Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs, 7e

149: Effects of Drugs and Substances on Lactation and Infants

INTRODUCTION

The chapter provides some summary data on medications and substances that may be taken by the mother during pregnancy and/or breast-feeding. Regardless of the designated risk category or presumed safety, no drug or substance should be used during pregnancy and/or breast-feeding unless it is clearly needed and the potential benefits clearly outweigh the risks. The table lists the generic medication name and, in parentheses, the Food and Drug Administration (FDA) fetal risk category followed by the breast-feeding compatibility. At the present time there is no formally FDA-sanctioned breast-feeding category, and the system used here is discussed later. Lastly, any reported effects on lactation or on infant effects based on breast milk consumption are noted. The editorial board has made an attempt to summarize the data based on the best information available for an individual agent where sources disagree. These data are subject to change as new information becomes available. The reader is advised to consult the FDA (www.fda.gov) and manufacturer's web site for the latest information concerning risks of these medications.

U.S. FDA FETAL RISK CATEGORIES

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CATEGORY A

Adequate studies in pregnant women have not demonstrated a risk to the fetus in the first trimester of pregnancy; there is no evidence of risk in the last two trimesters.

CATEGORY B

Animal studies have not demonstrated a risk to the fetus, but there are no adequate studies in pregnant women.

Animal studies have shown an adverse effect, but adequate studies in pregnant women have not demonstrated a risk to the fetus during the first trimester of pregnancy, and there is no evidence of risk in the last two trimesters.

CATEGORY C

Animal studies have shown an adverse effect on the fetus, but there are no adequate studies in humans. The benefits from the use of the drug in pregnant women may be acceptable despite its potential risks.

There are no animal reproduction studies and no adequate studies in humans.

CATEGORY D

There is evidence of human fetal risk, but the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks.

CATEGORY X

Studies in animals or humans or adverse reaction reports, or both, have demonstrated fetal abnormalities. The risk of use in pregnant women clearly outweighs any possible benefit.

BREAST-FEEDING COMPATIBILITY

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As noted, no formal system exists for categorizing drugs or substances and their effect on breast-feeding, lactation, and effects on the infant. The following system is used in this book:

CATEGORY (+): Generally compatible with breast-feeding.
CATEGORY (−): Avoid with breast-feeding. Toxicity can be seen.
CATEGORY (CI): Contraindicated.

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Drug (FDA Fetal Risk Category/Breast-Feeding Compatibility)

Effect on Lactation and Adverse Effects on Infant

Abacavir (C/−)

CDC recommends HIV-infected mothers to not breast-feed.

Acarbose (B/−)

No human lactation data available. Avoid breast-feeding until safety data available.

Acebutolol (B/−)

Associated with adverse effects in nursing infants.

Acetaminophen (B/+)

AAP classifies as compatible with breast-feeding.

Acetylcysteine (B/+)

No human lactation data available. Probably compatible.

Acyclovir (B/+)

AAP classifies as compatible with breast-feeding.

Adenosine (C/+)

IV drug, used in acute care situations, short half-life.

Albendazole (C/+)

Probably compatible. Low oral bioavailability suggests excretion into breast milk not clinically significant. Avoid ingestion with high-fat meal.

Albuterol (C/+)

Monitor nursing infant for agitation and spitting up. Use inhaled form to decrease maternal absorption.

Alendronate (C/+)

Probably compatible. Low plasma concentrations and rapid plasma clearance suggest minimal amounts excreted into breast milk.

Alfentanil (C/+)

Limited human lactation data available. Probably compatible.

Allopurinol (C/+)

Limited human lactation data available. Probably compatible. AAP classifies as compatible with breast-feeding.

Almotriptan (C/+)

No human lactation data available. Probably compatible. Low molecular weight of drug suggests excretion into breast milk but effect on nursing infant is unknown.

Alprazolam (D/−)

Excreted into breast milk. Because of the potent effects on neurodevelopment, probable withdrawal, lethargy, and weight loss in infant, use should be avoided during breast-feeding.

Amantadine (C/CI)

Causes release of levodopa in CNS.

Amikacin (D/+)

Low concentrations in breast milk because of poor oral absorption.

Amiloride (B/+)

Excreted into breast milk of lactating rats at higher concentrations than in blood. No human lactation data available. Probably compatible.

Amitriptyline (C/−)

Milk plasma ratio of 1.0. Use in breast-feeding may be of concern.

Amlodipine (C/+)

No human lactation data available. Low molecular weight suggests excretion into breast milk. Effects on nursing infant are unknown. Probably compatible.

Amoxapine (C/−)

Active metabolites in milk. Use in breast-feeding may be of concern.

Amoxicillin (B/+)

Monitor nursing infant for diarrhea.

Amphetamine (C/CI)

AAP classifies as contraindicated during breast-feeding. Monitor nursing infant for irritability and poor sleeping pattern.

Amphotericin B (B/+)

No human lactation data available. Probably compatible.

Amphotericin B lipid complex (B/+)

No human lactation data available. Probably compatible.

Ampicillin (B/+)

Monitor nursing infant for diarrhea.

Amprenavir (C/CI)

CDC recommends HIV-infected mothers to not breast-feed.

Aripiprazole (C/−)

No human lactation data available. Potential for toxicity. The low molecular weight of drug combined with the prolonged half-life and the active metabolite suggest that one or both will be excreted into breast milk. However, the extensive protein binding should limit the excretion. If mother breast-feeds while taking drug, observe nursing infant for potent CNS effects, orthostatic hypotension, seizures, dysphasia, nausea, and vomiting. Long-term evaluation is warranted.

Aspirin (C, D/−)

Use with caution. Monitor nursing infant for spitting up or bleeding. May affect platelet function. Increased risk with high doses used for rheumatoid arthritis (3–5 grams/day). Metabolic acidosis may occur.

Atazanavir (B/CI)

CDC recommends HIV-infected mothers to not breast-feed.

Atenolol (D/−)

Use with caution. Monitor nursing infant for signs of β-blockade such as bradycardia. Has been associated with significant effects in nursing infants (cyanosis and bradycardia).

Atorvastatin (X/CI)

Some excretion into breast milk is expected; therefore, the potential for adverse effects in nursing infants exists and breast-feeding should be avoided.

Atropine (C/+)

No adverse effects reported. AAP classifies as compatible with breast-feeding.

Azathioprine (D/−)

Potential for toxicity with the active metabolites of the drug.

Azithromycin (B/+)

Accumulates in breast milk. Limited human lactation data available. Probably compatible.

Aztreonam (B/+)

Excreted into breast milk in low amounts, and with the acidic nature of the drug and low lipid solubility, oral absorption is poor. Systemic effects in nursing infants are unlikely.

Bacitracin (C/+)

No human lactation data available. Topical use compatible.

Baclofen (C/+)

Limited human lactation data available. AAP classifies as compatible with breast-feeding.

