Common Problems Encountered by Breastfeeding Women

Medications; infant allergies

Maternal Medications and Breastfeeding

FamilyEducation Editor's Note: For the American Academy of Pediatrics' latest guidelines on medication safety for breastfeeding women (effective September 2013), click here. Many medications can be taken while breastfeeding, but always check with your doctor, who will likely consult a drug-safety database called LactMed for the most recent studies and information on medications for nursing women. Some of the information in the section below may change over time as new drugs and studies come out.

Nursing mothers naturally are concerned about the potential dangers of medications they take being transmitted to their babies through their breast milk. In fact, all drugs are excreted to some degree in breast milk, and medications should not be taken indiscriminately by nursing mothers. Many factors have an influence on the amount of drug that will be transferred into milk, including the dosage amount and dosing schedule, how the drug is taken (e.g., oral versus by injection), the physical and chemical properties of the drug, the amount of breast milk the baby drinks, how often the baby is fed, and how long the drug is needed. Fortunately, most medications taken by breastfeeding women are safe for nursing infants, because the amount of drug present in breast milk usually is minimal.

However, lack of information about drug excretion into breast milk frequently has resulted in misconceptions and exaggerations about the risks to the infant. Often, nursing mothers are mistakenly advised to wean their infants when the medication prescribed for them actually would have been compatible with breastfeeding. Or, a mother may decide not to take a medication she needs because she is worried that it could have a harmful effect on her baby.

Some drugs may cause temporary side effects in infants when they are passed into breast milk. One study examined adverse reactions in more than eight hundred infants who were breastfed by women taking medications. Although no major adverse effects requiring medical attention occurred in any of the infants, about 10 percent of women reported minor adverse reactions in their infants. Here are the most common reactions according to drug category: antibiotics caused diarrhea; prescription pain medication caused drowsiness; antihistamines caused irritability; and sedatives, antidepressants, and antiseizure medications caused drowsiness. In all cases, the benefits of breastfeeding were felt to outweigh the temporary, minor effects of a maternal medication on the infant.

A few drugs that are necessary to protect a mother's health are too toxic for breastfed babies. Included among those that are considered incompatible with breastfeeding are cancer chemotherapy medications, drugs that suppress the immune system, and lithium, used to treat bipolar disease (although some women have breastfed while taking lithium, without apparent harm to their infants). Other drugs, such as some antidepressants, may also be of concern.

In the past, many prescription drugs were said to be unsafe for nursing mothers simply because little information was available about how much of the drugs entered the breast milk. As medical knowledge about the topic has increased, many drugs that were previously considered to be contraindicated during breastfeeding are now considered to be compatible with nursing. Because knowledge about drug excretion in breast milk changes so rapidly, it is a good idea to get a second opinion whenever you are advised that breastfeeding is not possible with a certain medication. Ask the physician prescribing the drug, as well as your baby's doctor, before concluding that weaning is necessary. Often pharmacists, especially those at drug information centers, have the most up-to-date information. The Drug Information Service sponsored by the University of California at San Diego will answer inquiries from the public about medication use during breastfeeding. If the drug being prescribed poses a risk to nursing babies, the pharmacist might be able to suggest a safer alternative. The American Academy of Pediatrics (AAP) publishes and regularly updates an excellent reference for health professionals about the transfer of drugs and chemicals into human milk. Ask your doctor if he or she has a copy of the latest version of this AAP publication. Other helpful guidelines for breastfeeding women requiring medications are outlined below.

• Whenever your doctor prescribes a medicine for you, ask whether it is safe for breastfeeding. Whenever you are taking a drug, notify your baby's doctor and observe your infant carefully for possible side effects. Report these to your baby's doctor at once.
• Take only necessary and effective medications. When choosing over-the-counter drugs, avoid multi-ingredient medications to treat minor symptoms.
• When feasible, it is generally preferable to take a medication right after nursing your baby. For most drugs, the peak concentration in breast milk will usually be reached between feedings if the medication is taken right after nursing.
• When once-daily medications are prescribed, the dose can be taken just prior to your baby's longest sleep interval at night. Most long-acting drugs, however, will maintain a fairly constant level without identifiable peaks.
• If you are nursing and must take a medication that is believed to pose a risk to your infant (such as a radioactive compound), you can temporarily interrupt breastfeeding without permanently weaning. A rental electric breast pump can be used to express your milk at regular intervals and maintain your supply until you have completed the course of therapy and can safely nurse once again.
• When you have advance knowledge of the need to take a medication (e.g., for elective surgery), you can pump extra milk and freeze it prior to beginning your course of therapy. Your baby can be fed the stored breast milk while nursing is interrupted. Of course, you will have to pump and discard your milk while taking the drug that is unsafe for breastfeeding.

I cannot emphasize strongly enough that recreational drugs must NOT be taken by nursing women, both because of the very real risk such drugs pose to a baby as well as the danger that exists when a mother attempts to care for her infant while she is high. Several infant fatalities have occurred when babies ingested tainted milk from their nursing mothers who used illicit drugs.

