonists, (these dopamine affecting drugs are actually encouraged for breastfeeding mothers on a short term basis to stimulate milk production) may actually increase the rate of breastmilk production. Some drugs, such as birth control pills with estrogens, are well known for suppressing lactation if administered early postpartum. Stay away from estrogen-containing birth control pills until at least six weeks postpartum, and then watch your milk supply closely. If it is suppressed, stop the birth control pills.

Specific Drugs

Analgesics
The analgesics most commonly used by breastfeeding women are acetaminophen and ibuprofen. Both are ideal, because the levels they attain in breastmilk are largely subclinical, and both are cleared for pediatric use. (Whereas SSRIs are not approved for use in infants, but he recommends medication anyway.) Levels of ibuprofen transferred into milk following 400 mg maternal doses are generally less than 1 mg per liter of milk. Long-acting nonsteroidals (NSAIDS) such as naproxen (Aleve, Naprosyn) should be avoided, although they are not absolutely contraindicated if used only briefly, say for a few days.

Codeine and hydrocodone are often used for mild postpartum pain. The amount of codeine transferred into milk is marginal, although sedation and apnea have been reported with frequent, higher doses. If doses of codeine and hydrocodone are kept low and administered after breastfeeding, few cases of neonatal sedation have been reported. In many respects, morphine continues to be an ideal strong opiate for breastfeeding mothers in moderate to severe pain. Due to poor oral absorption (26 percent), morphine produces only minimal sedation in breastfed infants. Frequent and repeated exposure, however, can lead to accumulation in the infant and should be avoided.

Antihistamines/Decongestants
Breastfeeding women often use antihistamines, sometimes in combination with decongestants, for cold symptoms or seasonal allergies. The older families of antihistamines—diphenhydramine (Benadryl), chlorpheniramine(Chlor-Trimeton), and brompheniramine(Dimetapp)—may produce sedation in infants but not always. Because sedation in newborns may predispose them to breathing difficulties, nonsedating antihistamines, such as cetirizine (Zyrtec) and loratadine (Claritin), are preferred.

As for the decongestants present in many cold remedies, be cautious. (Yes, be cautious. He doesn't mention that you should not use many cold medicines while taking an antidepressant. If the drug you're taking is just another serotonin reuptake inhibitor in disguise, or some other serotonin increaser, then you risk serotonin syndrome. Look for the ingredient dextromethorphan in cold meds.) New data from my laboratories suggest that pseudoephedrine may significantly suppress milk production, and I no longer recommend it for breastfeeding mothers. Many antihistamine/decongestant preparations are not very effective for colds and flu symptoms anyway and may not prove beneficial enough to risk side effects in the infant. To treat seasonal allergies (allergic rhinitis), intranasal steroids are ideal for breastfeeding mothers, as their systemic absorption is minimal.

Antibiotics
Virtually all antibiotics are safe for breastfeeding mothers to use, with the possible exception of the "Cipro" family and the sulfonamides early postpartum. Penicillins, erythromycins, and cephalosporins enter milk only in trace levels and rarely produce allergies or changes in GI flora in the infant. Rashes, thrush, and diarrhea are the only likely consequences of exposure to these families of drugs, and they are rare. Although there are exceptions to this rule, most fluoroquinolone antibiotics (Cipro) should be avoided, but some of them (Ofloxacin) are not definitely contraindicated.

Sulfonamide drugs are seldom used during the last trimester of pregnancy and the first month postpartum, due to the potential for increasing free bilirubin levels in the infant. After the first month of life, sulfonamides are quite safe in most infants who do not have elevated bilirubin levels.

Metronidazole (Flagyl), which is commonly used for trichomoniasis, giardiasis, and anaerobic infections, is controversial due to rat studies that suggested it was mutagenic. Today Metronidazole is not considered mutagenic in humans, and it is commonly used in pediatrics, particularly with premature infants. The tetracyclines can be briefly used by breastfeeding women. While many of the older tetracyclines were poorly absorbed, especially in milk, this is not necessarily true for newer ones like doxycycline or minocycline. However, doxycycline is still preferred in pediatric patients because the risk of dental staining is lower than with other tetracycline products. If the treatments are kept brief (no more than several weeks), the amount transferred and the effect on skeletal growth and dental discoloration will be minimal.6

Antihypertensives
Antihypertensives include the beta receptors, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, and several others. Many of these agents have been thoroughly studied in breastfeeding mothers.7-10 Certain beta blockers, such as acebutolol and atenolol, have been associated with a higher incidence of hypotension and hypoglycemia in breastfed infants and should be avoided.11,12 Propranolol and metoprolol are probably preferred, due to their lower levels in milk. But all infants exposed to the beta blocker family should be closely monitored for apnea, weakness, and low blood sugar. Several of the calcium channel blockers, including verapamil, bepridil, nifedipine, and nimodipine, produce exceedingly low levels in milk and are therefore preferred.