Beclomethasone (C/+)

Limited human lactation data available. Probably compatible. May be excreted into breast milk.

Belladonna (C/+)

No human lactation data available. Probably compatible.

Benazepril (C 1st tri; D 2nd, 3rd tri/+)

No human lactation data available. Probably compatible. Other ACE inhibitors are excreted into breast milk in low amounts with no adverse effects on nursing infants.

Benztropine (C/−)

No human lactation data available. Probably compatible.

Betamethasone (C, D/+)

No human lactation data available. Molecular weight suggests excretion into breast milk. Probably compatible.

Bethanechol (C/−)

Limited human lactation data available. Low molecular weight suggests excretion into breast milk. Abdominal pain and diarrhea reported in nursing infant exposed to bethanechol.

Bisacodyl (C/+)

No human lactation data available. Although molecular weight is low enough for excretion into breast milk, only minimal amounts are absorbed into maternal circulation. Therefore, effects on nursing infant would be negligible.

Bismuth subsalicylate (C/−)

Use with caution because of potential for adverse effects from salicylates. Should be avoided.

Bisoprolol (C/−)

No human lactation data available. Excreted into milk of lactating rats. If used during breast-feeding, nursing infant should be observed for hypotension, bradycardia, and other signs and symptoms of β-blockade.

Botulinum toxin type A (C/+)

No human lactation data available. Probably compatible. Toxin not expected to appear in circulation and therefore will not appear in breast milk.

Brompheniramine (C/+)

Monitor nursing infant for agitation, poor sleeping pattern, and feeding problems. Probably compatible.

Budesonide (oral/inhaler/nasal) (B, inhaler; C, oral/+)

Systemic bioavailability of inhaled budesonide is low, so the actual amount in breast milk may also be low. Oral potency is 25 times more glucocorticoid activity than hydrocortisone; however, the clinical significance is unknown. Manufacturer suggests that mother who must use the PulmicortTurbuhaler stop breast-feeding.

Bumetanide (C/+)

No human lactation data available. Probably compatible. Diuretics may suppress lactation.

Buprenorphine (C/−)

Excreted into breast milk. May suppress milk production and result in lower amounts of weight gain in nursing infant. Mothers should avoid breast-feeding if taking buprenorphine.

Bupropion (B/−)

Excreted into breast milk. Effect on nursing infant is unknown but may be of concern.

Buspirone (B/−)

Limited human lactation data available. Potential toxicity exists. Buspirone and its metabolites are excreted into the milk of lactating rats. Potential exists for CNS impairment in nursing infant. May be of concern because of effects on the developing brain that may not be known until later in life.

Butorphanol (C/+)

Limited human lactation data available. Probably compatible. Excreted into breast milk at levels that are probably not clinically significant.

Caffeine (B/+)

Monitor nursing infant for irritability and poor sleeping pattern. No effect with moderate intake (2–3 cups/day).

Calcitonin—salmon (C/+)

May inhibit lactation.

Calcitriol (C/+)

High-dose supplementation in mothers can lead to elevated levels of vitamin D₂ in breast milk and subsequently lead to hypercalcemia in breast-fed infants. Caution is advised.

Candesartan (C 1st tri; D 2nd, 3rd tri/+)

No human lactation data available. Low molecular weight suggests that drug would be excreted into breast milk. Effects on nursing infant unknown.

Captopril (C 1st tri; D 2nd, 3rd tri/+)

Excreted into breast milk in low concentrations. Available data showed no effects on nursing infants. AAP classifies as compatible with breast-feeding.

Carbamazepine (D/+)

Risk of bone marrow suppression if taken chronically.

Carisoprodol (C/+)

Limited human lactation data available. Probably compatible. Observe nursing infant for sedation and other behavioral changes.

Carvedilol (C/−)

Casanthranol (C/+)

Limited human lactation data available. Probably compatible. Observe nursing infant for diarrhea.

Cascara sagrada (C/+)

Limited human lactation data available. Probably compatible. Observe nursing infant for diarrhea.

Cefaclor (B/+)

Excreted into breast milk in low concentrations. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction. Compatible with breast-feeding.

Cefadroxil (B/+)

Cefazolin (B/+)

Cefdinir (B/+)

Probably excreted into breast milk in low concentrations. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction. Compatible with breast-feeding.

Cefepime (B/+)

Cefixime (B/+)

Cefotaxime (B/+)

Cefotetan (B/+)

Cefoxitin (B/+)

Ceftazidime (B/+)

Ceftriaxone (B/+)

Cefuroxime (B/+)

Celecoxib (C/−)

Excreted into breast milk. Safest course of action is to avoid use during breast-feeding.

Cephalexin (B/+)

Cerivastatin (X/CI)

Excreted into breast milk. Because of potential for adverse effects, avoid use if breast-feeding.

Cetirizine (B/+)

Manufacturer states drug excreted into breast milk. Effects on nursing infant unknown but observe for sedation.

Chloral hydrate (C/+)

Monitor nursing infant for sedation and rash.

Chlordiazepoxide (D/−)

No human lactation data available. Low molecular weight suggests excretion into breast milk should be expected. Other benzodiazepines have produced adverse effects in nursing infants. Use should be avoided during breast-feeding.

Chlorhexidine (B/+)

No reports of excretion into breast milk available. Rinse nipples if chlorhexidine is used to cleanse them. Compatible with breast-feeding.

Chloroquine (C/+)

Insufficient amounts excreted in breast milk to provide adequate protection against malaria.

Chlorothiazide (C/+)

May suppress lactation, especially in the first month of lactation. Adverse effects have not been reported, but infant's electrolytes and platelets should be monitored.

Chlorpromazine (C/−)

Excreted into breast milk in low amounts. Observe nursing infant for sedation. AAP classifies it as a drug that is a concern for nursing infants because of drowsiness and lethargy and because of galactorrhea induced in adults.

Chlorpheniramine (B/+)

Monitor nursing infant for agitation, poor sleeping pattern, and feeding problems.

Cholecalciferol (C, D/+)

Compatible with breast-feeding. Excreted into breast milk in limited amounts. The Committee on Nutrition of the AAP recommends vitamin D supplementation in breast-fed infants if maternal intake is low or exposure to ultraviolet light is insufficient. Monitor serum calcium levels of nursing infant if mother is taking pharmacologic doses of vitamin D.

Cholestyramine (B/+)

Nonabsorbable resin. No human lactation data available. Drug binds fat-soluble vitamins, and prolonged use may result in deficiencies of these vitamins in mother and nursing infant.

Cimetidine (B/+)

Use with caution. May suppress gastric acidity in infant, inhibit drug metabolism, and cause CNS stimulation.

Ciprofloxacin (C/+)

Data are limited and the amount of drug in breast milk does not appear to represent significant risk to nursing infant. AAP classifies as compatible with breast-feeding. However, the manufacturer recommends that mother should wait 48 hours after last dose before breast-feeding.

