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It seems form social media that many babies are now being diagnosed and treated for reflux (GORD). Before labelling a baby as having a medical condition it is often useful to seek input from a breastfeeding expert and consideration of the position the baby is in after a breastfeed. Not all babies who throw up need treatment!
This fact sheet covers the medication used to treat reflux and GORD in babies and the preparation of PPI drugs for babies
Sadly our family has recently experienced the tragedy of an ectopic pregnancy and the loss of a very brief dream. This has made me much more aware of the incidence and risk of this condition over and above the post I wrote in April. So some more facts – as my friend commented today I hate to waste any opportunity to educate!
Ectopic pregnancy is a common, occasionally life-threatening condition, that affects 1 in 80 pregnancies. An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes. Symptoms usually develop between the 4th and 12th weeks of pregnancy. Women with an ectopic pregnancy may still be breastfeeding and wish to continue which can be supported.
- Ongoing bleeding that is sometimes red or brown/black and watery (like “prune juice”) should be investigated. The bleeding may be heavier or lighter than usual, but pregnancy test is still positive
- One-sided pain in your tummy which may be persistent or intermittent or a generalised discomfort with bloating and a feeling of fullness (not associated with eating) when lying down.
- Shoulder tip pain which is often described as pain unlike any you have ever experienced before. (Ectopic Pregnancy Trust)
Your GP will refer you urgently to the early pregnancy unit at your local hospital. You may have your Human Chorionic Gonadotropin (HCG levels) measured over a period of several days. If you are having a normal pregnancy these should double approximately every 48 hours. A smaller increase can indicate a risk of of this being an ectopic pregnancy but this will be confirmed with ultrasound scans, initially across your tummy. It is likely that a transvaginal (internal) ultrasound scan will be required where a specialised probe is placed into the vagina to get a more detailed look at the reproductive organs.
Unfortunately, if it is confirmed over a period that you have an ectopic pregnancy it is not possible to save the pregnancy and it must be removed either by surgery or the use of methotrexate. The cells have not been able to be nourished and can never develop into the baby you thought you were expecting which can be hard to deal with.
Rupture of ectopic pregnancy
In a few cases, an ectopic pregnancy can grow large enough to split open the fallopian tube. This is known as a rupture which can be very serious, and surgery needs to be carried out as soon as possible.
Signs of a rupture include a combination of:
- a sharp, sudden and intense pain in your tummy
- feeling very dizzy or fainting
- feeling sick
- looking very pale (NHS Choices)
Methotrexate and breastfeeding
Mothers who are currently breastfeeding an older child can continue 24 hours after the methotrexate is administered.
“It is apparent that the concentration of methotrexate in human milk is minimal, although due to the toxicity of this agent and the unknown effects on rapidly developing neonatal gastrointestinal cells, it is probably wise to pump and discard the mother’s milk for a minimum of 24 hours post dose if given as a single dose (e.g. 50 mg/m2 IM for ectopic pregnancy)” (Hale 2018).
Infant Monitoring: Should patient resume breastfeeding more than 24 hours after the last dose of maternal therapy, monitor the infant for vomiting, diarrhoea, blood in the vomit, stool or urine. Lab work could be drawn if clinical signs of liver or renal dysfunction, anaemia, thrombocytopenia or an inability to fight infection.
Lactmed reports a study of one mother who was given a single intramuscular dose of 65 mg (50 mg/square meter) of methotrexate for ectopic pregnancy. Six milk samples were obtained from 1 to 24 hours after the dose. Methotrexate was undetectable (<22.7 mcg/L) in all milk samples (Tanaka 2009). In some 20% of cases more than one cycle of methotrexate is required to expel the products of conception. For each cycle breastfeeding should be avoided for 24 hours.
Hale quotes a milk plasma ratio of > 0.08 and relative infant dose of 0.13% – 0.95%. Peak serum concentrations appear 30-60 minutes after intra muscular dose (Jones 2018). Pharmacokinetic data is very variable as there in considerable inter individual variation (Martindale 2017).
For more information on methotrexate administration, side effects and monitoring see www.ectopic.org.uk/patients/treatment/
Ectopic pregnancy and breastfeeding fact sheetBreastfeeding after surgery
After surgery breastfeeding can continue as normal as soon as you are awake and alert. If your nursling is unable to stay in hospital with you, you may need to express to avoid engorgement/blocked duct and to maintain your supply. Your expressed milk can be given to your baby at home. There is no need to pump and dump.
Sadly dreams dont always come true and babies are lost during pregnancy. If that happens and you are still breastfeeding a toddler do you have to stop? Lots of information here I wrote for www.essentialparent.com. Extracts taken from Why Mothers Medication Matters
It seems that many more women with chronic illnesses are having babies and breastfeeding. I have
included a chapter in the second edition of Breastfeeding and Medication on this. This fact sheet on lupus and hydroxychloroquine whilst breastfeeding is taken from the book, due to be published May 2018
One of the advantages of breastfeeding is that for many it may be months or even years before menstrual bleeding returns regularly. However, some mothers do experience heavy flow which needs to be treated. Tranexamic acid is usually the drug of choice at a dose of 1 g 3 times a day for up to 4 days, to be initiated when menstruation has started; maximum 4 g per day (BNF 2018). Mothers can continue to breastfeed as normal. There is one reported case of restless in the baby in a study of 21 mothers but in general it seems anecdotally, to cause few problems.
