Case

A mother of a 3 month old baby calls to tell you that she has been diagnosed with sinusitis and her physician has put her on Augmentin and Benadryl. She would like to know if she may continue to nurse her baby?
In many cases, drugs that are prescribed to nursing mothers have not been tested for their presence in breastmilk. The questions to be asked are is the drug really necessary, is this the safest drug for the mother's condition or are there alternatives, could the drug present a risk to the infant, and by altering the timing of the drug adminsitration, can you minimize the exposure?

Drugs contraindicated during Breastfeeding

1. Chemotherapeutic agents
2. Drugs of abuse-e.g. marijuana, heroin, PCP, nicotine 
3. Radioactive compounds- require interruption of nursing and must consult nuclear medicine specialist to determine how long radioactivity is present in milk. 
4. Antianxiety, Antidepressants, and Antipsychotic medications effects are not known but are of concern.

1. Candida infection of the breast- Topical antifungals like Nystatin and Lotrimin should be used and the infant should take oral preparations. Breastfeeding may continue
2. Mastitis and Breast Abscess- mother usually develops flu-like symptoms and infection often caused by Staphylococcus. May come from plugged duct and nursing may help treat the infection. Should use antibiotic, heat, and acetaminophen. Should not stop nursing.
3. Toxemia- generally drugs used to treat toxemia are contraindicated for nursing mothers and milk should be discarded until the medications are stopped
4. Urinary Tract Infections- May use penicillins, cephalasporins, gentamicin, and ampicillin. Avoid sulfa drugs in the first month and tetracyclines and chloramphenicol are contraindicated. 
5. Cytomegalovirus- although the breastmilk may contain viruses, it also contains antibodies that are protective against CMV. Therefore, breastfeeding should not be stopped in CMV infected mothers. Should avoid nursing if infant is preterm.
6. Tuberculosis- Mothers with positive skin test and negative chest radiographs may continue nursing while taking INH. If the mother has active TB, there should be no contact between the mother and the infant until the mother is being successfully treated. The mother may pump and discard milk and return to nursing later.
7. Hepatitis A- mother may nurse if she feels well. If she develops Hepatitis A 2 weeks prior to delivery or within one week of infants birth, infant should receive immunoglobulin
8. Hepatitis B- Infant should receive HBIG and HBV vaccine after birth and mother may nurse.  Although Hep B has been isolated from human milk, the predominant mode of transmission is vertical at the time of delovery.
9. Hepatitis C- Nursing is not contraindicated
10. Varicella- if both infant and mother have varicella at birth, they should both be isolated and nursing may continue. If only the mother has lesions, the baby should be isolated and mother may pump and milk given to the infant. It is a good source of antibodies. Acyclovir treatment of nursing mother is not a contraindication to breastfeeding.
11. Herpes- The infant should avoid contact with herpes lesions and if there are no vesicles on the breast, the mother may breastfeed. Other lesions should be covered while nursing.  Mother should observe cardful handwashing technique.
12. Syphilis-only contraindication is if there are syphilitic lesions on the breast. After the mother is treated and the sores are healed, nursing may resume
13. HIV- HIV positive mothers should not breastfeed because the virus is transmitted through the milk to the infant. In areas where substitutes for breast milk are not available, nursing should be done by HIV + mothers i.e. 3rd world countries.
14. Breast Cancer- There is no increased risk of breast cancer in mothers who breastfeed. If a mother is receiving radiation or chemotherapy, she should not nurse.

1. Committee on Drugs. The Transfer of Drugs and Other Chemicals Into Human Milk. Pediatrics. 1994; 93(1):37-150. 
2. Freed, G and Clark, S. Breastfeeding and Maternal Illness. Contemporary Pediatrics April 1996
3. Powers NG and Slusser W. Breastfeeding Update 2: Clinical Lactation Management. Pediatrics in Review. 1997; 18:147-161.
4. Slusser W and Powers NG. Breastfeeding Update 1: Immunology, Nutrition and Advocacy. Pediatrics in Review. 1997; 18:111-119.
5. 2000 Redbook
6. Committee on Drugs The Transfer of Drugs and other Chemicals into Human Milk. Pediatrics September 2001
7. Cahill John, and Wagner Carol. Challenges in Breastfeeding: Maternal considerations.  Contemporary Pediatrics May 2002
8. Cahill John and Wagner Carol. Challenges in Breastfeeding:: Neonatal considerations.  Contemporary Pediatrics.  May 2002.
9. American Academy of Pediatrics. Prevention of Rickets and Vitamin D Deficiency. Pediatrics Vol 111 April 2003
10. American Academy of Pediatrics Breastfeeding and the Use of Human Milk.  Pediatrics February 2005
11. Hale T. Drug Therapy and Breastfeeding: antibiotics Analgesics and Other Medications. NeoReviews. May 2005