Citalopram (C/−)

Doses >20 mg/day or concurrent use of other sedative agents may increase risk of adverse effects to nursing infants. Observe for toxicity. Long-term effects on neurobehavioral development are unknown. Avoid nursing around peak maternal concentrations—about 4 hours after a dose.

Clarithromycin (C/+)

No human lactation data available. Passage of drug into breast milk should be expected. Based on experience with other antibiotics such as erythromycin, risk to nursing infant is probably minimal.

Clavulanate (B/+)

No human lactation data available. Molecular weight suggests excretion into breast milk. Effects of β-lactamase inhibitors on nursing infants are unknown.

Clindamycin (B/+)

Excreted into breast milk. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction. AAP classifies as compatible with breast-feeding.

Clonazepam (D/−)

Monitor nursing infant for respiratory and CNS depression.

Clonidine (C/+)

Excreted in breast milk. Hypotension was not observed in nursing infants, although clonidine was found in the serum of these nursing infants. Long-term significance of this exposure is unknown.

Clopidogrel (B/+)

No human lactation data available. Low molecular weight suggests excretion into breast milk. Effects on nursing infants are unknown.

Clotrimazole (B/+)

Absorption from skin and vagina is minimal. Unlikely that the levels of this antifungal agent appear in breast milk.

Clozapine (B/−)

Concentrated in breast milk. Avoid breast-feeding.

Cocaine (C/CI)

Causes cocaine intoxication in infant from maternal intranasal use (hypertension, tachycardia, mydriasis, and apnea) and from topical use on mother's nipples (apnea and seizures).

Codeine (C, D/−)

Short-term therapy (1 or 2 days) with close monitoring is compatible; however, long-term therapy is not compatible with breast-feeding. Monitor nursing infant for sedation. Milk ejection reflex (letdown) may be inhibited.

Colchicine (D/+)

Excreted into breast milk. No adverse effects on nursing infants have been observed. Waiting 8–12 hours after dose to breast-feed minimizes exposure of nursing infant.

Cortisone (C, D/+)

No reports of the excretion of exogenous cortisone into human milk. Unlikely that it poses risk to nursing infant. Compatible with breast-feeding.

Cromolyn sodium (B/+)

No human lactation data available.

Cyclobenzaprine (B/−)

No reports of excretion into breast milk available. Low molecular weight suggests excretion should occur.

Dactinomycin (C/−)

No human lactation data available. Despite the high molecular weight, women receiving the drug should avoid breast-feeding because of the potential risk of severe adverse effects.

Dalteparin (B/+)

No human lactation data available. Based on the molecular weight and because the drug would be inactivated in the GI tract, the risk to the nursing infant would be negligible.

Darbepoetin alfa (C/+)

No human lactation data available. Passage into breast milk is not expected. Risk to nursing infant appears to be negligible.

Deferasirox (B/−)

No human lactation data available. Molecular weight and long elimination half-life suggest excretion into breast milk. Amount of oral absorption in infants unknown; in adults oral bioavailability is 70%. With the potential to deplete infant's iron stores, breast-feeding should be avoided during therapy.

Deferoxamine (C/+)

No human lactation data available. Molecular weight is low enough for some excretion into breast milk to be expected. Effects, if any, on nursing infant are unknown.

Delavirdine (C/CI)

No human lactation data available. Molecular weight suggests excretion into breast milk should be expected. Effect on nursing infant is unknown. CDC recommends HIV-infected mothers in developed countries to not breast-feed.

Desloratadine (C/+)

No human lactation data available. Desloratadine and loratadine are excreted into breast milk. Probably compatible.

Dexamethasone (C, D/+)

No human lactation data available. Excretion into breast milk should be expected. Probably compatible.

Dextroamphetamine (C/−)

May cause infant stimulation.

Dextromethorphan (C/+)

No human lactation data available. Low molecular weight suggests excretion into breast milk. Probably compatible. Use alcohol-free preparation.

Diatrizoate (C/+)

In one study, not detected in breast milk. Probably compatible.

Diazepam (D/−)

May cause infant sedation. May accumulate in breast-fed infants.

Diclofenac (B/+)

No human lactation data available. Manufacturer states that drug excreted into breast milk. Short half-life in adults. Probably compatible.

Dicloxacillin (B/+)

No human lactation data. However, other penicillins are excreted into breast milk in low concentrations. Adverse effects rare. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction.

Didanosine (B/CI)

Diethylstilbestrol (DES) (X/CI)

No human lactation data available. Possible decreased milk volume and decreased nitrogen and protein content could occur.

Digoxin (C/+)

Excreted into breast milk in small amounts. Monitor nursing infant for spitting up, diarrhea, and heart rate changes. Compatible with breast-feeding.

Dihydroergotamine (X/CI)

No human lactation data available. Molecular weight and long half-life suggests excretion into breast milk, but high protein binding will limit this. Concern for symptoms of ergotism—vomiting, diarrhea, and convulsions in nursing infants. Breast-feeding is contraindicated.

Diltiazem (C/+)

Excreted into breast milk. Two nursing infants were not affected. Probably compatible.

Dimenhydrinate (B/+)

No human lactation data available. Molecular weight suggests excretion into breast milk should be expected. Probably compatible. Caution—newborns and premature infants have increased sensitivity to antihistamines.

Diphenhydramine (B/+)

Excreted into breast milk but levels are thought not to be in sufficiently high amounts to affect nursing infant. Monitor nursing infant for agitation, poor sleeping pattern, and feeding problems. Probably compatible.

Diphenoxylate (C/−)

Active metabolite probably excreted into breast milk. Potential toxicity.

Dipyridamole (B/+)

Excreted into breast milk. Effect unknown on nursing infant. Probably compatible.

Diphtheria and tetanus vaccine (C/+)

No human lactation data. Probably compatible.

Docusate (calcium, potassium, sodium) (C/+)

Probably compatible. Monitor nursing infant for diarrhea.

Dolasetron (B/+)

No human lactation data available. Low molecular weight of drug suggests excretion into breast milk should be expected. Effects on nursing infant are unknown.

Dornase alfa (B/+)

No human lactation data available. Inhaled drug does not increase endogenous serum concentration of drug. Not expected to be excreted into breast milk. Negligible risk to nursing infant.

Doxycycline (D/+)

Excreted into breast milk in low concentrations. Theoretical dental staining and inhibition of bone growth is remote. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction. AAP classifies as compatible with breast-feeding.

Echinacea (C/−)

Avoid use during breast-feeding.

Efavirenz (C/CI)

Eletriptan (C/+)

Excreted into breast milk. Effects of exposure to nursing infants are unknown but low concentration not thought to be significant. Compatible with breast-feeding.

Emtricitabine (B/CI)

No human lactation data available. Molecular weight, low plasma protein binding, and long half-life suggest excretion into breast milk should be expected. Effect on nursing infant is unknown. CDC recommends HIV-infected mothers in developed countries to not breast-feed.