ACE inhibitors are more problematic. Due to extreme potency in neonates, they are universally contraindicated in the last trimester of pregnancy. Although the reported levels in milk are low, the use of these agents in the early neonatal period is probably too risky. Captopril or enalapril can probably be used by breastfeeding mothers several weeks to one month postpartum, with due caution.13,14

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Antidepressants
With the introduction of newer antidepressants, the number of patients receiving treatment for depression has risen significantly. Societal perception of antidepressant therapy has likewise changed to a point where it is quite acceptable to seek and receive treatment for depression. About 15 to 20 percent of postpartum women experience clinical depression, although about 80 percent will experience postpartum blues. Recent evidence that depression may interfere with optimal parenting, and that infants of depressed women may suffer from developmental problems, has increased the urgency of treating this syndrome in breastfeeding women.15, 16 (And by treating, he means - drugging! With drugs that are ineffective...)

The tricyclic family, which includes amitriptyline (Elavil) and numerous others, is the oldest family of antidepressants. According to more than 40 published articles about various members of this family, the amount transferred into human milk is for the most part quite low. However, tricyclics are replete with untoward side effects in the mother, including constipation, sedation, dry mouth, and blurred vision. They are also horribly toxic in overdose, and most clinicians are reluctant to prescribe them for patients who are already depressed and at risk for suicide. Thus far, however, neurobehavioral development of breastfed infants exposed to tricyclic antidepressants in breastmilk appears normal.17

The most popular family of antidepressants is the serotonin reuptake inhibitors (SSRIs), including fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and others. Prozac, the best-selling of this group, is presently the subject of some concern. It is metabolized to an active, long half-life metabolite called norfluoxetine, which has a long 360-hour half-life. This metabolite has been found in high levels in the plasma of several breastfed infants and has been correlated with a number of untoward effects such as colic, lengthy crying (the last thing a mom with PPD or Prozac-induced depression needs is a baby who won't stop crying), vomiting (to make the baby even better fed, more full and satisfied, and healthier than he would have been on straight breast milk from a depressed, un-medicated mother who didn't have to spend her whole life breastfeeding because her baby keeps throwing up and is never satisfied or full), decreased sleep (and we know that a depressed mother needs to stay up trying to get a baby to go to sleep, and that a baby who can't sleep will turn out so much healthier than the well-rested, non-resented baby of a non-medicated mom), watery stools, (more diapers to change, more clothes splattered and stained that need to be washed by the depressed mother) and coma. Because Prozac now has FDA clearance for use in pregnancy, infants of mothers taking it will be born with high levels of the drug in their plasma (And would infants whose mothers took it before it had FDA clearance have low levels of the drug? - OK now that's just me being sarcastic. But clearly Hale needs to do some better editing. LOL.) In these cases, it is possible that the small amount transferred in breastmilk will continue to build to toxic levels. ("FDA cleared" toxic levels!) Fluoxetine should no longer be viewed as a preferred product for breastfeeding mothers with newborns, whose infants may not be able to eliminate the drug well. In older infants it is probably much safer. (Yes, because coma in an older infant is much safer than coma in a younger one.)

The use of Zoloft, on the other hand, has been reported in more than 30 breastfed infants, and appears to transfer poorly to the infant and with no reported effects.18,19 Thus far plasma levels in most infants have been close to or below the limit of detection, (How can something be below a limit of detection? If you can't detect it, then it isn't present at all, so just say it was not detected.) with no reports of untoward effects in the infant. At this time, Zoloft is probably the SSRI of choice for nursing mothers (I should say so. Based on your totally convincing evidence. After all you did say you studied at least 30 babies. And with no effects on the babies. But you did detect the Zoloft in the blood of some of those 30 babies. And based on those 30, it's likely that Zoloft IS also detectable in other babies that you haven't studied. So a drug that "has no effects" - according to your extensive research- is probably the best one. Unless, of course, you are trying to get babies to act weird so that a doctor can diagnose THEM with some sort of disorder and write a prescription for meds for infant or childhood depression.) Several reports of Paxil use suggest that its levels in breastmilk are exceedingly low, and the amount transferred to the infant would be minimal. (Yay, minimal amounts of poison being given to my baby! Let's just put up a bumper sticker on the cafepress store that says - "Hale MD loves (with a heart) tainted PhRMA milk." I wonder, would HE drink a bottle of this stuff pumped from one of his patients on Zoloft, Paxil, or Prozac? What about 8 bottles of it per day?)

