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DrugUseduringBreastfeeding
Dateofrevision:December2014
M.S.BrochetBPharmMScS.ItoMDFRCPC
Thefollowingisanoverviewofdruguseduringbreastfeeding.Thisinformationisnotintendedtobea
comprehensivereviewthereaderisthereforeencouragedtoseekadditionalandconfirmatoryinformation.

PrinciplesofDrugUseduringBreastfeeding
Clinicianscanusethefollowinggeneralprinciplestomanagecaseswheredrugexposureinabreastfedinfantis
questioned:
Almostalldrugsareexcretedtosomedegreeinbreastmilk.

Breastmilk/feedinghastangiblemedicalandotherbenefitscomparedtoformula.1,2,3
Evenwhenthebreastmilk:maternalplasmaconcentrationratioapproachesorexceeds1,theamountofdrug
ingestedbytheinfantrarelyattainstherapeuticlevels.
Briefexposuretoadrug,asmightbeexpectedinthecaseofanalgesicsgiventorelievepostpartumpain,is
usuallyoflessconcernthanadruggivenforlongperiodsoftime.Theamountofdrugingestedbytheinfant
can,onoccasion,beminimizedbyfeedingtheinfantjustbeforeoratthetimeofmaternaldosing.
Inthecaseofchronicdrugtherapy,theinfantisusuallyexposedtolowerconcentrationsofthedrugwhile
breastfeedingthanwhilethefetusisinutero.Nevertheless,inmostcasesthelongtermconsequencesof
chronicexposuretosubtherapeuticlevelsofmedicationsarenotknown.
Recommendationsaboutbreastfeedingduringdrugtherapydependonknowingifsmallamountsofthedrug
(subtherapeuticamounts)takenforevenshortperiodsoftimemaybeassociatedwiththefollowing:
idiosyncraticreactions,e.g.,chloramphenicol
interferencewithgeneticallyabnormalmetabolicpathways,e.g.,nitrofurantoininpatientswithG6PD
deficiencies
synergisticeffectswithdrugstheinfantreceivestherapeutically,e.g.,caffeineincoffeeandteamay
enhanceeffectsoftherapeuticcaffeineoraminophyllineintheneonate

Cliniciansrequireareasonableknowledgeofpharmacologyandtherapeuticsinthenewbornaswellasa
knowledgeoftheamountofdrugexcretedinbreastmilk.
TheDrugsandLactationdatabase(LactMed)isareliableandauthoritativewebbasedresourceaboutdrug
excretioninbreastmilkandrecommendationsforbreastfeedingduringmaternaltherapy.5Itisfreeofchargeand
runbytheUSNationalLibraryofMedicine.LactMedishousedwithintheTOXNETWebsite.
Considerseveralimportantquestionswhenabreastfeedingmotherstartsdrugtherapy:4
IsthedrugabsorbedfromtheGItract?
Isthedrugevergivendirectlytoinfantsfortherapeuticreasons?
Doestheestimateddosedeliveredthroughbreastmilkapproachatherapeuticquantity?
Aretheeffectsofthedrugeasilyrecognizedintheinfant?
Arethereidiosyncraticorallergicreactionstothedrugthatarenotdoserelated?
Aretherelesstoxicalternativesformaternaltherapy?
Isthereapotentialfordrugaccumulationduringprolongedtherapy?
Couldsubtherapeuticdosesofthedrugmaskearlysignsofmedicalconditionsintheinfant?
Istheriskposedbythedrugsubstantialenoughtooutweighthesignificantprovenbenefitsofbreastfeeding?

DrugsCompatiblewithBreastfeeding
Drugsconsideredcompatiblewithbreastfeedingfaroutnumberthoseconsideredcontraindicatedduring
breastfeeding.Table1discussessomeexamplesofdrugsconsideredtobecompatiblewithbreastfeeding.
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Table1:DrugsCompatiblewithBreastfeedinga

Therapeutic
Class
Analgesics

Drugs/Drug
Classes
Compatiblewith
Breastfeeding
Acetaminophen,
morphine

Comments
Formostopioidanalgesics,theamountofdrugexcretedin
breastmilkissmall,andshorttermuseshouldbeofnomajor
concern.Ifusedforlongerthan3daysmonitorcloselyfor
drowsiness/sedation,difficultybreathing,difficultybreastfeeding,
decreasedtone,particularlyinprematureinfantsandneonates.6
Meperidineisanexceptioninneonates,thelonghalflivesof
meperidine(13h)andnormeperidine(63h)mayresultin
accumulationinplasma,possiblyleadingtoneurobehavioural
depression.7,8

Inaddition,usecodeinewithcautionatthelowesteffectivedose
fortheshortestperiodoftime.Motherswithultrarapid
metabolizerCYP2D6genotype(Chinese,Japanese,Hispanic0.5
1%Caucasian110%AfricanAmerican3%NorthAfrican,
Ethiopian,SaudiArabian1628%)mayexperienceintensified
effectsfromaregulardosingregimenofcodeineduetoincreased
conversionofcodeinetomorphine,causingmorphinetoxicity.
Resultanthighlevelsofmorphineinmaternalserumcouldcause
relativelyhighmorphinelevelsinbreastmilk.4Mothers

experiencingmorphinetoxicity,whetherduetothisgenotypeor
morphineoverdose,shouldnotbreastfeed.Codeineuseshouldbe
limitedtolessthan34daysinabreastfeedingmother.
OxycodoneandhydrocodonearealsometabolizedbyCYP2D6to
apotentactivemetaboliteseecodeineforinformationregarding
theultrarapidmetabolizerCYP2D6genotype.4Maternal
oxycodoneusehasbeenassociatedwithasimilarincidenceof
neonatalCNSdepressionascodeine 9andlevelsinbreastmilk

stronglycorrelatedwithplasmalevelsinonestudy.10Useof
oxycodoneorhydrocodonewhilebreastfeedingshouldbe
consideredonlyinpatientswhocannottakeotheropioidsand
shouldbelimitedtolessthan34days.
Theamountofmorphineexcretedinbreastmilkcouldreach
7.5%ofthepediatricdose.11Despitewidespreaduseofmorphine
bybreastfeedingmothers,thereisonlyonecasereportofa
nursinginfantwiththerapeuticplasmaconcentrations.12

Limiteddataindicatesthathydromorphoneisexcretedinto
breastmilkinsmallamounts.4

Datafortramadolarelacking.Shorttermusemaybeaconcern
duetoitslonghalflife(7hfortramadoland8.5hfortheactive
metaboliteinnewborns)especiallyinprematureinfants:monitor
forincreasedsleepiness.Excretionintobreastmilkislow,
thereforeitisunlikelytoaffecthealthybabies.Anexclusively
breastfedinfantwouldreceiveabout10%ofthetherapeuticdose
forachild.13

Methadonelevelsinhumanmilkarelow.Anexclusivelybreastfed
infantwouldreceive<5%oftheweightadjustedmaternaldose.b
Buprenorphinelevelsinmilkcouldreach2.5%oftheweight
adjustedmaternaldose binanexclusivelybreastfedinfant.Ithas
poororalbioavailabilityandlowdrugconcentrationsinbreastfed
infant'sserumandurinehavebeendocumented.Onestudy
suggestedthatextraduralbuprenorphineadministrationinthe
mothersuppressedinfantbreastfeedingbut3otherswere
inconclusive.14Levelsofmethadoneorbuprenorphineinbreast
milkareinsufficienttopreventsymptomsofneonatalabstinence
syndrome.4
Datafornaltrexonearelacking.Onecasereportnotedminimal
excretionintomilk.14,15
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Antibiotics

Aminoglycosides,
cephalosporins,
clindamycin,
fluoroquinolones,
macrolides,
metronidazole,
nitrofurantoin,
penicillins,
sulfonamides

Formanyantibiotics,theamountsingestedbyabreastfedinfant
willbebelowtherapeuticlevels(e.g.,penicillins,
cephalosporins),butmightbesufficienttoresultinidiosyncratic
reactions(e.g.,chloramphenicol)orcauseanemiainaninfant
withG6PDdeficiency(e.g.,nitrofurantoin,sulfonamides).Other
potentialproblemsaremodificationstothenormalGIfloraleading
tothrushanddiarrhea.However,clinicalsignificanceoftheserisks
isusuallynothighenoughtojustifydiscontinuationof
breastfeeding.
Aminoglycosidesareexcretedinbreastmilkwhenadministered
imorivtothemotherbecausethedrugsarepoorlyabsorbed
fromtheGItract,itisunlikelythatrenaltoxicityorototoxicity
wouldoccurintheinfant.
Onlysmallamountsoforalclindamycinareexcretedinbreast
milk(26%oftherecommendedpediatricdosage).Itisunlikely
thatthesequantitieswouldbeclinicallyrelevantbutatleastone
caseofbloodystoolshasbeenreportedinthebreastfedinfantofa
motherreceivingclindamycin.Topicalclindamycin(notusedinthe
nipplearea)isgenerallyassociatedwithlowermaternalsystemic
druglevelsandlowerbreastmilkexcretioncomparedtosystemic
use.14
Erythromycinisexcretedinbreastmilkinlowamountsandis
compatiblewithbreastfeeding.Limiteddataregarding
clarithromycinandazithromycindemonstratethatthesedrugs
areexcretedinbreastmilkinsmallamounts,buttheamountof
drugingestedbyabreastfedinfantislikelybelowtherapeutic
pediatriclevels.16,17Nodataareavailableregardingthe