Enalapril (C 1st tri; D 2nd, 3rd tri/+)

Enalapril and enalaprilat are excreted into breast milk in small amounts such that risk to nursing infant appears negligible/clinically insignificant. AAP classifies as compatible with breast-feeding.

Enfuvirtide (B/CI)

No human lactation data available. Molecular weight and high plasma protein binding should inhibit but not prevent excretion into breast milk. Effect on nursing infant is unknown. CDC recommends HIV-infected mothers in developed countries to not breast-feed.

Enoxaparin (B/+)

No human lactation data available. Based on high molecular weight and probable inactivation by GI tract, the passage of drug into breast milk and its risk to nursing infant is considered negligible.

Entecavir (C/CI HIV; C/+ hepatitis B)

No human lactation data available. Molecular weight and half-life suggest drug should be excreted into breast milk. Effects on nursing infants are unknown. Infants of HBsAg-positive or HBeAg-positive mothers should receive HBIG at birth and hepatitis B vaccine soon after birth. Then breast-feeding is permitted. Breast-feeding is contraindicated in HIV-1–positive mothers in the United States.

Ephedrine (C/−)

Limited human lactation data available. Observe nursing infant for irritability, excessive crying, and disturbed sleeping patterns. Avoiding breast-feeding is recommended.

Epoetin alfa (C/+)

No human lactation data available. Excretion into breast milk is not expected and drug would be digested in GI tract. No risk to nursing infant expected.

Epoprostenol (B/+)

No human lactation data available. Based on its rapid degradation, a physiologic pH, and the GI tract, amount of drug nursing infant exposed to would not be clinically significant.

Eprosartan (C 1st tri; D 2nd, 3rd tri/+)

No human lactation data available. Expect excretion into breast milk. Effects on nursing infant are unknown. AAP classifies ACE inhibitors, a similar class of agents, compatible with breast-feeding.

Ergotamine (X/CI)

Causes vomiting, diarrhea, and convulsions in the nursing infant. May hinder lactation. Breast-feeding is contraindicated.

Ertapenem (B/+)

Excreted into breast milk in low concentrations. Effects on nursing infant unknown but probably are not clinically significant. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction. Compatible with breast-feeding.

Erythromycin (B/+)

Excreted into breast milk in low concentrations. No reports of adverse effects in nursing infants. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction. Compatible with breast-feeding.

Escitalopram (C/−)

No human lactation data available. Expect excretion into breast milk. Effects on nursing infant unknown. Adverse effects have been seen with similar agent (citalopram), expect similar effects. Closely monitor nursing infants. AAP classifies other SSRIs as drugs for which effect on nursing infants is unknown but may be of concern.

Esomeprazole (B/−)

No human lactation data available. Expect excretion into breast milk. Effects on nursing infant unknown. Potential for toxic effects: headache, diarrhea and abdominal pain, suppression of gastric acid secretion. Half-life is short, 1–1.5 hours. Waiting 5–7.5 hours after dose should eliminate 97% of drug from plasma.

Estrogens, conjugated (X/+)

No adverse effects in nursing infants reported. May decrease milk volume, and nitrogen and protein content.

Ethambutol (B/+)

Excreted into breast milk. AAP classifies as compatible with breast-feeding.

Ethanol (D, X/−)

Passes freely into breast milk in levels similar to those in maternal serum. Because of risk of toxicity in nursing infant, safest course is to hold breast-feeding for 1–2 hours for each ounce of alcohol consumed.

Ethinyl estradiol (X/+)

No adverse effects in nursing infants reported. May decrease milk volume, and nitrogen and protein content. Monitor weight gain of infant and use lowest dose.

Famciclovir (B/−)

No human lactation data available. Expect excretion into breast milk. Avoid breast-feeding.

Famotidine (B/+)

Excreted into breast milk but to lesser extent than cimetidine and ranitidine. Effects on nursing infant are unknown. Potential risk for adverse effects; however, AAP classifies cimetidine as compatible with breast-feeding. Famotidine may be preferred because of lesser amount in breast milk.

Flecainide (C/+)

Excreted into breast milk but effects on nursing infant are unknown. Probably not toxic. AAP classifies as compatible with breast-feeding.

Fluconazole (C/+)

Excreted into breast milk. No drug-associated toxicity has been reported. AAP classifies as compatible with breast-feeding.

Flucytosine (C/−)

No human lactation data available. Because of potential serious adverse effects in nursing infant, breast-feeding should be avoided.

Fluoxetine (C/−)

Long-term effects on neurobehavioral development from exposure to potent serotonin reuptake blocker during period of rapid CNS development have not been adequately studied. Manufacturer recommends breast-feeding should be avoided during fluoxetine therapy. AAP classifies as effects on nursing infant unknown but may be of concern. Maternal benefits may outweigh risks to nursing infant if treating postpartum depression. Colic, irritability, sleep disorders, and poor weight gain may occur.

Fondaparinux (B/+)

No human lactation data available. Excretion into breast milk should be expected. Effects on nursing infants unknown but not thought to be clinically significant.

Fosamprenavir (C/CI)

Furosemide (C/+)

Excreted into breast milk. No reports of adverse effects in a nursing infant.

Gabapentin (C/+)

No human lactation data available. Probably compatible. Low molecular weight of drug suggests excretion into breast milk but effect on nursing infant is unknown.

Gadopentetate dimeglumine (MRI contrast) (C/+)

Excreted into breast milk in small amounts. Very little is absorbed systemically. AAP classifies as compatible with breast-feeding.

Ganciclovir (C/−)

No human lactation data available. Potential for serious toxicity in nursing infant. Avoid breast-feeding.

Gentamicin (C/+)

Small amounts excreted into breast milk and absorbed by nursing infants. Observe infant for bloody stools and diarrhea. AAP classifies as compatible with breast-feeding.

Ginkgo biloba (C/−)

No human lactation data available. Herbal product that is not standardized and may contain other compounds. Safest course is to avoid breast-feeding.

Ginseng (B/−)

No human lactation data available. Herbal product that is not standardized and may contain other compounds. Safest course is to avoid breast-feeding.

Glimepiride (C/+)

No human lactation data available. Molecular weight suggests excretion into breast milk should be expected. Risk of neonatal hypoglycemia. Breast-feeding women should consider insulin.

Glipizide (C/+)

Minimal to nondetectable levels in breast milk. Normal glucose levels in nursing infants.

Glucosamine (C/+)

No human lactation data available. Molecular weight and prolonged plasma protein elimination half-life suggest excretion into breast milk should be expected. Unbound drug is undetectable in plasma; therefore, little if any drug will be excreted into milk. Probably compatible.

Glyburide (C/+)

Nondetectable levels in breast milk. Normal glucose levels in nursing infants. Probably compatible.