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Contraceptives
As noted above, estrogen-containing oral contraceptives may dramatically suppress lactation and therefore infant growth. The estrogen component, if used early postpartum, is well known to significantly suppress lactation in some women, leading to early supplementation and ultimately suppression of breastfeeding. The progestins in general do not suppress lactation in most women; medroxyprogesterone (Depo-Provera) has been used by many women with success, although there have been some reports of milk suppression. Because of this risk, oral progestin-only mini pills are the preferred oral contraceptives for breastfeeding mothers.

Corticosteroids
Steroid use is categorized according to the method of administration: oral, inhaled, intranasal, or topical. The transfer of oral prednisone and prednisolone into human milk is generally quite low and is dependent on the maternal dose. With extremely high doses of 120 mg/day, breastmilk levels vary from 54 to 627 micrograms/liter of milk and only provide approximately 47 micrograms/day to the infant, an insignificant amount. The transfer of methylprednisolone into milk is equally minimal. In general, the systemic absorption of topical, inhaled, and intranasal steroids is so low that these agents are unlikely to pose problems for a breastfed infant. Although the topical application of low-potency steroids directly to the nipple can be overdone, minimal and infrequent applications cause no problems. But note that only low-potency steroid creams/ointments, such as hydrocortisone or triamcinolone, should be used on the nipple.

Finally, steroids have potent and long-lasting aftereffects in infants when misused, and the long-term exposure of breastfed infants to maternal steroids should be approached with a risk-versus -benefit assessment that includes length and duration of exposure, route of administration, and the overall maternal dose. The infant should be followed closely for appropriate growth and development parameters.

Herbal Medications
Herbal drugs are frequently viewed as safer alternatives to conventional medications, but this is not necessarily the case, particularly for pregnant and breastfeeding mothers. Most studies of herbal products are poorly done, and their reported efficacy is often exaggerated. (But studies done on pharmaceuticals are always top-notch, and the efficacy of drugs made by PhRMA is never exaggerated?) Herbals that contain anticholinergics, or more importantly the pyrrolizidine alkaloids, can be extremely dangerous and should be avoided. These include chapparal, jin bu huan, gerymander, comfrey tea, mistletoe, skullcap, margosa oil, mate tea, pennyroyal oil, blue cohosh, and many others.

Other herbals, however, have excellent safety profiles. There is little evidence of acute toxicity from fenugreek, for instance, commonly believed to stimulate milk production (although data documenting its milk-stimulating effect are sketchy at best). A significant body of literature exists suggesting that St. John's wort is relatively efficacious as an antidepressant and devoid of significant side effects. We do not know, however, if it transfers into human milk, or if it is safe in breastfeeding mothers. At this time, using herbal products while breastfeeding is risky at best, primarily due to our limited experience and knowledge, and should in general be avoided altogether. (St. Johns Wort has been claimed to increase serotonin just like SSRIs, so unless you see evidence otherwise I would say, definitely avoid it. However, notice how he says that herbals should be avoided altogether. Why hasn't he studied these products instead of spending his career only studying pharmaceutical, synthetic drugs? Could it be that he has an incentive somehow to promote medical solutions? Could someone be sponsoring the "safety" studies for breastfeeding moms in order to get more babies exposed to them and make them sicker?)

Vaccines
There are occasions when breastfeeding mothers may require vaccination, as in the case of women who are rubella negative, those who need influenza vaccines, (no thanks!) or those planning to visit foreign countries (because foreign countries are full of sick people whereas here in America we're all so healthy and non-contagious). While it is possible that even weakened (attenuated) viruses, such as those used in vaccines, can transfer to the infant, thus far no serious untoward effects have been reported. The Centers for Disease Control and the American Academy of Pediatrics clearly state that all vaccines can be safely used in breastfeeding mothers. (Perhaps the AAP needs to watch its language. Perhaps they should state that all vaccines (in their opinion) are considered safe to a breastfeeding infant exposed to components of a vaccine in mother's milk. However considering all the ingredients in vaccines - remember, there are other ingredients besides attenuated viruses - I want to know why Hale hasn't studied their effect on babies. Perhaps that would not be noticeable compared to the high exposure the babies already get from shots at "well" visits.)