excretionoftelithromycininbreastmilk.
Metronidazoleuseduringbreastfeedinghasraisedsome
concernsbasedonreportsthatitismutagenicinbacteriaand
carcinogenicinrodentsduringlifelongingestion.Specific
untowardeffectsinanursinginfantasaresultofmetronidazole
ingestionhavenotbeenreported.Withoutmoredirectevidenceof
theharmfuleffectsofshorttermuseinhumans,itseemsoverly
conservativetowithholdthedrugordiscontinuebreastfeedingin
patientswithsymptomaticinfections.Forthetreatmentof
trichomoniasiswithasingleoraldoseofmetronidazole2g,some
cliniciansnowrecommendaninterruptionofbreastfeedingfor12
24h,especiallywithyoungbabies.7Topicalmetronidazole(as

longasitisnotusedinthenipplearea)isconsideredcompatible
withbreastfeedingsincebloodlevelsandexcretionintobreastmilk
arelowerthanwithmaternalsystemicmetronidazoleuse.
Fluoroquinoloneshavetraditionallynotbeenusedininfants
becauseofconcernsregardingadverseeffectsonjoint
development.Studiesindicatelittlerisk.Shorttermuseof
ciprofloxacin,levofloxacin,norfloxacinorofloxacinis
acceptableinnursingmothers.Thesequinolonesareexcretedin
breastmilkinsmallamountswhichdonotresultinsignificant
serumconcentrationsinbreastfedinfants.Thecalciuminbreast
milkmayalsodecreasequinoloneabsorptionintheinfant.14
Therearenodataavailableformoxifloxacin.Maternaluseof
gatifloxacineyedropspresentsnegligibleriskforthenursing
infant.14

Thesulfonamidesareexcretedinbreastmilkinsmallamounts.
Thereareconcernsaboutthesedrugscausinganemiainaninfant
withG6PDdeficiencywhichismorecommoninthoseofAfrican,
Greek,middleeasternandsoutheastAsianorigin.Usewith
cautioninmothersbreastfeedingprematureinfantsorneonates
withhyperbilirubinemia.7Usealternativesunlesstheinfectionis
notrespondingtoothertherapy.
Theuseofnitrofurantoininbreastfeedingmothersisgenerally
safe,asonlysmallamountstransferintothebreastmilk.Despite
thelackofdocumentedreports,thereisapotentialriskof
hemolyticanemiainallnewbornsexposedtonitrofurantoinowing
totheirglutathioneinstability,especiallyininfantswithG6PD
deficiency.Althoughsomesuggestthatnitrofurantoinbeavoided
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ininfants<1month,studieshavenotedthatglutathionestability
mightbeestablishedbytheeighthdayoflife.Ininfants<1month,
analternativeantibioticmightbepreferredhowever,ifan
alternativewerenotavailable,theuseofnitrofurantoinwouldnot
beareasontoavoidbreastfeeding.Inanysuchcasethesuckling
infantshouldbemonitoredbyhisorherphysician.18
Somereviewsclassifytetracyclinesascontraindicatedin
breastfeedingbasedonconcernsofstainingofdentalenamelor
bonedeposition.Availabledataindicatethatharmisunlikelywith
shorttermuseoftetracyclines.Milklevelsarelowandcalciumin
breastmilklimitsabsorptionoftetracyclines.However,asa
precautionbasedonthetheoreticalrisk,prolongedorrepeated
coursesshouldbeavoidedduringbreastfeeding.14

Anticoagulants

Heparin
(unfractionatedand
lowmolecular
weight),warfarin

Heparin,administeredparenterallyforacuteshorttermtherapy
ofthrombophlebitis,hasnotbeenshowntobeexcretedinbreast
milk.Heparinisalargepolysaccharidemoleculethatisinactivated
intheGItractwhentakenorally.Itstransferintobreastmilkand
risktoabreastfedinfantareconsiderednegligible.7
Theamountofbenzylalcoholusedaspreservativeinmultidose
vialsofunfractionatedheparinorlowmolecularweightheparinis
toolowtoposeanyrisktoabreastfeedingbaby.11
Fewdataareavailableregardingtheeffectsoflowmolecular
weightheparinsduringbreastfeeding.Thereisacasereportof
12fulltermneonatesbeingbreastfedbymotherstreatedwith20
or40mgofenoxaparininjectedsubcutaneouslydaily.19No

anticoagulanteffects,asmeasuredbyantiXaactivitylevels,were
detectedinthebabies.Itisthoughtthatwiththerelativelyhigh
molecularweightofenoxaparinanditsinactivationintheGItract
iforallyingested,itstransferintobreastmilkandrisktoa
breastfedinfantshouldbeconsiderednegligible.7Nodrugwas
foundinbreastmilkof2patientswhoreceived500010000IUof
dalteparin.20Inastudyof15lactatingmothersafteroncedaily

routinedalteparin2500IUscnoquantitativecorrelationwasnoted
betweenantiXaactivitiesinplasmaandmilk.21Therearenodata
availableonexcretionintomilkofnadroparinortinzaparin
howeverbasedontheirmolecularweightandinactivationbythe
GItract,excretionintobreastmilkisexpectedtobenegligible.
Thereare3casereportsofdanaparoidusebybreastfeeding
mothers.Onereportdescribedtheuseoflepirudinduring
lactation.Theamountoftheselargemoleculesexcretedinto
breastmilkisexpectedtobeverysmall.Additionally,their
deactivationintheGItractafteroralingestionmakesrisktoa
breastfeedinginfantviaingestionfrombreastmilknegligible.22,
23

Theuseoffondaparinuxduringbreastfeedinghasnotbeen
describedinhumans.Althoughanimaldatasuggestthedrugis
excretedintomilk,theeffectonanursinginfantisprobablynot
clinicallysignificantbecauseitisnotabsorbedafteroral
ingestion.11,23

Amongbreastfedinfantswhosemothersweretakingwarfarin,the
drugwasundetectableinplasmaandthebleedingtimewasnot
affected.23

Antidepressants

Desvenlafaxine,
SSRIs,tricyclic
antidepressants,
venlafaxine

Exceptfordoxepintherearenoreportsofuntowardeffectsof
anyofthetricyclicantidepressantsinbreastfedinfants.24

Sertralineistransferredintobreastmilkresultinginanestimated
infantdoseofbetween0.5%and5%oftheweightadjusted
maternaldose b,25,26,27,28Thereisacasereportof

serotonergicsymptomsinaprematureinfantexposedinuteroand
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viabreastmilk,butacausativelinkisuncertain.29Therearealso
reportsofuneventfulbreastfeedingduringmaternalsertraline
use.30

Paroxetineistransferredintobreastmilkresultinginanestimated
infantdoseofbetween0.1%and4.3%oftheweightadjusted
maternaldose b.Inthesestudies,paroxetinewasnotdetectedin
theserumofthemajorityofinfants(inwhomitwasmeasured)
andnoadverseeffectswerereported.30,31,32,33,34

Theamountoffluoxetineexcretedinbreastmilkis218%ofthe
weightadjustedmaternaldose.b,25,26,27,28,30,31,32,
33,34,35Nearlytherapeuticserumconcentrationswere

reportedinsomesymptomaticinfants.36,37,38,39,40,41,
42,43,44Also,infantsbreastfedbymothersonfluoxetinehad
poorerweightgain,althoughthesignificanceisunclear.40Afew
casesofcolichavebeenassociatedwithfluoxetine.37,41

Becauseofthelonghalflivesoffluoxetineanditsactive
metabolites,cautionisadvised,particularlywhenbreastfeedinga
preterminfantorneonate.14

Excretionoffluvoxamineseemstobelowandnoadverseeffects
werereportedinthefewavailablecases.30,45
Theamountofcitalopramexcretedinbreastmilkis

approximately0.79%oftheweightadjustedmaternaldose b.In
onestudy,asingleinfantpresentedanuneasysleeppattern
whichimprovedwhenmaternaldosewasdecreased.46,47,48,
49Theamountofescitalopramexcretedinbreastmilkisless

than8%oftheweightadjustedmaternaldose bandnoadverse
effectswerereportedintheavailablecases.14

Venlafaxineanditsmetabolitesareexcretedinbreastmilkin
approximately59%oftheweightadjustedmaternaldose.b,50,
51Inonestudyof7infantstheactivemetaboliteO

desmethylvenlafaxinewasdetectedintheplasmaof4infants.No
adverseeffectswerereportedintheinfants.52Excretionof

desvenlafaxine(Odesmethylvenlafaxine)intobreastmilkisless
than7%ofthematernalweightadjusteddose bandserumdrug
levelsofbreastfedinfantsarelessthan6%ofsimultaneous
maternallevels.53

Althoughbupropion,moclobemideandmirtazapinehavenot
beenstudiedextensively,foreachofthesedrugstheamount
excretedinbreastmilkislessthan2%oftheweightadjusted
maternaldose.bNoadverseeffectswerereported14,54,55,56
,57,58,59exceptforbupropion(threecasereportsofpossible
seizure)althoughthesignificanceisunclear.60,61,62Limited

dataindicatethatexcretionoftrazodoneintobreastmilkislow,
butdataonitsactivemetabolitesarelacking.63,64,65,66The
amountofduloxetineexcretedintobreastmilkseemstobelow,
lessthan1%oftheweightadjustedmaternaldose bisexcreted
intobreastmilk.67,68
Overall,nosignificantshorttermeffecthasbeenreportedforthe
commonlyusedantidepressantssuchastricyclicsandSSRIs.
Clinicalsignificanceofreportedadverseeventsremainsunclear.
Basethechoiceofantidepressantsonthematernalconditionand
response.Nomatterwhatdrugisused,usecautionuntilmore
experienceisgained.