Guaifenesin (C/+)

No human lactation data available. Probably compatible.

Haemophilus b conjugate vaccine (C/+)

Compatible with breast-feeding.

Haloperidol (C/−)

Excreted into breast milk. Use may be of concern. Effects on nursing infant unknown. Possible decline in developmental score.

Heparin (C/+)

Not excreted into breast milk.

Hepatitis A vaccine (C/+)

No human lactation data available. Probably compatible.

Hepatitis B vaccine (C/+)

No human lactation data available. Probably compatible.

Heroin (B, D/CI)

Crosses into breast milk in sufficient amounts to cause addiction in nursing infant. Breast-feeding is contraindicated.

Human papillomavirus vaccine (B/+)

Compatible with breast-feeding.

Hydralazine (C/+)

Excreted into breast milk. No adverse effects noted in nursing infants. AAP classifies as compatible with breast-feeding.

Hydrochlorothiazide (B/+)

May suppress lactation, especially in the first month of lactation. Adverse effects have not been reported, but infant's electrolytes and platelets should be monitored.

Hydrocodone (C, D/+)

No human lactation data available. Molecular weight suggests excretion into breast milk should be expected. Observe nursing infant for GI effects, sedation, and changes in feeding patterns.

Hydrocortisone (C, D/+)

No human lactation data available. Unlikely that it poses risk to nursing infant. Compatible with breast-feeding.

Hydromorphone (B, D/+)

Excreted into breast milk. Monitor nursing infant for sedation. Milk ejection reflex (letdown) may be inhibited.

Hydroxychloroquine (C/+)

Excreted into breast milk. Slow elimination rate. Breast-feeding during daily therapy should be done with caution. Once- weekly doses significantly reduce amount of drug exposure to nursing infant. AAP classifies as compatible with breast-feeding. Amount in breast milk is not adequate to provide malaria protection for infant.

Hydroxyzine (C/+)

No human lactation data available. Molecular weight suggests excretion into breast milk should be expected. Effects on nursing infant unknown.

Ibuprofen (B/+)

Excreted into breast milk. Amount of drug available to nursing infant is minimal. AAP classifies as compatible with breast-feeding.

Imipenem-cilastatin (C/+)

Small amounts excreted into breast milk in amounts comparable to other β-lactam antibiotics. Effects on nursing infant are unknown.

Indinavir (C/CI)

Indomethacin (B, D/+)

Excreted into breast milk. One case report of seizure in nursing infant. AAP classifies as compatible with breast-feeding.

Influenza vaccine (C/+)

Maternal vaccination is compatible with breast-feeding.

Iodine (D/+)

May cause goiter.

Isoniazid (C/+)

Isoniazid and its metabolite are excreted into breast milk. Monitor nursing infant for signs and symptoms of peripheral neuritis or hepatitis. AAP classifies as compatible with breast-feeding.

Ivermectin (C/+)

Excreted into breast milk but no human lactation data available. Low drug levels in milk probably not a risk to nursing infant. AAP classifies as compatible with breast-feeding.

Kaolin/pectin (C/+)

No effect on nursing infant.

Ketamine (B/+)

Should be undetectable in maternal plasma ~11 hours after dose. Breast-feeding after this time should not expose the nursing infant to drug.

Ketoconazole (C/+)

Excreted into breast milk. Effects of exposure to nursing infants are unknown but not thought to be significant. AAP classifies as compatible with breast-feeding.

Ketorolac (C; D if used in 3rd tri or near delivery/+)

Excreted into breast milk in amounts that are considered clinically insignificant. AAP classifies as compatible with breast-feeding.

Labetalol (C/+)

Monitor nursing infant for hypotension and bradycardia.

Lactulose (B/+)

No human lactation data. Probably compatible.

Lamivudine (C/CI)

Excreted into breast milk. Effect on nursing infant is unknown. CDC recommends HIV-infected mothers in developed countries to not breast-feed.

Lamotrigine (C/−)

May be of concern. Consider monitoring infant's serum lamotrigine concentration.

Lansoprazole (B/−)

No human lactation data available. Excretion into breast milk is expected. Potential effects on nursing infant—carcinogenicity (animal data) and suppression of gastric acid secretion. Avoid breast-feeding.

Levetiracetam (C/+)

No human lactation data available. Low molecular weight and protein binding suggest excretion into breast milk should be expected. Effects on nursing infant are unknown. AAP classifies as compatible with breast-feeding.

Levofloxacin (C/+)

Excreted into breast milk. Effects on nursing infants are unknown. AAP classifies as compatible with breast-feeding.

Levothyroxine (A/+)

Probably does not interfere with neonatal thyroid screening.

Lindane (B/+)

No human lactation data available. Excreted into breast milk. Small amounts ingested by nursing infant are probably clinically insignificant. Waiting 4 days after discontinuing lotion should prevent exposure to nursing infant.

Linezolid (C/−)

No human lactation data available. Excretion into breast milk is expected. Effects on nursing infant unknown. Potential effects—myelosuppression and reversible thrombocytopenia. Avoid breast-feeding.

Lisinopril (C 1st tri; D 2nd, 3rd tri/+)

No human lactation data available. Excretion into breast milk should be expected. AAP classifies as compatible with breast-feeding.

Lithium (D/−)

Milk levels average 40% of maternal serum concentration. Monitor nursing infant for cyanosis, hypotonia, bradycardia, and other lithium toxicities.

Loperamide (B/+)

No human lactation data available. AAP classifies as compatible with breast-feeding.

Lopinavir (C/CI)

No human lactation data available. Molecular weight and lipid solubility suggest excretion into breast milk should be expected; however, extensive plasma protein binding should limit this. Effect on nursing infant is unknown. CDC recommends HIV-infected mothers in developed countries to not breast-feed.

Loratadine (B/+)

Loratadine and its metabolite are excreted into breast milk. Probably little clinical risk to nursing infant. AAP classifies as compatible with breast-feeding.

Lorazepam (D/−)

Monitor nursing infant for sedation, especially if exposure is prolonged.

Losartan (C 1st tri; D 2nd, 3rd tri/+)

No human lactation data available. Excretion into breast milk is expected. Effects of exposure to nursing infant are unknown. AAP considers compatible with breast-feeding.

Measles vaccine (X, C/+)

Compatible with breast-feeding.

Meclizine (B/+)

Medroxyprogesterone (D/+)

AAP classifies as compatible with breast-feeding.

Meningococcal vaccine (C/+)

No human lactation data. Probably compatible.

Meperidine (B, D/+)

Monitor nursing infant for sedation. Milk ejection reflex (letdown) may be inhibited. AAP classifies as compatible with breast-feeding.

Meropenem (B/+)

No human lactation data available. Expect excretion into breast milk. Potential effects on nursing infant are unknown.

Mesalamine (B/−)

Small amount excreted into breast milk. Risk of adverse effect (diarrhea) in nursing infant. AAP classifies as drug that should be used with caution during breast-feeding.