Alcohol
We know that small amounts of alcohol do transfer into human milk. The amount an infant receives following several drinks is not enough to harm most normal infants. Mothers should, however, limit their intake to no more than two small drinks. Some infants may not like the taste imparted to milk and may refuse breastfeeding, but this passes quickly. Women who drink excessively should wait until they are sober to begin breastfeeding. Chronic or binge drinking should, of course, be discouraged, as higher levels of alcohol are believed to significantly suppress milk production. (But what about the antidepressants? He can encourage use of drugs similar in action to cocaine and LSD, but he discourages alcohol? I am not saying I endorse binge drinking while breastfeeding, I am pointing out the irony.)

Pumping and Dumping
It would be extremely rare that a mother would need to pump and discard her milk, as most drugs pass into and then out of milk as the mother's blood levels drop. However, there are some occasions when complete cessation or short-term pumping and discarding would be advisable. This is particularly important with various radioactive drugs, certain anticancer drugs, drugs of abuse, (which are similar to the antidepressants he so enthusiastically endorses!) and various antibiotics (see Table 2).

In the last decade it has become increasingly evident that breastfed babies are the healthiest of babies. (I've never heard of formula causing a baby to go into a coma. I am not endorsing formula, I am pointing out that Hale endorses a drug for breastfeeding moms that can seriously harm a baby, while pretending that drug will not harm the baby and that breast milk will magically protect the baby from the effects of drug exposure. Just because mother's milk so incredibly perfect in its untainted state doesn't mean that babies are immune to drugs if they are breastfed.) Every pediatrician knows that breastfeeding is like an additional immunization, (There he goes with the illogical garbledeegook again. No, breastfeeding is not like an "additional immunization," vaccines are additional attempts to immunize. Breastfeeding is not additional anything. It's feeding your baby the way that moms have for millenia. It's passing the immunities to the diseases that you've come in contact with, through your own body, to your baby. Perhaps doctors should stop and think about this fact of human biology before they go calling breastfeeding "additional immunizations" and then trying to stick your baby with a PhRMA needle. I think I'll stick with the good old fashioned immunities that God intended my baby to have, thank you very much.) one that covers a wide array of bacteria, viruses, and other infections. Regarding the use of medications by breastfeeding mothers, many healthcare professionals worry about litigation and advise patients to totally discontinue breastfeeding while taking many medications. This is not necessary. In some cases, virtually any interruption of breastfeeding can lead to permanent loss of milk supply. (OK, here, we should be insisting not that the mother stop breastfeeding, or start pumping and dumping, but that the mother not use the dangerous drug. Besides, even if the drug or the interruption causes milk production to stop, it's simply not true that the loss is permanent. Women can relactate. See Dr. Jack Newman's website - articles on inducing lactation / adoptive nursing. If we gave women as much pressure or as much permission to try the natural route as Hale gives them to try SSRIs, we wouldn't be looking at so many interruptions of breastfeeding! Or, as Hale recommends, why not try REGLAN!!!!!!!! Oh, the PhRMA people have a pill for everything, don't they? First they interrupt your milk production with one drug, or cessation of breastfeeding, then they restart it with some antipsychotic drugs or REGLAN. Gee, how did the human race ever survive millenia without the wonderful companies of PhRMA?)

The question that should always be asked is, "Is this drug really necessary, or could the mother do without it?" If the drug is not really necessary or efficacious (as with cold or herbal remedies), (he sure does hate those herbals - and psychiatric drugs or just about any drug you could think of aren't always necessary as many people use alternative medicine for just about everything short of surgical emergencies.) don't expose your infant to it. In cases where the drug is important to the mother's health, the proper choice of medication is advised. Because so many physicians are not aware of the transfer of drugs into human milk, it has increasingly become the responsibility of the mother and other healthcare practitioners to educate them. Help is available from sources such as lactation consultants and La Leche League leaders. (A La Leche League member should educate her doctor? Though it's true that LLL members can offer a lot of information to moms about breastfeeding, let's not put the burden of educating the doctor on the patients. Besides, doctor's orders are not something you have to follow. The real question which the article supposedly sought to answer, is "Is it safe for my baby? Not, "Is it "important" to the mother's health?" Of course, most people do not understand how harmful antidepressants are to your health and mental state, so their knee jerk reaction is - if Hale says it is safe, go ahead and use it. Are SSRIs safe for your baby? Hale says that Prozac is not. He says Zoloft is safe- based on a whopping 30 cases he tested, in which he DID find Zoloft present in some babies and not in others. All SSRIs have the same basic strategy of attack on your brain and the same profile of side effects. Some are worse than others. But if you would not risk giving a "baby-sized" dose to your baby, based on reading the drug label, then you should not use it while nursing. If your doctor doesn't prescribe Zoloft to newborns or infants, why is he or she prescribing it to you, a breastfeeding mother?)

