breastfeeding and medications

[dmw2010]

I am a L/D nurse doing post-partum now. How do you handle breastfeeding while the mom is taking medications? I'm particularly concerned about narcotics. I read that codeine is rated as L3, but might be L5 depending on whether or not the mom is a "rapid metabolizer" of codeine. (I would hate to find that out the hard way.) Of course, patients aren't routinely tested for this enzyme, and although it is rare, a case study said that a baby died because his/her mother was a rapid metabolizer of codeine. I don't find the breast-feeding drug references helpful (particularly the one by Hale) because there is a lot of gray areas in the L3 drug category. Maybe I'm not using it effectively.

I asked a nurse at work how she handles the timing of narcotics and breastfeeding, but all she said was that she gave the narcotic immediately after mom breastfed. Well, in one circumstance, mom was in significant pain and so I gave her ibuprofen (L1) and had her feed the baby before giving her a narcotic. The ibuprofen didn't work and she continued to be in significant pain while we struggled with breastfeeding. Meanwhile, another nurse came in to see what the problem was, and told me to get her some pain medication, and then she continued to help her breastfeed. So it seems the nurses at my work didn't agree on how to manage this issue.

What if she comes back from PACU and wants to breastfeed ASAP and is in severe pain at the same time? Is it safe to breastfeed right after giving her a shot of narcotic (like dilaudid or demerol or percocet or T3?) What if I give her a narcotic after a feeding and she wants to feed again in 1 hour already? Also, what should I advise her when she's discharged when her milk comes in (which means the volume of milk will be greater, thus the baby might get a higher dose of narcotic). What if the baby is preterm and in the NICU?

I'm trying to be pro-breastfeeding and a good pain manager at the same time. I also don't want everyone baffled why the baby isn't feeding (or breathing) well, when all it ended up being was the narcotics the baby received from breastfeeding.

[klone, MSN, RN]

The benefits of breastfeeding far outweigh any risks of the narcotic. As long as the woman is alert enough to hold and care for her baby, it's okay. There are very very few meds that truly preclude breastfeeding.

[klone, MSN, RN]

You also need to keep in mind that in the first few days before the mature milk comes in, the quantity of milk the baby receives is very small, thus the amount of medication the baby would be getting is minuscule.

[cayenne06, MSN, CNM]

Yes, in the VAST majority of cases, the benefits of breastfeeding outweigh the risks to the fetus. This is true of mothers who smoke marijuana (although you will find many who disagree), drink alcohol, smoke cigarettes, and those who are on medication assisted treatment for opioid addiction.

Give pain meds as needed, feed baby on demand. Counsel mothers that there is no need to restrict their diet or avoid normal amounts of caffeine and alcohol when breastfeeding. Counsel smoking mothers that while it is best for their health and their children's health to stop smoking, breastfeeding will reduce their child's risk of SIDs, which is elevated by having a smoking parent. Advise moms that most meds are fine while breastfeeding, and they should check with a trained lactation consultant regarding any safety concerns.

Our low breastfeeding rate is shameful and we should do everything we can to support a healthy breastfeeding relationship. I could go ON and ON about all the things we as nurses do that sabotoge breastfeeding. Skin to skin for a minimum of an hour after birth should be standard. All necessary newborn assessments can be done on mom's belly. Weights and measures are not time sensitive! Baths should be delayed until breastfeeding has been initiated. Bulb suctioning should ONLY be done for a clear indication, and should be documented as such. Monitoring for neonatal hypoglycemia should be done based on symptoms and risk factors- and I'm sorry, but plain old LGA/SGA babies (barring other issues) should not be monitored as a matter of course because a) "normal" neonatal glucose values are not based on values from exclusively breastfed babies, and b) more importantly, babies who are receiving glucose monitoring receive formula supplementation at a shockingly high rate, in an attempt to avoid/correct borderline "abormal" levels. Makes me crazy.

Okay, /rant over.

Long story short, give the meds and breastfeed on demand.

ETA- many may disagree, but I think that breastfed babies should only receive formula supplementation in the hospital with a doctor's order. (not that peds are always all the knowledgeable about breastfeeding, sigh. IDEALLY, any supplementation in the hospital should require a consult from an IBCLC, but. . . pipe dream, I know.)

[Marymoomoo]

^ditto.

Here's some info on how medications pass into human milk: Drug entry into Human Milk | InfantRisk Center

And here's the ABM protocol on the use of anesthesia and analgesia during bfing: http://www.bfmed.org/Media/Files/Protocols/Protocol_15_revised_2012.pdf

[vintagemother, BSN, CNA, LVN, RN]

Thank you Klone and Cayenne! As a mom who breastfed (6 yrs of breastfeeding 3 kids) I am glad to learn more info that supports other moms to breastfed!