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Oral Medicine

Authors: Dr. Sunira Chandra, Dr. Kunal Sah

Abstract
Most of the dentists prescribe drugs to nursing mothers. But only few, knows its pharmacokinetics adverse affects to fetus. Dentist should be very causious before prescribing any drug to the nursing mothers. Prescription of various contraindicated drugs to nursing mothers can compromise baby growth, their intellectual ability and in some cases even causes death. This paper review various contraindicated drugs or drugs having various adverse effects and should be not given to nursing mother.

Key words: Drugs, nursing mother, contraindications

Introduction
Breast milk is the nutrition of choice newborns. The American Academy of Pediatrics recommends exclusive breastfeeding for a minimum of 6 month and introduction of appropriate solid food from 6 month to 1 year. Beyond 1 year, breastfeeding continues for as long as both infant and mother desire, although after 1 year, breastfeeding should complement a full diet of solid foods and fluids.

Breast feeding patient presents a number of unique management problems for oral health care providers. Cli­nicians are responsible for provid­ing safe and effective care for the mother, while also considering the safety of the fetus or newborn. They must consider the effects of medications, which may be distributed from the maternal plasma through the placenta to the fetus, or to breast milk, exposing the nursing infant to potentially dan­gero us concentrations. This article summarizes various drugs which are contraindicated during breastfeeding or have some adverse effect on nursing infants.

Passage of drugs from plasma to milk
With the increasing recognition of the benefits of breast-feeding, cli­nicians must often weigh the ben­efits versus risks of drug therapy in lactating women. The rate of pas­sage of a drug from plasma to milk is an important determinant of the concentration of the drug in milk. Mechanisms of excretion of drugs in breast milk include both passive diffusion and carrier-me­diated transport.

The amount of a drug excreted in breast milk de­pends on the characteristics of the drug, such as the drug's molecu­lar weight, lipid solubility, pKa, and plasma protein binding. Small, water-soluble non electro­lytes pass into milk by simple diffu­sion through aqueous channels in the mammary epithelial mem­brane that separates plasma from milk. Equilibrium is reached rap­idly, and the drug's concentration in milk approximates plasma lev­els. With larger molecules, only the lipid soluble, nonionized form passes through the membrane.

The pKa of weak electrolytes is an important determinant of drug concentration in milk, because the pH of milk is generally lower (more acidic) than that of plasma, and milk can act as an "ion trap" for weak bases. At equilibrium, basic drugs may be more concen­trated in milk relative to plasma. Conversely, acidic drugs are lim­ited in their ability to enter milk, because the concentration of nonionized free form in milk is higher than in plasma, and a net transfer of the drug from milk to plasma occurs.

Drug therapy for breast feeding patient

The following should be considered before prescribing drugs to lactating women:

  • Is drug therapy really necessary? If drugs are required, consultation between the pediatrician and the mother’s physician can be most useful in determining what options to choose.
  • The safest drug should be chosen, for example, acetaminophen rather than aspirin for analgesia.
  • If there is a possibility that a drug may present a risk to the infant, consideration should be given to measurement of blood concentrations in the nursing infant.
  • Drug exposure to the nursing infant may be minimized by having the mother take the medication just after she has breastfed the infant or just before the infant is due to have a lengthy sleep period.

The American Academy of Pediatrics published guidelines and a classification system for drugs used in lactating women.

The American Academy of Pediatrics: Classification System
ND : No data available
C : Compatible with breastfeeding
CC : Compatible with breastfeeding but use caution
SD : Strongly discouraged in breastfeeding
X : Contraindicated in breastfeeding

These classifications are based on controlled studies in animals or humans and on data gathered from using the drugs in pregnant women. Most medications fall into the category "No data available."