Human milk is the most wondrous immunization and nutritious food you can give your infant. Removing the infant from the breast for specious reasons should be resisted with all the science we can muster. Fortunately, we now have the data to support us in this effort. (Let's take a look at his specious reasons! How much "science" can you muster up when you are very determined? As we have seen from PhRMA in the past, a lot! Instead of advocating for the idea that it's a battle between giving a baby formula and treating the depression, a responsible person would advocate for preserving the breastfeeding relationship and not introducing toxic, psychotropic medications into the mother's body, or the baby's. A responsible person would say, breastfeed, don't use drugs. And here are some TRULY safe alternatives!)

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NOTES S
1. T. W. Hale and K. F. Ilett, "Drug Therapy and Breastfeeding," Contemporary Clinical Gynecology and Obstetrics 1 (2001): 129-148.
2. P. A. Anderson, "Drug Use during Breast-feeding," (Review) Clinical Pharmacy 10 (1991): 594-624. .
3. T. W. Hale and K. F. Ilett, Drug Therapy and Breastfeeding: From Theory to Clinical Practice (London: Parthenon Publishing Group, 2001), 1-93.
4. P. N. Bennett, "Use of the Monographs on Drugs," in Drugs and Human Lactation, 2nd ed. (Amsterdam: Elsevier, 1996), 67-74. .
5. "The Transfer of Drugs and Other Chemicals into Human Milk," Pediatrics 108 (2001): 776-789.
6. Report of the Committee on Infectious Diseases: Red Book 2000, 25th ed. (Elk Grove Village, IL: American Academy of Pediatrics, 2000).
7. R. G. Devlin and P. M. Fleiss, "Captopril in Human Blood and Breast Milk," J Clin Pharmacol 21 (1981): 110-113.
8. C. W. Redman et al., "The Excretion of Enalapril and Enalaprilat in Human Breast Milk," Eur J Clin Pharmacol 38 (1990): 99.
9. B. Sandstrom and C. G. Regardh, "Metoprolol Excretion into Breast Milk," Br J Clin Pharmacol 9 (1980): 518-519.
10. M. T. Smith et al., "Propranolol, Propranolol Glucuronide, and Naphthoxylactic Acid in Breast Milk and Plasma," Ther Drug Monit 5 (1983): 87-93.
11. M. J. Boutroy et al., "To Nurse When Receiving Acebutolol: Is It Dangerous for the Neonate?" Eur J Clin Pharmacol 30 (1986): 737-739.
12. M. S. Schimmel et al., "Toxic Effects Of Atenolol Consumed during Breast Feeding," J Pediatr 114 (1989): 476-478. (Published erratum appears in J Pediatr 116, no. 1 (1990): 158.)
13. See Note 7. .
14. See Note 8.
15. D. Sinclair and L. Murray, "Effects of Postnatal Depression on Children's Adjustment to School. Teacher's Reports." Br J Psychiatry 172 (1998): 58-63.
16. E. M. Zekoski et al., "The Effects of Maternal Mood on Mother-infant Interaction," J Abnorm Child Psychol 15 (1987): 361-378.
17. A. Buist and H. Janson, "Effect of Exposure to Dothiepin and Northiaden in Breast Milk on Child Development," Br J Psychiatry 167 (1995): 370-373.
18. J. H. Kristensen et al., "Distribution and Excretion of Sertraline and N-desmethylsertraline in Human Milk," Br J Clin Pharmacol 45 (1998): 453-457.
19. Z. N. Stowe et al., "Sertraline and Desmethylsertraline in Human Breast Milk and Nursing Infants," Am J Psychiatry 154 (1997): 1255-1260.

