dilauded and breastfeeding

[leannanavy]

I'm a SN. During clinical (ended two days ago) on med-surg floor, a 29 y.o. lactating mother of three was receiving 2mg of dilauded IV q2h prn for (dvt in one leg with 2 large hematomas f/unknown source) and klonopin 5mg po q6h. She brought her pump to preserve the milk for an 8-week old w/nka uncomplicated vag delivery. Pt described baby as thriving. During shift change, the oncoming nurse planned to tell pt to pump n dump (bc of the diluaded) but big mouth me said (during shift change) I thought narcotics were safer than benzos. I think I offended the nurses I shadowed by sharing my opinion. My rationale for the big mouth statement; I got 10mg percocet PO Q4h for both c-sections, one in '98 at 36 weeks, 2nd in '11 at 40 weeks. I shared concerns about percocet to both (different) lactation nurses, both said it's ok.

I got a Satisfactory and everyone else an Outstanding (it's not an F and am thankful I passed.) I initiated a conference w/my nursing program director and clinical coordinator to discuss my clinical experience because I was unhappy about not getting an O. They (director and coordinator) said dilauded is a Cat C drug and thus not safe. They said it's good to share knowledge but nurses tend to have egos (and when I become one I'll understand) and may have felt "like I showed them up." I explained feeling Klonopin was more dangerous than dilauded they ignored the Klonopin comment. I then came home and researched both diluaded and Klonopin and discovered dilauded is a cat c and klonopin is a cat d drug, but the med/surg nurses weren't worried about the klonopin only the dilauded. Pt didn't have a substance abuse hx (f/what i understand even if she did, her pain should still be treated)

My question is if you're the nurse of an 8 week old (healthy) pt, would you recommend the mother pump and dump, if so, why? Which of the two drugs would pose the larger risk and why? What would you have done in this situation and

Any advice (regarding what I should've done and what you'd have recommended to the pt) is greatly appreciated. Not sure I want to go into peds but in the event I do, this info will come in handy if not, it's still good to know in the event I'm confronted w/this situation in the future.

Thank you, thank you, thank you in advance.

Leanna

[klone, MSN, RN]

Leana, in my opinion you are exactly right. As long as the woman is awake and alert enough to hold her baby, it is absolutely safe for a baby to breastfeed while the woman is on narcotics. And like you, I would be more concerned about the Klonopin than the Dilaudid.

In the future, I recommend you use Thomas Hale's "Medications and Mother's Milk" for all drug/breastfeeding safety questions. His text is considered the gold standard. Here is something he has said:

According to Thomas Hale, RPh, PhD (Medications and Mothers’ Milk 2014, p. 7-12): “It is generally accepted that all medications transfer into human milk to some degree, although it is almost always quite low. Only rarely does the amount transferred into milk produce clinically relevant doses in the infant… Most importantly, it is seldom required that a breastfeeding mother discontinue breastfeeding just to take a medication. It is simply not acceptable for the clinician to stop lactation merely because of heightened anxiety or ignorance on their part. The risks of formula feeding are significant and should not be trivialized. Few drugs have documented side effects in breastfed infants, and we know most of these.”

You should never use pregnancy category risks (A, B, C, etc) to determine if it's safe while breastfeeding, because the mechanism by which drugs enter breastmilk is completely different than how a drug enters fetal circulation via the placenta.

The lactation category risk for Dilaudid is L3, which is considered "moderately safe". I don't have my book in front of me at home to give you the lactation risk category for clonazepam, but I do know that it can be sedating in the infant, and I would suggest talking to the provider about switching her to a different medication (not sure if she's taking it for seizures or as an anxiolytic, or...) at least temporarily - once the infant is a bit older, metabolism of medications changes drastically and older infants are way better at metabolizing maternal medications than newborns.

[klone, MSN, RN]

Here is what Thomas Hale himself has said to a nursing mother who is taking clonazepam (hopefully the link will work for you):

https://www.infantrisk.com/forum/showthread.php?1238-Clonopin

[Elvish, BSN, DNP, RN, NP]

I'd agree with you as well. The first thing that jumped out at me was their use of whether a drug is Cat C, D, etc. As klone said already, that's not an appropriate way to measure a med's safety in lactation. This is not knowledge a med-surg nurse will use every day, so I'd rather use it as an educational opportunity rather than criticize them for it. But there are many many drugs that are safe to use while BFing that we don't use in pregnancy (even so, we give Cat C drugs all the time when benefit > risk). There is very little that is truly contraindicated during BFing (things like cocaine, heroin, and some antipsychotics and anticonvulsants).

Most opiates are not found in high enough concentrations in breastmilk to be clinically significant to a nursing baby. Mothers' bodies will metabolize most of the drug before it is excreted in milk.

I too would be more worried about Klonopin than Dilaudid. I took a low-dose benzo for a short time while breastfeeding, but my daughter was almost 2 years old and not getting nearly as large a volume of milk as would an 8-week-old...and I took it on a very limited basis, not around the clock like this mother's Klonopin. Lots of things to consider here.

Good for you for thinking critically.