Antiepileptics

Carbamazepine,
clonazepam,
phenytoin,valproic
acid

Theexcretionintomilkislow:approximately5%and2%ofthe
weightadjustedmaternaldose bforcarbamazepineandits

epoxidemetabolite,lessthan4%forvalproicacid,andlessthan
8%forphenytoin.Noadverseeffectsduetocarbamazepine,
phenytoinorvalproateexposureviabreastmilkwereobservedat

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6yearsinaprospectiveobservationalmulticenterstudy.69Limited
dataforclonazepamindicatethattheweightadjustedmaternal
doseis<3%thereforeriskfortoxicityisexpectedtobelow.14
Howeverthelonghalflifeandlipophilicityofclonazepamcouldbe
aconcern.Despitesporadiccasereportsofadverseeffects,these
antiepilepticsarebelievedtobecompatiblewithbreastfeeding.7,
70

Phenobarbital,ethosuximideandprimidonemaywarrantmore
cautionbecausetheinfant'sexposuremayreachtherapeutic
levels.Theinfantexposurelevelsforphenobarbital,ethosuximide
andprimidoneareestimatedat100%,50%and>10%,
respectively,ofthelevelsexpectedwhenthedrugisgivendirectly
toaninfantinatherapeuticdose.70Whetherthishighlevel
exposureprecludesbreastfeedingornotdependsonvarious
factorsineachindividualcase.Inselectedcases,regular
monitoringofclinicalsigns(e.g.,lethargy,poorfeeding,sedation)
andofdrugconcentrationsinbreastmilkand/orininfant'splasma
mayguidebreastfeeding.
Lamotrigineplasmalevelsashighas50%ofmaternalserum
levelswerefoundinbreastfedinfantswhosemothersweretaking
lamotrigine.Manyinfantshavebeenbreastfedwithoutadverse
reactionsbutthisdrugmaybeofconcern.14
Noadverseeffectsduetolamotrigineexposureviabreastmilk
wereobservedat6yearsinaprospectiveobservational
multicenterstudy.69

Gabapentinexcretionintobreastmilkis1.33.8%oftheweight
adjustedmaternaldose bandserumdruglevelsofbreastfed

infantsare<12%ofsimultaneousmaternallevels.71,72,73
Dataontopiramatearelacking.Thelongeliminationhalflifeand
inadequatelystudiedpossiblelongtermeffectsonneurobehaviour
andcognitivedevelopmentmaybeofconcern.
Clobazam,levetiracetam,oxcarbazepine,pregabalinand
vigabatrinhavenotbeenextensivelystudiedandtheiruseduring
breastfeedingshouldbeevaluatedonanindividualbasis.

Antifungals

AmphotericinB,
caspofungin,
fluconazole,
ketoconazole,
topicalantifungals

DataonamphotericinBarelacking.However,itisvirtually
unabsorbedorallyandiscommonlyusedinpediatrics.74,75

Althoughdataarelackingontopicalfungicidalagentslike
clotrimazole,miconazole,terconazoleandnystatinin
breastfeeding,systemicabsorptioninthemotherisverypoor.Milk
levelsareprobablytoolowtobeclinicallyrelevant.Mostofthese
topicalantifungalsareusedinpediatrics.
Dataoncaspofungininbreastfeedingarelackingbutithaspoor
oralbioavailability.
Fluconazoleexcretionintomilkislowafteroraladministrationof
150mg,amountingto16%oftheweightadjustedmaternaldose b
andlessthan6%ofadailypediatricdose.7Adverseeffectsinthe
infantshavenotbeenreported.Dataonlargerdosesarelacking.
However,breastfeedingmustbecontinuedduringtreatmentfor
yeastmastitiswithfluconazole100200mgdailyfor23weeks.
Thismaternaldoseproducesanamountofdruginmilkthatis
insufficientfortreatmentoforalthrushintheinfant.14
Dataregardingitraconazoleandvoriconazolearelacking
fluconazoleispreferred.7

Lessthan1%oftheweightadjustedmaternaldose bisexcretedin
breastmilkafteranoraldoseofketoconazole200mg.This
amountisalsolessthanthedailypediatricdose.Maternal
systemicabsorptionaftershampooapplicationisconsidered
negligible.14,74,76

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Cetirizine,
desloratadine,
fexofenadine,
loratadine

Loratadineandfexofenadine(basedonterfenadinedata)result
ininfantexposurelevelsof<1%oftheweightadjustedmaternal
dose.b,77,78
Desloratadineistheactivemetaboliteofloratadine.The
calculatedmaximumexpecteddoseofdesloratadineinmilkis
0.46%ofthematernalweightadjusteddose bofloratadine.77

Althoughdataoncetirizinearelacking,useduringbreastfeeding
isconsideredacceptablesincethedrugissafelyusedininfants>6
months.11
Theestimatedamountofdiphenhydramineababyisexposedto
throughbreastmilkislow(approximately0.3%ofapediatric
dose).Occasionaluseisnotexpectedtocauseadverseeffects.
Nonsedatingantihistaminesarepreferredforlongertermuseas
anecdotalreportssuggestapossibledecreaseinmilk
production.14

Otherantihistaminesmaybegiven,butdataontheconcentrations
ofthesedrugsinbreastmilkarelacking.Infantsshouldbe
monitoredforirritabilityordrowsiness.79
Antihistaminesarenotusuallycontraindicatedduring
breastfeeding.Alternativestooralantihistaminesthatmaybe
consideredduringbreastfeedingincludenasallyadministered
corticosteroidsorcromolyn.Cromolynandnedocromileye
dropsareconsideredacceptableduringbreastfeedingbecauseof
theirlowbioavailability.7

Antihypertensives Labetalol,
metoprolol,
propranolol
Benazepril,
captopril,enalapril,
quinapril,ramipril
Methyldopa
Diltiazem,
nifedipine,
verapamil
Hydrochlorothiazide,
furosemide

Betablockersthataresafetouseevenintheneonatalperiodare
labetalol,metoprololandpropranolol.70,80,81

Acebutolol,atenololandsotalol(althoughthelatterisnot
indicatedasanantihypertensiveagent)maycauserelativelyhigh
exposurelevels,10%,25%and20%,respectively,ofthose
expectedwhenthedrugisgivendirectlytoaninfantina
therapeuticdose.Thismaynotbeaprobleminpostneonatal
infants.However,exercisecautionintheearlyneonatalperiod
becausenewbornsmayhavelowclearanceofatenololandsotalol
asaresultofimmaturerenalfunction(lowGFR).Signsofbeta
blockadehavebeenreportedinabreastfedinfantofawoman
takingatenolol(bradycardia,cyanosis,hypotension,hypothermia)
andacebutolol(hypotension,bradycardia,tachypnea,
drowsiness).82,83,84

MethyldopaandsomeACEinhibitors(benazepril,captopril,
enalapril,quinaprilandramipril)arenotexcretedintobreast
milkinclinicallysignificantamountsandareconsideredcompatible
withbreastfeeding.11,14,85,86Dataconcerningtheuseof
angiotensinIIreceptorantagonistsduringlactationare
lacking.Usewithcautioninbreastfeedingmothers.7

Nifedipineisexcretedintobreastmilkinlowamountsandno
adverseeffectshavebeenreportedininfants.Itisconsidered
compatiblewithbreastfeeding.Verylimiteddataindicatesamounts
ofdiltiazemandverapamilinbreastmilkarelowandwouldnot
beexpectedtohaveanyadverseeffectsinbreastfedinfants.14

Dataondiureticsarelacking.Intensediuresismaydecrease
breastmilkproduction.Hydrochlorothiazide50mgdailyis
consideredacceptableduringbreastfeedingbasedonacasereport
whereanexclusivelybreastfedinfantreceived<1%oftheusual
neonataldose.14Althoughthereislittledataavailableregarding
theamountoffurosemideinbreastmilk,itsshorthalflife,high
proteinbindingandextensiveuseinneonatesandpediatrics
indicatethatsmallmaternaldosesmaybeacceptable.11

Antimalarial
agents

Chloroquine,
mefloquine,

Theverysmallamountofchloroquine,mefloquineand
proguanilexcretedinbreastmilkisnotthoughttobeharmfultoa

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proguanil

nursinginfant.7
Thereisnoinformationontheamountofprimaquinethatenters
intohumanbreastmilkbutthedrugmaycauseseverehemolysis
inG6PDdeficientindividuals.Becausedataarenotyetavailable
onthesafetyandefficacyofatovaquone/proguanilininfants
weighing<11kg,themedicationshouldnotbegiventoawoman
whoisbreastfeedinganinfantlessthanthisweightunlessthe
potentialbenefittothewomanoutweighsthepotentialrisktothe
infant.Considermefloquine.
Quantityofantimalarialmedicationtransferredinbreastmilkis
insufficienttoprovideadequateprotectionagainstmalaria.Infants
whorequirechemoprophylaxisshouldreceivetherecommended
dosagesofappropriateantimalarialdrugs.87,88

Antimanicagents

Lithiumshouldbeusedwithcautioninbreastfeedingmothers.
Lithiumisexcretedinbreastmilk,occasionallyinquantities
sufficienttoproduceinfantserumlevelsrangingfrom1050%of
maternalserumlevels.Inaninfantexposedtolithiuminuteroand
throughbreastfeeding,cyanosis,Twaveabnormalitiesand
decreasedmuscletonewerereported.Otherstudieshave
reportednoadverseeffects.7,89
Monitoringofdrugconcentrationsinmilkand/orinfant'sserum
maybejustified.90,91Considerperiodicthyroidevaluationofthe
infantaslithiumcanreducethyroxineproduction.Monitorchanges
ininfanthydrationcarefullyashydrationstatuscangreatlyalter
lithiumserumlevels.7