Metformin (B/+)

Excreted into breast milk. Nursing infants had normal blood glucose levels.

Methadone (B, D/+)

Generally compatible with breast-feeding. Monitor nursing infant for sedation, depression, and withdrawal on cessation of methadone treatment. AAP classifies as compatible with breast-feeding.

Methamphetamine (C/CI)

AAP classifies amphetamines as contraindicated during breast-feeding. Monitor nursing infant for irritability and poor sleeping pattern.

Methimazole (D/+)

Potential for interfering with thyroid function.

Methocarbamol (C/+)

Any amounts of drug excreted into breast milk probably not clinically significant.

Methyldopa (B/+)

Risk of hemolysis and increased liver enzymes.

Methylphenidate (C/−)

Excreted into breast milk. Potential toxicity will probably occur in 1st month of life. Observe nursing infant for signs and symptoms of CNS stimulation—decreased appetite, insomnia, and irritability.

Metoclopramide (B/−)

Increases milk production. Effects on nursing infant unknown but may be of concern because it is a dopaminergic-blocking agent.

Metolazone (B/+)

May suppress lactation, especially in the first month of lactation. Adverse effects have not been reported but infant's electrolytes and platelets should be monitored.

Metoprolol (C/−)

Monitor nursing infant for bradycardia and hypotension.

Metronidazole (B/−)

Discontinue during breast-feeding. Do not nurse until 12–24 hours after discontinuing to allow excretion of drug.

Minocycline (D/+)

Excreted into breast milk in low concentrations. Theoretical dental staining and inhibition of bone growth are remote. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction. Compatible with breast-feeding.

Mirtazapine (C/−)

Excreted into breast milk. Long-term effects on neurobehavioral development unknown. AAP classifies other antidepressants as drugs for which effect on nursing infant is unknown but may be of concern.

Montelukast (B/+)

Monitor nursing infant for sedation. Milk ejection reflex (letdown) may be inhibited.

Morphine (C/+)

Excreted into breast milk. AAP classifies as compatible with breast-feeding. Long-term effects on neurobehavioral development are unknown.

Mumps vaccine (C/+)

No human lactation data. Probably compatible.

Nafcillin (B/+)

No human lactation data. Refer to Penicillin.

Nalbuphine (B/+)

No human lactation data available. Expect small amount of drug to be excreted into breast milk. Amounts are clinically insignificant.

Nalorphine (D/+)

No human lactation data available.

Naloxone (B/+)

No human lactation data available.

Naltrexone (C/−)

No human lactation data available. Expect excretion into breast milk. Effects on nursing infant are unknown. Potential adverse effects of drug—alteration of opioid receptors in the brain; altered levels of some hormones of hypothalamic, pituitary, adrenal, and gonadal origin.

Naproxen (B/+)

Passes into breast milk in very small quantities. Effects on nursing infant are unknown. AAP classifies as compatible with breast-feeding.

Naratriptan (C/+)

No human lactation data available. Excretion into breast milk should be expected. Effects on nursing infant are unknown.

Nelfinavir (B/CI)

Nevirapine (C/CI)

Excreted into breast milk. CDC recommends HIV-infected mothers in developed countries to not breast-feed.

Nicotine (transdermal, others) (D/−)

May be of concern. Excessive amounts may cause diarrhea, vomiting, tachycardia, irritability, decreased milk production, and decreased weight gain.

Nifedipine (C/+)

Manufacturer states significant amounts of drug excreted into breast milk. No human lactation data available.

Nitrofurantoin (B/+)

Excreted in breast milk in small amounts. Monitor nursing infants with G6PD deficiency for hemolytic anemia.

Nortriptyline (C/−)

Excreted into breast milk in low concentrations. No adverse effects noted in breast-feeding infants. Long-term effects of chronic exposure to antidepressants in nursing infants are unknown with concern for effects on the infant's neurobehavioral development. AAP classifies as drug for which effect on nursing infant is unknown but may be of concern.

Nystatin (C/+)

Poorly absorbed if at all. Excretion into breast milk would not occur.

Olanzapine (C/−)

Sedation has occurred in nursing infants. Decreasing dose may eliminate this problem but may affect control of mother's disease. Avoid use during breast-feeding.

Olsalazine (C/−)

Active metabolite, 5-aminosalicylic acid (mesalamine), is excreted into human milk. Diarrhea reported in nursing infant of mother receiving mesalamine.

Omeprazole (C/−)

Limited human lactation data available. Excretion into breast milk is expected. Effects on nursing infant are unknown. Use during breast-feeding should be avoided. Concern for suppression of gastric acid secretion and carcinogenicity observed in animals.

Ondansetron (B/+)

No human lactation data available. Expect excretion into breast milk. Effects on nursing infant are unknown.

Oral contraceptives (all classes) (X/+)

Causes dose-dependent suppression of lactation. Decreased weight gain, milk production, and nitrogen and protein content of human milk have been associated with this drug. Changes probably only significant in malnourished mothers. Use lowest dose possible. AAP classifies drug as compatible with breast-feeding.

Orlistat (B/+)

No human lactation data available. Limited systemic bioavailability would suggest that it would not appear in breast milk.

Oseltamivir (C/+)

No human lactation data available. Molecular weight suggests excretion into breast milk should be expected. Effect on nursing infant is unknown.

Oxacillin (B/+)

Excreted into breast milk in low concentrations. Adverse effects rare. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction.

Oxcarbazepine (C/+)

One report of use during human lactation. No adverse effects reported. AAP classifies carbamazepine as compatible with breast-feeding; oxcarbazepine can be also considered compatible.

Oxycodone (B/+)

Monitor nursing infant for drowsiness.

Pamidronate (D/+)

No human lactation data available. Molecular weight, prolonged half-life, and lack of metabolism suggest drug will be excreted into breast milk. Considering the bioavailability, the amount absorbed by the nursing infant will be clinically insignificant. Probably compatible.

Pantoprazole (B/+)

Excreted into breast milk in small amounts. Has potential for suppression of gastric acid secretion in nursing infant but overall risk of toxicities is low.

Paregoric (B, D/+)

Probably excreted into breast milk. Limited human lactation data available. Probably compatible.

Paroxetine (D/−)

Effect on nursing infant is unknown but may be of concern.

Penicillin G (all forms) (B/+)

All antibiotics are excreted in breast milk in limited amounts. Monitor nursing infant for rash, diarrhea, and spitting up.

Pentamidine (C/CI)

Systemic concentrations reached with aerosolized drug are very low. Breast milk levels would be nil.

Pentobarbital (D/−)

Excreted into breast milk. Effects on nursing infant are unknown.

Permethrin (B/+)

No human lactation data available. Little if any drug expected to be excreted into breast milk. CDC considers permethrin or pyrethrins with piperonyl butoxide treatment of choice for pubic lice during lactation.