Some Drugs That Should Not Be Taken During Breastfeeding*

• Cancer chemotherapy drugs
• Drugs that suppress the immune system
• Lithium
• All illicit drugs
• Radioactive drugs (usually taken for diagnostic scans)

Some Common Drugs That Usually Are Compatible with Breastfeeding*

• Acetaminophen
• Antibiotics (most)
• Antihistamines (most)
• Antiseizure medications (most)
• Blood pressure medications (many)
• Blood thinners (most)
• Diuretics (most)
• Ibuprofen
• Insulin
• Over-the-counter medications (most)
• Pain medications (most)
• Prednisone
• Thyroid replacement hormone

Some Drugs Whose Effects in Breastfed Infants Are Unknown but May Be of Concern*

• Antianxiety medications, such as Valium
• Antidepressants, such as Prozac, Zoloft
• Antipsychotic medications, such as Thorazine
• A few antibiotics, including chloramphenicol and ciprofloxacin

Infant Reactions to Maternally Ingested Foods
While true allergy to mother's milk has never been proved, some breastfed infants react adversely to certain foods consumed by their nursing mothers. Mothers of these babies typically report that their infant becomes fussy three to six hours after the mother has eaten an offending food. It usually takes one to four hours for allergic components of foods to appear in mother's milk. A baby may react within minutes after nursing, but usually within two to four hours. The reaction can continue as long as the offending substance remains in the mother's system and continues to enter her milk. This can be three to four days or longer after eating certain foods.

Common Offending Foods in the Mother's Diet
The most common foods that provoke allergic reactions in nursing in-fants include milk and other dairy products, wheat, eggs, peanuts, soy, fish, corn, and citrus. Often the food (or foods) the baby reacts to is something the mother eats daily or something she ate frequently during her pregnancy, such as orange juice or a peanut butter sandwich.

Typical Infant Symptoms of Allergy
Common allergic symptoms seen in breastfed babies include skin rashes, red cheeks, vomiting, diarrhea, runny nose, cough or congestion, fussiness, and "colic." Breastfed babies who are fussy due to allergies to foods in the mother's diet tend to be adequately nourished, or even overweight, rather than underweight. As a result of their frequent fussiness and apparent discomfort, their mothers may try to nurse more often and can end up overfeeding their babies.

Not all adverse reactions to foods the mother ingests are true allergies. Babies can be sensitive to foods in other ways than an allergic reaction. For example, babies might be extra fussy and irritable if their mothers consume too many caffeinated drinks, or they can become gassy due to broccoli, onions, or cabbage in the mother's diet. These unfavorable reactions are not true allergic reactions.

Keeping a Food/Behavior Diary
If you think your baby is reacting to something in your diet, discuss this with your child's doctor. You also should start keeping a meticulous food/behavior diary. Record on this daily log what and when you eat, when you nurse your infant, and the time and type of problem behavior observed in your baby. A sample food/behavior diary is available at the here. While you are keeping a record, simplify your meals. Try to eat only three food items at a meal. Avoid multiple seasonings and multiple ingredient dishes. By scanning your daily diary, you should be able to track the relationship, if any, between your baby's symptoms and specific foods you eat.

Eliminate Offending Foods
Don't get overzealous and go on a drastic elimination diet. Instead, be a sleuth as you review your diary to determine the most likely offending foods. This kind of detective work often pays off. Usually, only a few foods in your diet cause a problem for your baby. Completely eliminate the one or two most likely offensive foods for at least four to five days-preferably a week. That should be long enough to get the food entirely out of your system. At the end of a week, rechallenge with the particular food to see if your baby's symptoms reappear. Far too many women arbitrarily eliminate foods in hopes of reducing colicky behavior in their baby. I've met breastfeeding women who have restricted their intake to only half a dozen foods in a desperate attempt to improve their baby's symptoms. A drastic elimination diet is only likely to reduce your milk supply and make you feel like a martyr. Women who eliminate major food groups, such as dairy products, from their diets should receive nutrition counseling from a registered dietitian or their physician. Such women may require appropriate supplements to replace essential nutrients in the eliminated foods.

Prevention of Allergies in At-risk Infants
Infants at high risk for allergic disease include those who have a parent, sibling, or other close relative with food allergies, asthma, or eczema. Prolonged exclusive breastfeeding has been shown to reduce the likelihood of allergic symptoms in these at-risk infants. Breastfeeding is especially protective if the mother also eliminates the most common allergenic foods mentioned earlier from her diet during pregnancy and as long as she is nursing. Mothers of potentially allergic babies should also rotate their foods, avoiding eating any single food on a daily basis. Try to resist cravings and avoid eating large quantities of one food. You might be able to eat a small amount of an offending food every three or four days, but not every day. Once your baby starts solid foods, discuss with her doctor the plan for introducing new foods, especially allergenic ones like milk, egg, wheat, peanut butter, corn, citrus, and shellfish. If you have a strong family history of allergic disease or believe your baby displays allergic-type symptoms, I suggest you seek consultation with a pediatric allergist or an environmental medicine specialist. Allergic disease can be a chronic, frustrating problem-even a life-threatening one if anaphylaxis (severe allergic reaction with shock and airway obstruction) occurs.

*List is not inclusive