Antipsychotics

Chlorpromazine,
haloperidol,
olanzapine,
quetiapine,
risperidone

Theamountofolanzapineexcretedintobreastmilkislessthan
4%oftheweightadjustedmaternaldose.bFewadverseeffects
havebeenreportedamongbreastfedinfantsbutmonitoringfor
irritability,tremorandinsomnia(especiallyinthose<2months
old)isrecommended.14,92,93,94,95

Lessthan0.5%oftheweightadjustedmaternaldose bof
quetiapineisexcretedintobreastmilk.Monitorinfants
(particularlythose<2monthsold)forsedation.Nodevelopmental
problemsoradverseeventshavebeennotedininfantsbreastfed
duringmaternaluse.14,96,97,98
Theamountofrisperidoneexcretedintobreastmilkis<5%of
theweightadjustedmaternaldose b.Althoughnoadverseeffects
ininfantshavebeenreported,monitorforsedation,especiallyin
infants<2monthsold.14,99

Chlorpromazineisexcretedintobreastmilkinlowamounts(4%
oftherecommendedpediatricdose)butmilklevelsdonotappear
tocorrelatewellwiththematernaldoseorserumlevel.Monitor
theinfantforexcessivedrowsinessduringbreastfeeding.14,100

Clozapineappearstobeexcretedintobreastmilkinlowamounts
(1.2%oftheweightadjustedmaternaldose b).Useduring
breastfeedingmaybeofconcernduetoitsseriousadverseeffect
profile(agranulocytosisandCNSdepression).Monitorinfantfor
excessivesedation.Periodicmonitoringoftheinfant'swhiteblood
cellcountisadvisable.14,100,101
Theuseofhaloperidolmaybeofconcernduetolackofdata.
Doses<40mg/dayareexcretedinlowamountsinbreastmilk.
Infantsshouldbemonitoredforsedationandextrapyramidal
effects.100

Casereportsforaripiprazole,flupentixol,methotrimeprazine,
paliperidone,perphenazine,trifluoperazine,ziprasidoneand
zuclopenthixolindicatethatthesemedicationsareexcretedinto
breastmilkinlowamounts(<1%oftheweightadjustedmaternal
dose b).11Dataarelackingforloxapineandpimozide.
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Antivirals

Acyclovir,
valacyclovir

Acyclovirandvalacyclovir(whichisalmostentirelytransformed
toacyclovir)excretionintomilkarelow(lessthan1%ofthe
maximaldailypediatricdosage).Noadverseeffectswerereported
inbreastfedinfants.102
Nostudieshavebeenreportedontheexcretionofamantadinein
humanmilk.However,amantadineisadopamineagonist.Clinical
studiesusingamantadineconcurrentlywithneuroleptic
medicationshavedemonstratedadecreaseofprolactinand
galactorrheainducedbyneurolepticdrugs.Thematernalprolactin
levelinamotherwithestablishedlactationmaynotaffecther
abilitytobreastfeed.103,104
Dataonfamciclovirinbreastfeedingandpediatricsarelacking.
Acyclovirandvalacyclovirarepreferred.14

Oseltamivir

Sincetheamountofoseltamivirexcretedinbreastmilkseemsto
below(lessthan1%oftheusualpediatricdosageand0.5%ofthe
weightadjustedmaternaldose bafter75mgtwicedailyfor5days
ina9monthspostpartumnursingmother),itwouldnotbe
expectedtocauseanyadverseeffectsinbreastfedinfants,
especiallyiftheinfantisolderthan2months.105,106

Nodataareavailableregardingtheexcretionofzanamivirin
breastmilk,butduetothepoorinhaledabsorptionandverylow
plasmalevels,itwouldnotbeexpectedtocauseanyadverse
effectsinbreastfedinfants.106

Anxiolyticsand
sedatives

Lorazepam,
oxazepam

Ifusedoccasionallyasasedative,benzodiazepinesarenot
contraindicatedduringbreastfeeding.107Benzodiazepineswith

shorterhalflives,lowerlipophilicityandnoactivemetabolitesare
preferredinbreastfeedingmothers(e.g.,oxazepam,lorazepam).
Benzodiazepinestakenoveralongerperiodoftimetotreat
chronicmaternalconditionsmaybeofconcern.The
benzodiazepinesandtheirmetabolitesareexcretedinbreastmilk,
arepoorlymetabolizedbytheneonate,andhavebeenassociated
withdrowsinessinnursinginfants.Consequently,discouragethe
chronicuseofabenzodiazepineinbreastfeedingmothersunless
theinfant'sconditioniscloselymonitored.

Asthmatherapy

Inhaled
bronchodilators,
inhaled
corticosteroids

Inhaledbronchodilatorsandinhaledcorticosteroidsare
acceptableduringbreastfeedingasbioavailabilityandmaternal
serumlevelsarelow.108

Theaverageamountofterbutalineanexclusivelybreastfedinfant
wouldreceiverangesfrom0.20.7%oftheweightadjusted
maternaldose.bSerumlevelswereundetectableintheinfantin
onecase.109,110
Theamountofinhaledbudesonideinbreastmilkislow(0.3%of
theweightadjustedmaternaldose b).111

Nodataareavailableregardingtheexcretionofomalizumabinto
breastmilk.
Dataonexcretionoftheleukotrienereceptorinhibitor
montelukastintomilkarelacking.However,itdoesnotpenetrate
theCNSormanyothertissuesandishighlyproteinbound,making
theprobabilityofthebabybeingexposedviabreastmilklikely
verylow.7Themanufacturerofzafirlukastindicatesthatitis
excretedintomilkinlowconcentrations(0.5%oftheweight
adjustedmaternaldose b).112Ithasbeenusedinchildrenas
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youngas12months.113

Contraceptives

Progestinonly
formulations

Progestinonlycontraceptivesshouldbeconsideredforpost
partumwomenandmaybeintroducedimmediatelyafterdelivery
(or46weekspostpartuminthecaseoflevonorgestrel
intrauterinedevicetoallowtimeforuterineinvolution).Estrogen
containingcontraceptives(includingpills,patch,vaginalring)
shouldnotbestarteduntilbreastfeedingisfullyestablished
(approximately6weeks)asevenlowdoseformulationscan
decreasemilkyield.114

Corticosteroids

Prednisolone,
prednisone

Prednisoneandprednisoloneareexcretedinbreastmilkinlow
amountsandarenotexpectedtocauseadverseeffectsinthe
baby.Dependingonmaternaldoseadministered,babywillbe
exposedto110%ofaneonataldose.11,115Theoretically,high

dosemethylprednisoloneintravenouspulsetherapymayresult
inbreastmilklevelsthatcouldapproachtherapeuticdosesforthe
nursinginfant.Recommendationsforthetimeperiodduringwhich
toavoidbreastfeedingaftertheinfusionrangefrom448hours.14

Decongestants,
oral

Pseudoephedrine

5.5%oftheweightadjustedmaternaldosage bisexcretedin
breastmilkafterasingleoraldoseof60mgof
pseudoephedrine.Decreasedmilkproductionwasreportedatthe
samedosage.Irritabilitywasreportedininfantsexposedto
pseudoephedrineinonestudyofbreastfeedingmothers.79,116
Useshouldbelimitedtoafewdaysanddiscontinuedifadecrease
inmilkproductionisobserved.Nodataareavailableontheuseof
phenylephrineduringbreastfeeding,thereforeanalternatedrug
maybepreferred,especiallywhilenursinganewbornorpreterm
infant.
Intranasalisotonicsalinesolutionsortopicaldecongestants
(oxymetazoline,xylometazoline)arepreferredoveroral
decongestants.

Diabetestherapy

Insulin,metformin

Humaninsulinisnormallyfoundinbreastmilk.Amountof
syntheticinsulinsecretedintobreastmilkisunknownbut,if
secreted,thispeptidewouldbedestroyedintheinfant'sGItract
withnosignificantabsorption.7

Metforminlevelsinmilkarelowandinfantswouldreceiveless
than0.5%oftheirmother'sweightadjusteddosage.Itis
sometimesdetectableinlowlevelsintheserumofbreastfed
infantsbutnoadverseeffectsinbreastfedinfantswerereportedin
onestudy.Metforminshouldbeusedwithcautionwhilenursing
newbornandprematureinfantsandthosewithrenal
impairment.14
Theamountofglyburideexcretedinbreastmilkseemstobelow
(lessthan1%oftheweightadjustedmaternaldose b):noadverse
effectsonbreastfedinfant'sbloodglucosehavebeenreportedbut
dataarelimited.117
Nodataareavailableregardingtheexcretionofacarboseinto
breastmilk.However,lessthan2%ofadoseofacarboseis
absorbedfromthemother'sGItractmakingitunlikelythatany
drugreachestheinfantthroughbreastmilk.118

Nodataareavailableregardingtheexcretionofgliclazide,
glimepiride,nateglinide,pioglitazone,repaglinideand
rosiglitazoneinbreastmilk.Analternatedrugmaybepreferred,
especiallywhilenursinganewbornorpreterminfant.Some
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expertsrecommendmonitoringthebreastfedinfant'sblood

glucoseduringmaternaltherapywithhypoglycemicagents.118

Gastrointestinal
drugs

Antacids,sucralfate

Aluminum,calciumandmagnesiumantacidsandsucralfate
arepartiallyorpoorlyabsorbedorallyandareconsideredsafeto
use.7

Antidiarrheals

Useofloperamideduringbreastfeedingisunlikelytoaffectthe
infantasitisminimallyabsorbedorally.Basedonitschemicaland
pharmacologicalsimilaritytonarcotics,occasionalsmalldosesof
diphenoxylatemaybeacceptablewhilebreastfeedinganolder
infant,butalternativesarepreferred,especiallywhilenursinga
newborn.7,14

GImotilityagents

Theexcretionintomilkofdomperidoneandmetoclopramide
arelessthan0.05%and6%respectivelyofadailypediatricdose.
Noadverseeventsarereportedfordomperidonebutintestinal
discomfortwasreportedin2breastfedinfantsofmotherstaking
metoclopramide.119,120,121Domperidoneisusedtoincrease
milkproductioninsomewomenwhodonotrespondtoa
nonpharmacologicapproach.

