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    Promoting Drug Safety During Breastfeeding

    Pharmacists can help women who breastfeed by identifying the safest drugs and dosage schedules to minimize exposure.

     

    Vitamin C and echinacea are often used by patients to manage or prevent colds.11,16 Echinacea should be avoided women who are breastfeeding because some echinacea products have been found to be contaminated. R Vitamin C may be used when dosing adjustments are considered. Adult patients should not exceed 2 g/day of vitamin C.

    Vaccinations

    Table 3Vaccines provide an excellent source of protection and should be considered in breastfeeding mothers where indicated.18 Most pregnant women receive pertussis (Tdap) and inactivated influenza vaccinations during their pregnancy to protect the baby from serious complications and to provide some short-term immunity. Influenza vaccine should be offered to breastfeeding mothers if there are no other contraindications, but live influenza vaccine is not recommended. Table 3 summarizes the CDC recommendations for various vaccines.

    Anti-infectives

    The majority of antibiotics are excreted in breast milk in small concentrations.1,8 There is a theoretical concern regarding the safety of breastfed infants whose mothers, are taking antibiotics because of alteration of normal bowel flora, possible abnormal culture results if a fever occurs in the breastfed infant, and allergic reactions.

    The AAP considers penicillins, cephalosporins and erythromycin compatible with breastfeeding.1 Side effects that may occur with these antibiotics include diarrhea, rash, and thrush. Other macrolides such as azithromycin and clarithromycin have low systemic concentrations in infants of breastfeeding mothers, although some evidence suggests that infants may be at higher risk of gastric outlet obstruction with use. Sulfamethoxazole/trimethoprim is considered compatible with breastfeeding, but it should be avoided in jaundiced, sick, stressed, or premature babies due to the possibility of bilirubin displacement and kernicterus. Short-term use of tetracycline and fluoroquinolones is also compatible with breastfeeding, but absorption by the infant may be reduced by the calcium in breast milk. Topical ophthalmic and otic quinolones are believed to have reduced exposure to the infant.

    Metronidazole is excreted in breast milk in concentrated amounts.8 Case reports have shown diarrhea as well as oral and rectal Candida infection in infants. Women should be instructed to postpone breastfeeding for 12 to 24 hours following a 2-gram single dose. Topical and vaginal formulations of metronidazole are believed to have reduced concentrations in breast milk.

    Azole antifungals are used for Candida infection of the nipples, milk ducts, and vagina in breastfeeding mothers.8 Topical formulations may be applied to the nipples after feeding and wiped off prior to the next feeding. Oral fluconazole is considered second line, but may be used for more severe infections.1

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