Phenobarbital (D/−)

Monitor nursing infant for sucking problems, sedation, rashes, and withdrawal. AAP classifies as drug that has caused major adverse effects in some nursing infants. Use caution if breast-feeding.

Phenytoin (D/+)

Monitor nursing infant for methemoglobinuria (rare). Keep maternal phenytoin in therapeutic range.

Piroxicam (C/+)

Excreted into breast milk in amounts that probably do not present a risk to nursing infant. AAP classifies as compatible with breast-feeding.

Pneumococcal vaccine (C/+)

No human lactation data available. Probably compatible.

Poliovirus inactivated vaccine (C/+)

No human lactation data available. Probably compatible.

Poliovirus live vaccine (C/+)

Compatible with breast-feeding. To prevent inhibition of the vaccine, breast-feeding should be withheld 6 hours before and after administration of vaccine.

Pravastatin (X/CI)

No human lactation data available. Excreted into breast milk. Because of the potential for adverse effects in the nursing infant, avoid use during lactation.

Prednisolone (C, D/+)

Trace amounts have been measured in breast milk. Concentration did not pose clinically significant risk to nursing infant. AAP classifies as compatible with breast-feeding.

Prednisone (C, D/+)

Trace amounts have been measured in breast milk. Concentration did not pose clinically significant risk to nursing infant. AAP classifies as compatible with breast-feeding.

Pregabalin (C/−)

No human lactation data available. Expect excretion into breast milk. Effects on nursing infants are unknown. Monitor nursing infant for dizziness, somnolence, blurred vision, peripheral edema, myopathy, and decreased platelet count. Avoid use during breast-feeding.

Probenecid (C/−)

Excreted into breast milk. Toxicity observed probably related to concurrent antibiotic administered. Observe nursing infant for diarrhea.

Procainamide (C/+)

Excreted in and accumulates in milk. AAP classifies as compatible with breast-feeding. Long-term effects of exposure in nursing infants are unknown.

Prochlorperazine (C/−)

Other phenothiazines excreted into breast milk, so prochlorperazine excretion expected. Sedation in nursing infant a possible side effect.

Propoxyphene (C, D/+)

Monitor nursing infant for withdrawal after long-term high-dose maternal use.

Propranolol (C/−)

Monitor nursing infant for hypotension and bradycardia.

Propylthiouracil (D/+)

Monitor thyroid function of infant periodically.

Pseudoephedrine (C/+)

Monitor nursing infant for agitation.

Pyrazinamide (C/+)

Excreted into human milk in small amounts. Probably compatible.

Pyrimethamine (C/+)

Excreted into breast milk. AAP classifies as compatible with breast-feeding.

Quetiapine (C/−)

Excreted into breast milk. No reports of adverse effects in nursing infants. Long-term effects of this exposure are unknown. Manufacturer recommends avoiding breast-feeding.

Quinidine (C/+)

Monitor nursing infant for rash, anemia, and arrhythmias. Risk of optic neuritis with chronic use.

Quinine (X/+)

Excreted into breast milk. No adverse effects reported in nursing infants. G6PD should be ruled out in infants at risk for the disease. AAP classifies as compatible with breast-feeding.

Quinupristin/dalfopristin (B/−)

No human lactation data available. Probably not excreted into breast milk. Caution—may alter the bowel flora of nursing infants. There is the potential for the development of resistant strains of VRE. Breast-feeding is not recommended.

Ranitidine (B/+)

Excreted into breast milk. Effects on nursing infant are unknown. Decreases gastric acidity but effect on nursing infant has not been studied. AAP classifies similar agent (cimetidine) as compatible with breast-feeding.

Remifentanil (C/+)

No human lactation data available. Expect excretion into breast milk. Very short half-life. Other narcotic agents are classified as compatible with breast-feeding by AAP.

Rifabutin (B/CI)

No human lactation data available. Excretion into breast milk expected. Milk may be stained brown-orange color. Effects on nursing infants are unknown but serious toxicity (leukopenia, neutropenia, rash) are potential adverse effects. Contraindicated if nursing mother is HIV-1 infected.

Rifampin (C/+)

Excreted into breast milk in amounts that pose very little risk to nursing infants. No adverse effects reported. AAP classifies as compatible with breast-feeding.

Rifapentine (C/+)

No human lactation data available. Expect excretion into breast milk. May cause red-orange discoloration. Effects on nursing infants are unknown. AAP classifies rifampin, a similar agent, as compatible with breast-feeding.

Rifaximin (C/+)

No human lactation data available. Expect excretion into breast milk but in very small amounts due to limited systemic absorption. Effects on nursing infants are unknown but probably not clinically significant.

Risperidone (C/−)

Excreted into breast milk. AAP classifies other antipsychotic drugs for which the effects on nursing infants are unknown but may be of concern, especially with long-term use. Could possibly alter short- and long-term CNS function.

Ritonavir (B/CI)

Rizatriptan (C/+)

No human lactation data available. Expect excretion into breast milk. Effects on nursing infants are unknown.

Rubella vaccine (C/+)

Compatible with breast-feeding. ACOG and CDC recommend vaccination of susceptible women in immediate postpartum period.

Salmeterol (C/+)

No human lactation data available. Expect excretion into breast milk but maternal plasma levels after inhaled dose are very low to undetectable. It is unlikely that clinically significant amounts would appear in breast milk.

Saquinavir (B/CI)

Scopolamine (C/+)

No human lactation data available. Excreted into breast milk. AAP classifies as compatible with breast-feeding.

Secobarbital (D/+)

Excreted into breast milk. Amount and effects on nursing infants are unknown. AAP classifies as compatible with breast-feeding.

Senna (C/+)

Observe nursing infant for diarrhea. AAP classifies as compatible with breast-feeding.

Sertraline (C/−)

Effect on nursing infant is unknown but may be of concern. Concentrated in human milk.

Simvastatin (X/CI)

No human lactation data available. Expect excretion into breast milk. Because of the potential for adverse effects in the nursing infant, avoid use during lactation.

Smallpox vaccine (X/CI)

CDC recommends breast-feeding women should not routinely be vaccinated; however, if nursing woman is exposed to smallpox or monkeypox, she should be vaccinated and stop breast-feeding.

Sotalol (B/−)

Milk levels 3–5 times maternal serum levels. Could cause bradycardia and hypotension.

Spironolactone (C/+)

Unknown if spironolactone is excreted into breast milk, but metabolite is found in breast milk—probably insignificant amount. Effects on nursing infants unknown. AAP classifies as compatible with breast-feeding.

SSKI (potassium iodide) (D/+)

The significance to nursing infant of chronic ingestion of higher levels of iodine unknown. AAP recognizes maternal use of iodides during lactation may affect infant's thyroid activity by producing elevated iodine levels in breast milk; it classifies as compatible with breast-feeding. Consider monitoring infant's thyroid function.