H2antagonists

Thoughconsideredsafeforusebybreastfeedingmothers,
cimetidineandranitidinemayconcentrateinmilkwhereas
famotidineandnizatidinehavethelowestconcentrations,
makingthempreferablechoices.7,23Ranitidinehasbeenwidely
usedinpediatricsprimarilyforgastroesophagealreflux.Adverse
effectshavenotbeenreportedinnursinginfants.

Laxatives

Psylliumisacceptabletouseduringbreastfeedingbecauseitis
notabsorbedfromtheGItract.Therehavebeennocasesofloose
stoolsreportedinbreastfedinfants.14
Docusate,bisacodylandmagnesiumhydroxidearenot
appreciablyabsorbedfromtheGItractandthereforethesedrugs
areunlikelytobefoundinthematernalserumorbreastmilk.7,
14Onepostpartumpatientreceivingalaxativecontaining

docusateinadoseof120mgdailyinadditiontodanthron100mg
dailystatedthatdiarrheaoccurredinherbreastfedinfant.14
Usualdosesofsennaareacceptabletouseduringbreastfeeding.
However,alaxativeeffectwasobservedinafewcasereports.
Cascaraisnotafirstlinechoiceduetocasereportsofalaxative
effectinbreastfedinfantsandunknownoralabsorption.7,14
Nodataareavailableregardingtheexcretionoflactuloseinto
breastmilkhoweverlessthan3%ofadoseoflactuloseis
absorbedfromthemother'sGItract,makingitunlikelythatany
drugreachestheinfantthroughbreastmilk.11
Oralpolyethyleneglycol(e.g.,PEG3350)andrectalglycerin
arenegligiblyabsorbedfromtheGItractandunlikelytohave
significantlevelsinbreastmilk.11

Misoprostol

Misoprostollevelsinbreastmilkarelowamountingestedbythe

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nursinginfantwouldnotbeexpectedtocauseadverseeffects.14

Protonpump
inhibitors

Protonpumpinhibitorsareunstableinanacidmilieuand,when
ingestedviamilk,wouldprobablybedestroyedintheinfant's
stomachpriortoabsorption.7Pantoprazoleandomeprazoleare
excretedinmilkinsmallquantities.122,123Lansoprazoleand
omeprazoleareusedforthetreatmentofgastroesophagealreflux
inneonatesandpediatrics.Esomeprazoleisthesenantiomerof
omeprazoleandthereforewouldalsonotbeexpectedtocause
anyadverseeffectsinbreastfedinfants.123

Migrainetherapy

Eletriptan,
sumatriptan

Occasionaluseofsumatriptanandeletriptanseemstobe
acceptablebecausetheamountofthesedrugsexcretedintomilk
islow(3.5%and0.02%oftheweightadjustedmaternaldosage,b
respectively).Dataonalmotriptan,frovatriptan,naratriptan,
rizatriptanandzolmitriptanarelacking.7

Becausethereislimitedpublishedexperiencewithergotamine,
dihydroergotamineandmethysergideduringbreastfeeding,and
adverseeffectsintheinfantcannotberuledout,mostauthorities
considerthesedrugstobeundesirabletousewhilenursing.7,14

Musclerelaxants

Cyclobenzaprine,
methocarbamol

Theexcretionofcyclobenzaprine,methocarbamoland
orphenadrineintomilkhasnotbeenreported.However,
occasionalcyclobenzaprineandmethocarbamolexposuresare
acceptablebecauseofcyclobenzaprine'sstructuralsimilaritiesto
amitriptyline(seeAntidepressants)andtheveryshorthalflifeof
methocarbamol.Noadverseeventshavebeenpublished,but
infants(especiallythosethatarenewbornorpremature)shouldbe
monitoredforsedationwhilenursing.7

NSAIDs

Diclofenac,
flurbiprofen,
ibuprofen,
indomethacin,
naproxen

MostNSAIDshavebeenshowntobepresentinbreastmilkin
smallamountsandareconsideredsafetouse.Theuseofshort
actingdrugs,suchasibuprofenandflurbiprofen,maybe
preferredoverthosewithalongerhalflifesuchasnaproxen.7

Lessthan1%ofthepediatricdoseofdiclofenacisexcretedinto
breastmilk.Diclofenacalsohasashorthalflife.14,126

Theamountofindomethacinexcretedinbreastmilkislessthan
4%ofatypicalneonataldoseanditisconsideredsafetousewhile
breastfeeding.However,otheragentswithmorepublished
informationonuseduringbreastfeedingmaybepreferable
especiallywhilenursinganewbornorpreterminfant.11
Dataoncelecoxibarelimitedtoafewinfantsbutmilklevelswere
lowandadverseeffectswerenotnotedwhentakenshortterm.7
Moredataareneededtodeterminerisksincethedrughasalong
halflifeandhighoralabsorption.

Scabicides,
pediculicides

Permethrin

Permethrin5%creamisthetreatmentofchoiceforscabies.
Permethrin1%orpyrethrins/piperonylbutoxidemaybeused
forthetreatmentofheadlicewhilebreastfeeding.124Topical
absorptionofpermethrinandpyrethrinsislow.Permethrinis
rapidlymetabolizedtoinactivemetabolitesandexcretedinurine.
Overttoxicityisunlikely.Avoidapplicationonnipples.
Percutaneousabsorptionofpiperonylbutoxideisunknown.7,125

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Lindaneisnotrecommendedbecauseitisabsorbedthroughthe
mother'sskinandexcretedintomilkfat.Directcontactoflindane
withneonatalskinresultsinsignificantabsorption.Directexposure
ispotentiallytoxicininfantswithreportsofelevatedliver
enzymes,seizuredisordersandhypersensitivity.Itmayalsohave
estrogeniceffectsthatcouldinhibitlactation.14,125Lindaneisnot
currentlyavailableinCanada.

Smoking
cessation

Nicotine
replacement
therapy

Dataonnicotinepatchesarelimitedbuttheamountofnicotine
andcotinineexcretedinbreastmilkseemtobelessthan8%of
theweightadjustedmaternaldose b.Witha21mgtransdermal

patch,nicotinepassesintobreastmilkinamountsequivalentto
smoking17cigarettesdaily.Lowerpatchstrengthsof7and14mg
provideproportionatelyloweramountsofnicotinetothebreastfed
infant.Nostudiesonnicotinesprayornicotinegumuseinnursing
mothershavebeenreported.Nicotinegummayproducelarge
variationsinpeaklevelswhengumischewedrapidly:fluctuations
similartosmokingitself.Somecliniciansrecommendtowait23h
afterusingthegumbeforebreastfeeding.127
Dataonvareniclinearelackingbuttransferispossibleandeffect
onCNSisaconcern.7

Forinformationontheuseofbupropionduringbreastfeeding,see
Antidepressants.

Thyroidagents

Antithyroidagents

Theestimatedlevelofexposuretopropylthiouracilin
breastfeedinginfantsislessthan1%ofthetherapeuticdose
standardizedbyweight,andthethyroidfunctionoftheinfantisnot
affected.128Methimazoleindosesupto20mg/dayhasbeen
documentednottoaffecttheinfant'sthyroidfunction.129,130,
131Foreitherdrug,noadverseeffectsinbreastfedinfantshave

beenreportedsofarandmonitoringofinfants'thyroidfunctionis
notnecessaryifdevelopmentisprogressingnormally.131

Thyroidhormones

Levothyroxineiscompatiblewithbreastfeeding.Thyroid
hormonescrossintobreastmilkinlowamounts.Theirpresenceis
notlikelytoaffecttheinfant'sthyroid.23

Vaccines

WomenwhoarebreastfeedingcanbevaccinatedwithTd,Tdap,
pneumococcal,meningococcal,hepatitisA,hepatitisB,HPV,
rabies,typhoid,MMR,varicella,HPVandcholeravaccinesif
indicated.
SafetyoftheJapaneseencephalitisvaccineinbreastfeedingis
unknownanditshouldbeadministeredonlyiftheriskofdisease
outweighstheunknownriskofvaccination.Yellowfevervaccineis
notrecommendedforbreastfeedingwomenandBCGvaccine
shouldbeusedwithcaution.Womenwhoreceivesmallpoxvaccine
aspostexposureprophylaxisshouldavoidbreastfeedingandother
closecontactwiththeirbabyuntilthescabhasseparatedfromthe
vaccinationsite.132

a. Thislistisnotexhaustiveordefinitive.Drugsnotlistedinthetablearenotnecessarilycontraindicated.Individualizedrisk

assessmentisrequiredwhenprescribinganymedicationtoabreastfeedingwoman.
b. Weightadjustedmaternaldoseisamother'sdosebasedonbodyweight(e.g.,mg/kg).Expertsrecommendthatanamountof
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drugreceivedbytheinfantviabreastmilkwhichis>10%oftheweightadjustedmaternaldoseshouldbeatheoreticallevelof
concernwhenconsideringtheacceptabilityofdrugexposure.Theestimatedamountofdrugreceivedbytheinfantviabreastmilk
iscalculatedbymultiplyingthestandardmilkintake(150mL/kg/day)bythedrugconcentrationinbreastmilk.
Abbreviations:G6PD=glucose6phosphatedehydrogenaseGFR=glomerularfiltrationrate

DrugsforNonmedicalUse
Tobaccosmokingandalcoholingestionarethemostcommonsourcesofnonmedicinaldrugexposureinbreastfed
infantsinCanada.Becausetheysooftenoccurinthesameindividual,itisdifficulttostudytheirindependent
effects.Increasingly,thesedrugsareusedtogetherwithillicitdrugssuchasmarijuanaandcocaine.