Thomas W. Hale, RPh, PhD, is an associate professor of pediatrics at Texas Tech University School of Medicine at Amarillo and a leading authority in the field of lactation. He is the author of three books on using drugs while breastfeeding, including Medications and Mothers' Milk, the top-selling reference on drugs and breastfeeding in the world. To order any of his three books in this field or other breastfeeding books go to www.iBreastfeeding.com or call Pharmasoft Publishing: 800-378-1317, 806-376-9900. In addition to his books, Dr. Hale has an academic website for the distribution of information on using drugs with breastfeeding patients: neonatal.ama.ttuhsc.edu/lact.

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Table 1.1. Partial list of medications of concern or those contraindicated

Drug: Effect on lactation/infant
ACE inhibitors: High risk of hypotension in young neonates but no problem for older infants
Acebutolol: Low blood pressure, low glucose levels, and breathing difficulties (apnea)
Amphetamines: Loss of appetite, agitation; risk does not justify use
Anticancer agents: Possible immunosuppression/toxicity in neonate
Barbiturates: Monitor for infant sedation
Benzodiazepines (Valium drugs): Chronic use may lead to infant sedation and/or dependence
Bromocriptine (Parlodel): Inhibits lactation; suppresses prolactin
Cabergoline (Dostinex): Inhibits lactation and prolactin
Cocaine: Infant intoxication
Ergotamine: Inhibits lactation and prolactin
Estrogens: Suppresses lactation; use with caution
Fluoroquinolones: Some may produce bloody diarrhea
Lithium: Monitor maternal/infant plasma levels and thyroid function; use with great caution
Lovastatin and others: Lowers cholesterol; risk does not justify use
Methotrexate: Possible immunosuppression; loss of white blood cells; accumulation in gastrointestinal tract
NSAIDS: Avoid prolonged use of long half-life NSAIDS; GI distress, diarrhea
Antipsychotics: May induce sedation, increase risk of apnea
Radioactive Iodine-131: Accumulation in milk/breasts; thyroid toxicity/carcinoma a

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Table 2. Radioactive and other medications for which temporary pumping and discarding of milk is recommended

Medication: Recommended Period of Interrupted Breastfeeding
Radioactive Iodine-131: Complete cessation
Radioactive Iodine-123: 24 hrs for 10 mCi(millicurie); 12 hours for 4 mCi
Radioactive Iodine-125: Complete cessation
Tc-99m Pertechnetate: 24 hrs for 30 mCi; 12 hrs for 12 mCi
Tc-99m Sulfur Colloid: 6 hrs for 12 mCi
Tc-99m WBC: 24 hrs for 5 mCi; 12 hrs for 2 mCi
Gallium-67: 1 month for 4 mCi; 2 weeks for 1.3 mCi; 1 week for 0.2 mCi
Indium-111: 1 week for 0.5 mCi
Thallium-201: 24-48 hrs following 111 MBq (megabecquerel)
Cisplatinin: 3-7 days postinfusion
Cocaine: 24 hours
Metronidazole: 12-24 hours following 2-gram dose only
Doxorubicin: Complete cessation
Copper-64: 50 hours

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Table 3.Some of many medications considered safe for use by breastfeeding mothers

Penicillin antibiotics
Cephalosporin antibiotics
Flagyl (Metronidazole)
Reglan (metoclopramide)
Zoloft (sertraline) ******************Considered safe by someone who doesn't know a lot about Zoloft and measured a whopping 30 babies
Paxil (paroxetine) *******************The most addictive of the SSRIs on the market!
Motrin, Advil (Ibuprofen)
Tylenol (acetaminophen)
Inderal (propranolol)
Zithromax (azithromycin)
Erythromycin antibiotics
Codeine
Morphine at moderate doses
Pepcid(famotidine)
Prilosec (omeprazole)
Heparin
Insulin
Diflucan (fluconazole)
All vaccines

Ideal drug characteristics for breastfeeding mothers:

Drugs with shorter half-lives
Drugs with poor oral absorption
Drugs low in toxicity
Drugs that are non-sedating

Suggestions for breastfeeding mothers

Use medications only when necessary.
Be flexible; choose medications that are preferred for breastfeeding mothers.
Medications cleared by the FDA for infants are generally safe for breastfeeding mothers, too.
Avoid maternal peak blood levels when breastfeeding.
Use drugs that are poorly absorbed or inactive orally.
Use drugs with shorter half-lives.