St. John's wort (C/−)

Unknown if any of the constituents and possible contaminants are excreted into breast milk or if exposure represents risk to nursing infant.

Stavudine (C/CI)

Sucralfate (B/+)

Minimal, if any, drug expected to be excreted into breast milk because only small amounts systemically absorbed.

Sulbactam (B/+)

Excretion into breast milk expected. Effects on nursing infants are unknown. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction. AAP classifies as compatible with breast-feeding.

Sulfamethoxazole (C/−)

Avoid in ill, stressed, or preterm infants and those with hyperbilirubinemia or G6PD deficiency.

Sulfasalazine (B, D/−)

May cause diarrhea in nursing infants. AAP classifies as drug that has been associated with significant effects on some nursing infants and should be given to nursing mother with caution.

Sulindac (B, D/−)

No human lactation data available. Because of prolonged half-life, use safer alternatives—diclofenac, fenoprofen, flurbiprofen, ibuprofen, ketoprofen, ketorolac, or tolmetin—during breast-feeding.

Sumatriptan (C/+)

Excreted into breast milk. Absorption from GI tract is inhibited so amount reaching nursing infant is probably negligible. AAP classifies as compatible with breast-feeding.

Telmisartan (C 1st tri; D 2nd, 3rd tri/+)

No human lactation data available. Molecular weight suggests that excretion into breast milk should be expected. Effects on nursing infant are unknown. AAP classifies as compatible with breast-feeding.

Temazepam (X/−)

Excreted into breast milk. Observe nursing infant for sedation and poor feeding.

Tenofovir (B/CI)

Terbutaline (B/+)

Monitor nursing infant for agitation and spitting up. Use inhaled form to decrease maternal absorption if available.

Tetanus/diphtheria toxoids and acellular pertussis vaccine (C/+)

Compatible with breast-feeding.

Tetracycline (D/+)

THC (marijuana) (X/CI)

AAP classifies as drug that should not be used during breast-feeding.

Theophylline (C/+)

AAP classifies as compatible with breast-feeding. Monitor nursing infant for irritability.

Tobramycin (C, D/+)

Excreted into breast milk. No adverse effects reported, and because of poor oral absorption, ototoxicity is not a risk. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction. Compatible with breast-feeding.

Topiramate (C/−)

Excreted into breast milk. No adverse effects noted in limited number of exposed nursing infants. However, potential for adverse effects—fatigue, somnolence, difficulty with concentration/attention, aggressive reaction, confusion, difficulty with memory, ataxia, purpura, epistaxis, infections (viral and pneumonia), anorexia, and weight loss. Observe nursing infants for signs of toxicity.

Tramadol (C/+)

Drug and its active metabolite excreted into breast milk. Effects on nursing infants unknown.

Trazodone (C/−)

Excreted in breast milk. Effects on nursing infant are unknown but may be of concern.

Tretinoin (systemic) (D/+)

Vitamin A and probably tretinoin are natural constituents of breast milk. No human lactation data available on amounts excreted into breast milk after doses for treatment of promyelocytic leukemia or risk to nursing infant. Probably compatible.

Trimethoprim/sulfamethoxazole (C/+)

Excreted into breast milk in low concentrations. Considered negligible risk to nursing infant. AAP classifies as compatible with breast-feeding.

Valacyclovir (B/+)

Lack of adverse effects seen with acyclovir, the primary metabolite of valacyclovir. Considered compatible with breast-feeding.

Valganciclovir (C/CI)

Active metabolite, ganciclovir, has potential to cause serious toxicity. HIV-1–infected mothers in developed countries should not breast-feed. Breast-feeding contraindicated.

Valproic acid (D/−)

Generally compatible with breast-feeding per AAP but carries risk of fatal hepatotoxicity.

Valsartan (C 1st tri; D 2nd, 3rd tri/+)

No human lactation data available. Low molecular weight suggests excretion into breast milk is expected. Effects on nursing infant are unknown. AAP considers compatible with breast-feeding.

Vancomycin (B/+)

Excreted into breast milk. Effects on nursing infant are unknown but vancomycin is poorly absorbed from GI tract. The bowel flora of nursing infants may be altered and there is the potential for interference with the interpretation of an infectious workup. Observe nursing infants for possible allergic reaction. Compatible with breast-feeding.

Varicella vaccine (C/+)

Compatible with breast-feeding.

Venlafaxine (C/−)

Excreted into breast milk. Long-term effects on neurobehavioral and cognitive development from exposure to potent serotonin reuptake inhibitors during a period of rapid CNS development have not been adequately studied. AAP classifies as drug for which effect on nursing infant is unknown but may be of concern.

Verapamil (C/+)

Excreted into breast milk. Limited human lactation data available. Probably compatible.

Voriconazole (D/−)

No human lactation data available. Low molecular weight suggests excretion into breast milk. Potential for toxicity in neonatal period. Avoid breast-feeding.

Warfarin (X/+)

Maternal warfarin therapy does not appear to pose a significant risk to normal full-term infants. Other oral anticoagulants are contraindicated in lactating women.

Zanamivir (C/+)

No human lactation data available. Low molecular weight and pharmacokinetics of drug suggest it will be excreted into breast milk. Effects on nursing infants are unknown but risk of harm is low.

Zidovudine (C/CI)

It is recommended that HIV-1–infected mothers in developed countries to not breast-feed.

Zolmitriptan (C/+)

No human lactation data available. Molecular weight and low protein binding suggest drug and its active metabolite will be excreted into breast milk. Effects on nursing infant are unknown.

Zolpidem (B/+)

Excreted into breast milk in small amounts which would indicate few adverse effects, if any, would occur in nursing infant. Observe for increased sedation, lethargy, and changes in feeding habits.

AAP, American Academy of Pediatrics; ACE, angiotensin-converting enzyme; ACOG, American Congress of Obstetricians and Gynecologists; CDC, Centers for Disease Control and Prevention; CI, contraindicated; CNS, central nervous system; FDA, U.S. Food and Drug Administration; GI, gastrointestinal; HBIG, hepatitis B immune globulin; HIV, human immunodeficiency virus; IV, intravenous; SSRIs, selective serotonin reuptake inhibitors; tri, trimester; VRE, vancomycin-resistant enterococci.

REFERENCES

Listen

Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation. 9th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2011.

Hale TW. Medications and Mother's Milk. 14th ed. Amarillo Texas: Hale Publishing; 2010.

LactMed Online. U. S. National Library of Medicine: Bethesda, MD; 2011. http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT. Accessed January, 2012.

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149: Effects of Drugs and Substances on Lactation and Infants

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INTRODUCTION

U.S. FDA FETAL RISK CATEGORIES

CATEGORY A

CATEGORY B

CATEGORY C

CATEGORY D

CATEGORY X

BREAST-FEEDING COMPATIBILITY

REFERENCES

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