Table2:BreastfeedingandNonmedicalUseofDrugs
Drug

Comments

Alcohol

Notcompatiblewithbreastfeeding.Thealcoholmetabolizingcapacity(alcoholandaldehyde
dehydrogenase)isprematurethroughouttheneonatalandinfantileperiod.Overall,motor
developmentisslightlyslowerininfantsbreastfedbymotherswhoregularlydrinkalcohol.
Chronicorheavyconsumersofalcoholshouldnotbreastfeed.7

Shorttermalcoholconsumptionbynursingmothersreportedlyhasanimmediateeffectonthe
odourcharacteristicsofthemilkandthefeedingbehaviouroftheirinfants,resultinginless
consumptionofmilk.133Toavoidexposureoftheinfanttoalcohol,breastfeedingmothers
shouldnotconsumealcoholorshouldconsumenomorethanonedrink23hbefore
breastfeeding.7

Caffeine

Hypothetically,anursinginfantingests0.11%ofthematernaldoseafterthemotherdrinks1
2cupsofcoffee.Thisisaninsignificantamountofthedrug,butitmustberememberedthat
thehalflifeofcaffeineis80hinthetermnewbornand97.5hinaprematureinfant(2030
timesthatofanadult).Therefore,repeatedingestionmightleadtoaccumulationofcaffeinein
theinfantduringthefirst2weeksofpostnatallife.Thishasyettobestudied.

Recreational
orstreet
drugs

Nosystematicstudiesofrecreationalorstreetdrug(ordrugmetabolite)excretionexist.

Tobacco

Discourageduringbreastfeedingbecausetherearewelldocumentedhealthriskstothemother
andinfantfromsecondhandsmoke.Infantexposuretonicotineislargelythroughinhalation
ofsecondhandsmoke.Inmothersunwillingtostopsmokingduringbreastfeeding,itshouldbe
notedthatbreastfedbabiesofmotherswhocontinuetosmokehavebetterimmunityandless
respiratoryinfectionsthanbottlefedbabiesofmotherswhocontinuetosmoke.134
Nicotineisconcentratedinhumanbreastmilk.135,136Onestudysuggeststhatcigarette
smokingsignificantlyreducesbreastmilkproduction.137
Encouragenursingmotherstospeaktotheirhealthcareprovidersregardingoptionsfor
smokingcessation.

References
1. KramerMS,AboudF,MironovaEetal.Breastfeedingandchildcognitivedevelopment:newevidencefroma
largerandomizedtrial.ArchGenPsychiatry200865(5):57884.
2. VerhasseltV,MilcentV,CazarethJetal.Breastmilkmediatedtransferofanantigeninducestoleranceand
https://www.etherapeutics.ca/tc.showPrintableChapter.action?chapterId=ci709

14/19

8/4/2015

eTherapeutics+Complete:TherapeuticChoices:DrugUseduringBreastfeeding

protectionfromallergicasthma.NatMed200814(2):1705.
3. SectiononBreastfeeding.Breastfeedingandtheuseofhumanmilk.Pediatrics2012129(3):e82741.
4. SachsHCCommitteeonDrugs.Thetransferofdrugsandtherapeuticsintohumanbreastmilk:anupdate
onselectedtopics.Pediatrics2013132(3):e796809.
5. AkusM,BartickM.Lactationsafetyrecommendationsandreliabilitycomparedin10medicationresources.
AnnPharmacother200741(9):135260.
6. HealthCanadaJanssenOrtho.ImportantsafetyinformationaboutuseofTylenolwithCodeineNo.2,3,4
andelixirinnursingmothersandultrarapidmetabolizersofcodeineOctober6,2008.Availablefrom:
healthycanadians.gc.ca/recallalertrappelavis/hcsc/2008/14526aeng.php.AccessedOctober1,2013.
7. HaleTW.Medicationsandmothers'milk:amanualoflactationalpharmacology.15thed.Amarillo(TX):Hale
Publishing2012.
8. WittelsB,ScottDT,SinatraRS.Exogenousopioidsinhumanbreastmilkandacuteneonatalneurobehavior:
apreliminarystudy.Anesthesiology199073(5):8649.
9. LamJ,KellyL.CiszkowskiCetal.Centralnervoussystemdepressionofneonatesbreastfedbymothers
receivingoxycodoneforpostpartumanalgesia.JPediatr2012160(1):337.
10. SeatonS,ReevesM,McLeanS.Oxycodoneasacomponentofmultimodalanalgesiaforlactatingmothers
afterCaesareansection:relationshipsbetweenmaternalplasmabreastmilkandneonatalplasmalevels.
AustNZJObstetGynaecol200747(3):1815.
11. FerreiraE,MartinB,MorinC.Grossesseetallaitement:guidethrapeutique.2nded.Montral(QC):CHU
SainteJustine2013.
12. RobieuxI,KorenG,VandenberghHetal.Morphineexcretioninbreastmilkandresultantexposureofa
nursinginfant.ClinToxicol199028(3):36570.
13. IlettKF,PaechMJ,PageSharpMetal.Useofasparsesamplingstudydesigntoassesstransferoftramadol
anditsOdesmethylmetaboliteintotransitionalbreastmilk.BrJClinPharmacol200865(5):6616.
14. DrugsandLactationDatabase(LactMed).Bethesda(MD):U.S.NationalLibraryofMedicine.Availablefrom:
toxnet.nlm.nih.gov/cgibin/sis/htmlgen?LACT.AccessedOctober2,2013.
15. ChanCF,PageSharpM,KristensenJHetal.Transferofnaltrexoneanditsmetabolite6,betanaltrexolinto
humanmilk.JHumLact200420(3):3226.
16. SedlmayrT,PetersF,RaaschWetal.[Clarithromycin,anewmacrolideantibiotic.Effectivenessinpuerperal
infectionsandpharmacokineticsinbreastmilk].GeburtshilfeFrauenheilkd199353(7):48891.[German].
17. KelseyJJ,MoserLR,JenningsJCetal.Presenceofazithromycinbreastmilkconcentrations:acasereport.
AmJObstetGynecol1994170(5Pt1):13756.
18. ZaoJ,KorenG,BozzoP.Usingnitrofurantionwhilebreastfeedinganewborn.CanFamPhys201460(6):539
40.
19. GuillonneauM,deCrepyA,AufrantCetal.[Breastfeedingispossibleincaseofmaternaltreatmentwith
enoxaparin].ArchPediatr19963(5):5134.[French].
20. HarenbergJ,LeberG,ZimmermannRetal.[Preventionofthromboembolismwithlowmolecularweight
heparininpregnancy].GeburtshilfeFrauenheilkd198747(1):158.[German].
21. RichterC,SitzmannJ,LangPetal.Excretionoflowmolecularweightheparininhumanmilk.BrJClin
Pharmacol200152(6):70810.
22. LindhoffLastE,BauersachsR.Heparininducedthrombocytopeniaalternativeanticoagulationinpregnancy
andlactation.SeminThrombHemost200228(5):43946.
23. BriggsGG,FreemanRK,YaffeSJ.Drugsinpregnancyandlactation:areferenceguidetofetalandneonatal
risk.9thed.Philadelphia(PA):LippincottWilliams&Wilkins2011.
24. FreyOR,ScheidtP,vonBrenndorffAI.Adverseeffectsinanewborninfantbreastfedbyamothertreated
withdoxepin.AnnPharmacother199933(6):6903.
25. BirnbaumCS,CohenLS,BaileyJWetal.Serumconcentrationsofantidepressantsandbenzodiazepinesin
nursinginfants:acaseseries.Pediatrics1999104(1):e11.
26. StoweZN,HostetterAL,OwensMJetal.Thepharmacokineticsofsertralineexcretionintohumanbreast
milk:determinantsofinfantserumconcentrations.JClinPsychiatry200364(1):7380.
27. DoddS,StockyA,BuistAetal.Sertralineinpairedbloodplasmaandbreastmilksamplesfromnursing
mothers.HumPsychopharmacol200015(4):161264.
28. EppersonN,CzarkowskiKA,WardO'BrienDetal.Maternalsertralinetreatmentandserotonintransportin
breastfeedingmotherinfantpairs.AmJPsychiatry2001158(10):16317.
29. MllerMJ,PreuC,PaulTetal.Serotonergicoverstimulationinapreterminfantaftersertralineintakevia
breastmilk.BreastfeedMed20138(3):3279.
https://www.etherapeutics.ca/tc.showPrintableChapter.action?chapterId=ci709