I am frequently asked about taking prochlorperazine (Buccastem® or Stemetil ®) to treat nausea due to labarynthitis, vertigo or dizziness. It is a drug I would be happy to prescribe and have used it myself as have my two breastfeeding daughters. It seems a frequently asked question when the air pressure changes rapidly.
Raynaud’s phenomenon affects up to 10% of otherwise healthy women aged 21-50 years of age. It is 9 times more common in women than men.
Yet many doctors are unaware that Raynaud’s can affect breastfeeding. It produces deep pain after feeds with a mother often automatically covering her nipples or massaging them to restore the blood flow. Symptoms are often mis-diagnosed as thrush when in fact the use of fluconazole can make the symptoms worse by causing further vasoconstriction.
Most mothers who experience problems with Raynaud’s during breastfeeding, have a history of cold hands and feet or a close relative who has. It may be that in a family it is routine to wear thick socks and gloves, maybe a vest without realising that they may be “unusual” in their response to the cold.
Babies of mothers with Raynaud’s may be born early and / or smaller because of restriction of blood flow to the placenta. It is not uncommon for there to be a maternal (or close family) history of migraines.
Symptoms which differentiate Raynaud’s phenomenon with other causes of breast pain are:
- Pain in both breasts after feeds
- Pain which may be precipitated by being cold or for example going down the freezer aisle in a supermarket
- Rapid 3 colour change in the nipples after feeds
- Pain that is resolved by warmth or gentle massage
- A history or close family history of poor circulation
Treatment of Raynaud’s during breastfeeding
- Don’t ignore the fact that pain after breastfeeds may be due to less than perfect attachment of the baby at the breast. A white tip to the nipple after feeds is not the same as the tri colour change typical of Raynaud’s
- Nifedipine 30mg a day (either as 10mg three times a day or long acting 30mg once daily. The amount in breastmilk is too small to affect babies although it may give the mother hot flushes and / or headaches. The following extract is taken from Breastfeeding and Medication 2nd Ed to be published May 2018
- High doses of vitamin B6 (Newman 2012), magnesium (Smith 1960, Turlapaty Leppert1994), calcium (DiGiacomo 1989), fatty acids (Belch 1985) and fish oil supplementation (DiGiacomo 1989) have also been suggested but take a minimum of 6 weeks to be effective. Ginger 2000mg-4000mg daily. Capsules usually contain 500mg. It may also be beneficial to add ginger to your diet, to drink ginger tea, or to put a spoonful of ground ginger in your bathing water (Royal Free hospital www.royalfree.nhs.uk/pip_admin/docs/Raynaudsnatural_186.pdf)
Nifedipine relaxes vascular smooth muscle and dilates coronary and peripheral arteries. It has activity in reducing blood pressure and in the treatment of Reynaud’s syndrome
Nifedipine is almost completely absorbed from the GI tract but undergoes extensive first-pass metabolism. It is up to 98% bound to plasma proteins. It is used to treat hypertension (Penny and Lewis 1989; Ehrenkranz et al. 1989) and also to improve circulation in Reynaud’s disease (cold extremities and nipple vasospasm) in doses up to 30 mg daily (Lawlor-Smith and Lawlor-Smith 1996; Garrison 2002; Anderson et al. 2004). Side effects for the mother include flushing and headache, which may limit its usefulness. It is present in breastmilk but in levels too small to be harmful and there have been no reports of adverse effects in babies (see Chapter 5).
In Taddio et al’s study (1996) of 21 women taking 40 mg daily the babies were estimated to be exposed to 0.1% of the maternal weight adjusted dose via breastmilk. Nifedipine is widely used to treat pre-eclampsia and eclampsia in the mother together with methyldopa or a beta blocker. Ehrenkranz et al. (1989) studied one woman who took 10, 20 or 30 mg three times daily on different days. Using the maximum dose transferred by the 30 mg regimen, the authors estimated that the baby would be exposed to the authors estimated that an exclusively breastfed infant would receive an estimated maximum of 7.5 µg per kilogramme of nifedipine daily. Its relative infant dose is quoted as 2.3–3.4% (Hale 2017 online access).
The BNF reports that the amount secreted into breastmilk is too small to be harmful but that manufacturer advises it should be avoided.
Compatible with breastfeeding.
- Anderson JE, Held N, Wright K, Raynaud’s phenomenon of the nipple: a treatable cause of painful breastfeeding, Pediatrics, 2004;113(4):e360–4.
- Ehrenkranz RA, Ackerman BA, Hulse JD, Nifedipine transfer into human milk, J Pediatr, 1989;114:478–80.
- Garrison CP, Nipple vasospasm, Raynaud’s syndrome, and nifedipine, J Hum Lact, 2002;18(4):382–5.
- Lawlor-Smith LS, Lawlor-Smith CL, Raynaud’s phenomenon of the nipple: a preventable cause of breastfeeding failure?, Med J Aust, 1996;166:448. Letter.
- Penny WJ, Lewis MJ, Nifedipine is excreted in human milk, Eur J Clin Pharmacol, 1989;36:427–8.
- Taddio A; Oskamp M; Ito S; Bryan H; Farine D; Ryan D; Koren G,. Is nifedipine use during labour and breastfeeding safe for the neonate?, Clin Invest Med, 1996;19(4 Suppl.):S11. Abstract.