A statement on the transfer of drugs and chemicals into human milk was first published in1983, with revisions in 1989 and 1994. Information continues to become available. The current statement is intended to revise the lists of agents transferred into human milk and describe their possible effects on the infant or on lactation, if known (Tables 1–6). If a pharmacologic or chemical agent does not appear in the tables, it does not mean that it is not transferred into human milk or that it does not have an effect on the infant; it only indicates that there were no reports found in the literature. These tables should assist the physician in counseling a nursing mother regarding breastfeeding when the mother has a condition for which a drug is medically indicated.

Conclusion
Dentist should be very causious before prescribing any drug to the nursing mothers. Prescription of various contraindicated drugs to breastfeeding mothers can compromise baby growth, their intellectual ability and in some cases even causes death.The clinician's primary goal should be to provide necessary care for the patient while minimizing the risk to her newborn. Prior to the initiation of dental treatment or when complications arise during care, a consultation with the patient's obstetrician is always re­quired.

TABLE 1: CYTOTOXIC DRUGS THAT MAY INTERFERE WITH CELLULAR METABOLISM OF THE NURSING INFANT

Drugs Reason for Concern, Reported Sign or Symptom in Infant, or Effect on Lactation
Cyclophosphamide Possible immune suppression; unknown effect on growth or association with carcinogenesis; neutropenia
Cyclosporine Possible immune suppression; unknown effect on growth or association with carcinogenesis
Doxorubicin Possible immune suppression; unknown effect on growth association with carcinogenesis
Methotrexate Possible immune suppression; unknown effect on growth or association with carcinogenesis; neutropenia

TABLE 2: DRUGS OF ABUSE FOR WHICH ADVERSE EFFECTS ON THE INFANT DURING BREASTFEEDING HAVE BEEN REPORTED

Drugs Reported Effect or Reasons for Concern
Amphetamine Irritability, poor sleeping pattern
Cocaine Cocaine intoxication: irritability, vomiting, diarrhea, tremulousness, seizures
Heroin Tremors, restlessness, vomiting, poor feeding
Phencyclidine Potent hallucinogen

TABLE 3: RADIOACTIVE COMPOUNDS THAT REQUIRE TEMPORARY CESSATION OF BREASTFEEDING

Compound Recommended Time for Cessation of Breastfeeding
Copper 64 Radioactivity in milk present at 50 h
Gallium 67 Radioactivity in milk present for 2 wk
Indium 111 Very small amount present at 20 h
Iodine 123 Radioactivity in milk present up to 36 h
Iodine 125 Radioactivity in milk present for 12 d
Iodine 131 Radioactivity in milk present 2–14 d

TABLE 4: DRUGS FOR WHICH THE EFFECT ON NURSING INFANTS IS UNKNOWN BUT MAY BE OF CONCERN

Drugs Reported or Possible Effect
Anti-anxiety Drugs
Alprazolam
Diazepam
Lorazepam
Midazolam
Perphenazine
Prazepam
Quazepam
Temazepam
 
Antidepressants Drugs
Amitriptyline
Amoxapine
Bupropion
Clomipramine
Desipramine
Dothiepin
Doxepin
Fluoxetine
Fluvoxamine
Imipramine
Nortriptyline
Paroxetine
Sertraline
Trazodone
Colic, irritability, feeding and sleep disorders, slow weight gain
Antipsychotic Drugs
Chlorpromazine
Chlorprothixene
Clozapine
Haloperidol
Mesoridazine
Trifluoperazine
Galactorrhea in mother; drowsiness and lethargy in infant; decline in developmental scores

Decline in developmental scores
Others
Amiodarone
Chloramphenico
Clofazimine
Lamotrigine
Metoclopramide
Metronidazole
Tinidazole
Possible hypothyroidism
Possible idiosyncratic bone marrow suppression
Potential for transfer of high percentage of maternal dose; possible increase in skin pigmentation
Potential therapeutic serum concentrations in infant
None described; dopaminergic blocking agent
In vitro mutagen; may discontinue breastfeeding for 12–24 h to allow excretion of dose when single-dose therapy given to mother
See metronidazole