15/19

8/4/2015

eTherapeutics+Complete:TherapeuticChoices:DrugUseduringBreastfeeding

30. HendrickV,FukuchiA,AltshulerLetal.Useofsertraline,paroxetineandfluvoxaminebynursingwomen.Br
JPsychiatry2001179:1636.
31. BeggEJ,DuffullSB,SaundersDAetal.Paroxetineinhumanmilk.BrJClinPharmacol199948(2):1427.
32. OhmanR,HaggS,CarleborgLetal.Excretionofparoxetineintobreastmilk.JClinPsychiatry
199960(8):51923.
33. StoweZN,CohenLS,HostetterAetal.Paroxetineinhumanbreastmilkandnursinginfants.AmJPsychiatry
2000157(2):1859.
34. MisriS,KimJ,RiggsKWetal.Paroxetinelevelsinpostpartumdepressedwomen,breastmilk,andinfant
serum.JClinPsychiatry200061(11):82832.
35. EppersonCN,JatlowP,CzarkowskiKetal.Maternalfluoxetinetreatmentinthepostpartumperiod:effects
onplateletserotoninandplasmadruglevelsinbreastfeedingmotherinfantpairs.Pediatrics
2003112(5):e4259.
36. MorettiME,SharmaA,BarOzBetal.Fluoxetineanditseffectsonthenursinginfant:aprospectivecohort
study.ClinPharmacolTher199965(2):141.
37. KristensenJH,IlettKF,HackettLPetal.Distributionandexcretionoffluoxetineandnorfluoxetineinhuman
milk.BrJClinPharmacol199948(4):5217.
38. TaddioA,ItoS,KorenG.Excretionoffluoxetineanditsmetabolite,norfluoxetine,inhumanbreastmilk.J
ClinPharmacol199636(1):427.
39. YoshidaK,SmithB,CraggsMetal.Fluoxetineinbreastmilkanddevelopmentaloutcomeofbreastfed
infants.BrJPsychiatry1998172:1758.
40. ChambersCD,AndersonPO,ThomasRGetal.Weightgainininfantsbreastfedbymotherswhotake
fluoxetine.Pediatrics1999104(5):e61.
41. LesterBM,CuccaJ,AndreozziLetal.Possibleassociationbetweenfluoxetinehydrochlorideandcolicinan
infant.JAmAcadChildAdolescPsychiatry199332(6):12535.
42. HaleTW,ShumS,GrossbergM.Fluoxetinetoxicityinabreastfedinfant.ClinPediatr(Phila)
200140(12):6814.
43. SuriR,StoweZN,HendrickVetal.Estimatesofnursinginfantdailydoseoffluoxetinethroughbreastmilk.
BiolPsychiatry200252(5):44651.
44. PiontekCM,WisnerKL,PerelJM.Serumfluvoxaminelevelsinbreastfedinfants.JClinPsychiatry
200162(2):1113.
45. KristensenJH,HackettLP,KohanRetal.Theamountoffluvoxamineinmilkisunlikelytobeacauseof
adverseeffectsinbreastfedinfants.JHumLact200218(2):13943.
46. RamponoJ,KristensenJH,HackettLPetal.Citalopramanddemethylcitalopraminhumanmilkdistribution,
excretionandeffectsinbreastfedinfants.BrJClinPharmacol200050(3):2638.
47. SchmidtK,OlesenOV,JensenPN.Citalopramandbreastfeeding:serumconcentrationandsideeffectsin
theinfant.BiolPsychiatry200047(2):1645.
48. SpigsetO,CarieborgL,OhmanRetal.Excretionofcitalopraminbreastmilk.BrJClinPharmacol
199744(3):2958.
49. HeikkinenT,EkbladU,KeroPetal.Citalopraminpregnancyandlactation.ClinPharmacolTher
200272(2):18491.
50. HendrickV,AltshulerL,WertheimerAetal.Venlafaxineandbreastfeeding.AmJPsychiatry
2001158(12):208990.
51. IlettKF,HackettLP,DusciLJetal.DistributionandexcretionofvenlafaxineandOdesmethylvenlafaxinein
humanmilk.BrJClinPharmacol199845(5):45962.
52. IlettKF,KristensenJH,HackettLPetal.DistributionofvenlafaxineanditsOdesmethylmetaboliteinhuman
milkandtheireffectsinbreastfedinfants.BrJClinPharmacol200253(1):1722.
53. RamponoJ,TeohS,HackettLPetal.Estimationofdesvenlafaxinetransferintomilkandinfantexposure
duringitsuseinlactatingwomenwithpostnataldepression.ArchWomensMentHealth201114(1):4953.
54. BriggsGG,SamsonJH,AmbrosePJetal.Excretionofbupropioninbreastmilk.AnnPharmacother
199327(4):4313.
55. BaabSW,PeindlKS,PiontekCMetal.Serumbupropionlevelsin2breastfeedingmotherinfantpairs.JClin
Psychiatry200263(10):9101.
56. HaasJS,KaplanCP,BarenboimDetal.Bupropioninbreastmilk:anexposureassessmentforpotential
treatmenttopreventpostpartumtobaccouse.TobControl200413(1):526.
57. AichhornW,WhitworthAB,WeissUetal.Mirtazapineandbreastfeeding.AmJPsychiatry
2004161(12):2325.
58. KristensenJH,IlettKF,RamponoJetal.Transferofantidepressantmirtazapineintobreastmilk.BrJClin
https://www.etherapeutics.ca/tc.showPrintableChapter.action?chapterId=ci709

16/19

8/4/2015

eTherapeutics+Complete:TherapeuticChoices:DrugUseduringBreastfeeding

Pharmacol200763(3):3227.
59. BuistA,DennersteinL,MaguireKPetal.Plasmaandhumanmilkconcentrationsofmoclobemideinnursing
mothers.HumanPsychopharmacolClinExp199813(8):57982.
60. ChaudronLH,SchoeneckerCJ.Bupropionandbreastfeeding:acaseofapossibleinfantseizure.JClin
Psychiatry200465(6):8812.
61. CorriveauD.UtilisationdeWellbutrinSRchezlafemmeenceinteetchezlafemmeallaitant.In:
GlaxoSmithKline,PersonalCommunication2001.
62. NeumanG,ColantonioD,DelaneySetal.Bupropionandescitalopramduringlactation.AnnPharmacother
201448(7):92831.
63. VerbeekRK,RossSG,McKennaEA.Excretionoftrazodoneinbreastmilk.BrJClinPharmacol
198622(3)36770.
64. MisriS,CorralM,WardropAAetal.Quetiapineaugmentationinlactation:aseriesofcasereports.JClin
Psychopharmacol200626(5):50811.
65. MisriS,SivertzK.Tricyclicdrugsinpregnancyandlactation:apreliminaryreport.IntJPsychiatryMed
199121(2):15771.
66. NewportDJ,RitchieJC,KnightBTetal.Venlafaxineinhumanbreastmilkandnursinginfantplasma:
determinationofexposure.JClinPsychiatry200970(9):130410.
67. LoboED,LoghinC,KnadlerMPetal.Pharmacokineticsofduloxetineinbreastmilkandplasmaofhealthy
postpartumwomen.ClinPharmacokinet200847(2):1039.
68. BoycePM,HackettLP,IlettKF.Duloxetinetransferacrosstheplacentaduringpregnancyandintomilkduring
lactation.ArchWomensMentHealth201114(2):16972.
69. MeadorKJ.Breastfeedingandantiepilepticdrugs.JAMA2014311(17):17978.
70. ItoS.Drugtherapyforbreastfeedingwomen.NEnglJMed2000343(2):11826.
71. OhmanI,VitolsS,TomsonT.Pharmacokineticsofgabapentinduringdelivery,intheneonatalperiod,and
lactation:doesafetalaccumulationoccurduringpregnancy?Epilepsia200546(10):16214.
72. OhmanI,TomsonT.Gabapentinkineticsduringdelivery,intheneonatalperiod,andduringlactation.
Epilepsia200950(Suppl10):108.
73. KristensenJH,IlettKF,HackettLPetal.Gabapentinandbreastfeeding:acasereport.JHumLact
200622(4):4268.
74. MactalHaafC,HoffmanM,KuchtaA.Useofantiinfectiveagentsduringlactation,Part3:Antivirals,
antifungals,andurinaryantiseptics.JHumLact200117(2):1606.
75. IlettKF,KristensenJH.Druguseandbreastfeeding.ExpertOpinDrugSaf20054(4):74568.
76. ReedBR.Dermatologicdruguseduringpregnancyandlactation.DermatolClin199715(1):197206.
77. HilbertJ,RadwanskiE,AffrimeMBetal.Excretionofloratadineinhumanbreastmilk.JClinPharmacol
198828(3):2349.
78. LucasBD,PurdyCY,ScarimSKetal.Terfenadinepharmacokineticsinbreastmilkinlactatingwomen.Clin
PharmacolTher199557(4):398402.
79. ItoS,BlajchmanA,StephensonMetal.Prospectivefollowupofadversereactionsinbreastfedinfants
exposedtomaternalmedication.AmJObstetGynecol1993168(5):13939.
80. SandstromB,RegardhCG.Metoprololexcretionintobreastmilk.BrJClinPharmacol19809(5):5189.
81. HoTK,MorettiME,SchaefferIJetal.Maternalbetablockerusageandbreastfeedingintheneonate.Pediatr
Res199945(4):67A.
82. SchimmelMS,EidelmanAI,WilschanskiMAetal.Toxiceffectsofatenololconsumedduringbreastfeeding.J
Pediatr1989114(3):4768.
83. DumezY,TchobroutskyC,HornychHetal.Neonataleffectsofmaternaladministrationofacebutolol.BrMed
J(ClinResEd)1981283(6299):10779.
84. BoutroyMJ,BianchettiG,DubrucCetal.Tonursewhenreceivingacebutolol:isitdangerousforthe
neonate?EurJClinPharmacol198630(6):7379.
85. JonesHM,CummingsAJ.Astudyofthetransferofalphamethyldopatothehumanfoetusandnewborn
infant.BrJClinPharmacol19786(5):4324.
86. WhiteWB,AndreoliJW,CohnRD.Alphamethyldopadispositioninmotherswithhypertensionandintheir
breastfedinfants.ClinPharmacolTher198537(4):38790.
87. CommitteetoAdviseonTropicalMedicineandTravel(CATMAT).Canadianrecommendationsforthe
preventionandtreatmentofmalariaamonginternationaltravellers.CanCommunDisRep200430(Suppl
1):162.Availablefrom:www.phacaspc.gc.ca/publicat/ccdrrmtc/09vol35/35s1/page5eng.php.Accessed
October2,2013.
88. Recommendationsforthepreventionofmalariaamongtravelers.MMWRRecommRep199039(RR3):110.
https://www.etherapeutics.ca/tc.showPrintableChapter.action?chapterId=ci709