 

 

Psychotropic drugs, the compounds listed under anti-anxiety, antidepressant, and antipsychotic categories, are of special concern when given to nursing mothers for long periods. Although there are very few case reports of adverse effects in breastfeeding infants, these drugs do appear in human milk and, thus, could conceivably alter short-term and long-term central nervous system function. TABLE 5: DRUGS THAT HAVE BEEN ASSOCIATED WITH SIGNIFICANT EFFECTS ON SOME NURSING INFANTS AND SHOULD BE GIVEN TO NURSING MOTHERS WITH CAUTION

 

 

Drugs Reported Effect
Acebutolol Hypotension; bradycardia; tachypnea
5-Aminosalicylic acid Diarrhea
Atenolol Cyanosis; bradycardia
Bromocriptine Suppresses lactation; may be hazardous to the mother
Aspirin (salicylates) Metabolic acidosis
Clemastine Drowsiness, irritability, refusal to feed, high-pitched cry, neck stiffness
Ergotamine Vomiting, diarrhea, convulsions (doses used in migraine medications)
Lithium One-third to one-half therapeutic blood concentration in infants
Phenindione Anticoagulant: can increased prothrombin and partial thromboplastin time
Phenobarbital Sedation; infantile spasms after weaning from milk containing phenobarbital, methemoglobinemia
Primidone Sedation, feeding problems

Blood concentration in the infant may be of clinical importance.

TABLE 6: FOOD AND ENVIRONMENTAL AGENTS: EFFECTS ON BREASTFEEDING

Agents

Reported Sign or Symptom in Infant or Effect on Lactation

Aspartame Caution if mother or infant has phenylketonuria
Chocolate (theobromine) Irritability or increased bowel activity if excess amounts (16 oz/d) consumed by mother
Fava beans Hemolysis in patient with G-6-PD deficiency
Hexachlorobenzene Skin rash, diarrhea, vomiting, dark urine, neurotoxicity, death
Lead Possible neurotoxicity
Mercury, methylmercury May affect neurodevelopment
Silicone Esophageal dysmotility
Tetrachloroethylene cleaning fluid (perchloroethylene) Obstructive jaundice, dark urine

References

  • American Academy of Pediatrics, Committee on Drugs. The transfer of drugs and other chemicals into human breast milk. Pediatrics 1983; 72:375–383.
  • American Academy of Pediatrics, Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics. 1989; 84:924–936.
  • American Academy of Pediatrics Committee on Drugs: The transfer of drugs and other chemicals into human milk. Pediatrics 1994; 93(1):137-150.
  • Meadows, M. Pregnancy and the Durg Dilemma. FDA consumer magazine. May-June 2001.
  • Briggs GC: Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 5th ed. Baltimore: Williams and Wilkins, 1998.
  • Hale T 1999. Medications and Mothers’ Milk 8th ed, Pharmasoft Medical Publishing, Texas
  • American Academy of Pediatrics. The transfer of drugs and other chemical into human milk. Pediatrics 2001; 108(3): 776- 789.
  • Drugs in Breastmilk http://www.ukmicentral.nhs.uk/drugpreg/qrg_p1.htm
  • Drugs, Pregnancy, and Lactation http://www.obgynnews.com/content/drugspregnancylactation
  • Howard C, Lawrence R. Breast-feeding and drug exposure. Obs Gynec Clin of Nth Am 1998; 25(1) 195-217.
  • The Merck Manual of Medical Information. www.merck.com/mmpe/sec19/ch266/ch266c.html
  • American Academy of Pediatrics, Committee on Drugs. Psychotropic drugs in pregnancy and lactation. Pediatrics. 1982;69:241–244.
  • Berke RA, Hoops EC, Kereiakes JC, Saenger EL. Radiation dose to breast-feeding. J Nucl Med. 1973;14:51–52.

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