17/19

8/4/2015

eTherapeutics+Complete:TherapeuticChoices:DrugUseduringBreastfeeding

Availablefrom:www.cdc.gov/mmwr/preview/mmwrhtml/00001584.htm.AccessedOctober2,2013.
89. VigueraAC,NewportDJ,RitchieJetal.Lithiuminbreastmilkandnursinginfants:clinicalimplications.AmJ
Psychiatry2007164(2):3425.
90. TunnessenWW,HertzCG.Toxiceffectsoflithiuminnewborninfants:acommentary.JPediatr
197281(4):8047.
91. MorettiM,KorenG,VerjeeZetal.Monitoringlithiuminbreastmilk:anindividualizedapproachforbreast
feedingmothers.TherDrugMonit200325(3):3646.
92. KirkM.ZyprexaEmploichezlesfemmesenceintesouallaitantes.In:TouzinJ,ed.Toronto(ON):EliLilly
Canada,Inc.2008:15.
93. GiladO,MerlobP,StahlBetal.Outcomeofinfantsexposedtoolanzapineduringbreastfeeding.Breastfeed
Med20116(2):558.
94. GardinerSJ,KristensenJH,BeggEJetal.Transferofolanzapineintobreastmilk,calculationofinfantdrug
dose,andeffectonbreastfedinfants.AmJPsychiatry2003160(8):142831.
95. BrunnerE,FalkDM,JonesMetal.Olanzapineinpregnancyandbreastfeeding:areviewofdatafromglobal
safetysurveillance.BMCPharmacolToxicol201314:38.
96. LeeA,GiesbrechtE,DunnEetal.Excretionofquetiapineinbreastmilk.AmJPsychiatry2004161(9):1715
6.
97. RamponoJ,KristensenJH,IlettKFetal.Quetiapineandbreastfeeding.AnnPharmacother200741(4):711
4.
98. YazdaniBrojeniP,TaguchiN,GarciaBournissenFetal.Quetiapineinhumanmilkandsimulationbased
assessmentofinfantexposure.ClinPharmacolTher201087(Suppl1):S34.
99. WeggelaarNM,KeijerWJ,JanssenPK.Acasereportofrisperidonedistributionandexcretionintohuman
milk:howtogivegoodadviceifyouhavenotenoughdataavailable.JClinPsychopharmacol
201131(1):12931.
100. YoshidaK,SmithB,CraggsMetal.Neurolepticdrugsinbreastmilk:astudyofpharmacokineticsandof
possibleadverseeffectsinbreastfedinfants.PsycholMed199828(1):8191.
101. DevVJ,KruppP.Adverseeventprofileandsafetyofclozapine.RevContempPharmacother19956:197
208.
102. SheffieldJS,FishDN,HollierLMetal.Acyclovirconcentrationsinhumanbreastmilkaftervalaciclovir
administration.AmJObstetGynecol2002186(1):1002.
103. SieverLJ.Theeffectofamantadineonprolactinlevelsandgalactorrheaonneuroleptictreatedpatients.J
ClinPsychopharmacol19811(1):27.
104. CorreaN,OplerLA,KaySRetal.Amantadineinthetreatmentofneuroendocrinesideeffectsof
neuroleptics.JClinPsychoharmacol19877(2):915.
105. WentgesvanHoltheN,vanEijkerenM,vanderLaanJW.Oseltamivirandbreastfeeding.IntJInfectDis
200812(4):451.
106. TanakaT,NakajimaK,MurashimaAetal.SafetyofneuraminidaseinhibitorsagainstnovelinfluenzaA
(H1N1)inpregnantandbreastfeedingwomen.CMAJ2009181(12):558.
107. KellyLE,PoonS,MadadiPetal.Neonatalbenzodiazepinesexposureduringbreastfeeding.JPediatr
2012161(3):44851.
108. NAEPPexpertpanelreport.Managingasthmaduringpregnancy:recommendationsforpharmacologic
treatment2004update.JAllergyClinImmunol2005115(1):3446.
109. LindbergC,BoreusLO,deChateauPetal.Transferofterbutalineintobreastmilk.EurJRespDis
1984134:8791.
110. LonnerholmG,LindstromB.Terbutalineexcretionintobreastmilk.BrJClinPharmacol198213(5):72930.
111. FaltA,BengtssonT,KennedyBMetal.Exposureofinfantstobudesonidethroughbreastmilkofasthmatic
mothers.JAllergyClinImmunol2007120(4):798802.
112. eCPS.Ottawa(ON):CanadianPharmacistsAssociation2013.Accolate[productmonograph].Available
from:www.etherapeutics.ca.Subscriptionrequired.
113. BerlinCM,BriggsGG.Drugsandchemicalsinhumanmilk.SeminFetalNeonatalMed200510(2):14959.
114. BlackA,FrancoeurD,RoweTetal.Canadiancontraceptionconsensus.JObstetGynaecolCan
200426(4):34787,389436.
115. OstL,WettrellG,BjorkhemIetal.Prednisoloneexcretioninhumanmilk.JPediatr1985106(6):100811.
116. AljazafK,HaleTW,IlettKFetal.Pseudoephedrine:effectsonmilkproductioninwomenandestimationof
infantexposureviabreastmilk.BrJClinPharmacol200356(1):1824.
117. FeigDS,BriggsGG,KraemerJMetal.Transferofglyburideandglipizideintobreastmilk.DiabetesCare
200528(8):18515.
https://www.etherapeutics.ca/tc.showPrintableChapter.action?chapterId=ci709

18/19

8/4/2015

eTherapeutics+Complete:TherapeuticChoices:DrugUseduringBreastfeeding

118. EverettJA.Useoforalantidiabeticagentsduringbreastfeeding.JHumLact199713(4):31921.
119. KauppilaA,ArvelaP,KoivistoMetal.Metoclopramideandbreastfeeding:transferintomilkandthe
newborn.EurJClinPharmacol198325(6):81923.
120. KauppilaA,AnuntiP,KivinenSetal.Metoclopramideandbreastfeeding:efficacyandanteriorpituitary
responsesofthemotherandthechild.EurJObstetGynecolReprodBiol198519(1):1922.
121. LewisPJ,DevenishC,KahnC.Controlledtrialofmetoclopramideintheinitiationofbreastfeeding.BrJClin
Pharmacol19809(2):2179.
122. PlanteL,FerronGM,UnruhMetal.Excretionofpantoprazoleinhumanbreast.JReprodMed
200449(10):8257.
123. MarshallJK,ThompsonAB,ArmstrongD.Omeprazoleforrefractorygastroesophagealrefluxdiseaseduring
pregnancyandlactation.CanJGastroenterol199812(3):2257.
124. CentersforDiseaseControlandPrevention,WorkowskiKA,BermanSM.Sexuallytransmitteddiseases
treatmentguidelines,2006.MMWRRecommRep200655(RR11):194.
125. PortoI.Antiparasiticdrugsandlactation:focusonanthelmintics,scabicides,andpediculicides.JHumLact
200319(4):4215.
126. TaketomoCK,HoddingJH,KrausDM.Pediatric&neonataldosagehandbook:acomprehensiveresourcefor
allclinicianstreatingpediatricandneonatalpatients.18thed.Hudson(OH):Lexicomp2011.
127. IlettKF,HaleTW,PageSharpMetal.Useofnicotinepatchesinbreastfeedingmothers:transferofnicotine
andcotinineintohumanmilk.ClinPharmacolTher200374(6):51624.
128. KampmannJP,JohansenK,HansenJMetal.Propylthiouracilinhumanmilk.Revisionofadogma.Lancet
19801(8171):7367.
129. AziziF.Effectofmethimazoletreatmentofmaternalthyrotoxicosisonthyroidfunctioninbreastfeeding
infants.JPediatr1996128(6):8558.
130. AziziF,KhoshniatM,BahrainianMetal.Thyroidfunctionandintellectualdevelopmentofinfantsnursedby
motherstakingmethimazole.JClinEndocrinolMetab200085(9):32338.
131. MandelSJ,CooperDS.Theuseofantithyroiddrugsinpregnancyandlactation.JClinEndocrinolMetab
200186(6):23549.
132. Part3:Vaccinationofspecificpopulations.Immunizationinpregnancyandbreastfeeding.In:PublicHealth
AgencyofCanada.Canadianimmunizationguide.Availablefrom:www.phacaspc.gc.ca/publicat/ciggci/p03
04eng.php#a8.AccessedNovember19,2013.
133. MennellaJA,BeauchampGK.Thetransferofalcoholtohumanmilk.Effectsonflavorandtheinfant's
behavior.NEnglJMed1991325(14):9815.
134. DoreaJG.Maternalsmokingandinfantfeeding:breastfeedingisbetterandsafer.MaternChildHealthJ
200711(3):28791.
135. LuckW,NauH.Nicotineandcotinineconcentrationsinserumandmilkofnursingsmokers.BrJClin
Pharmacol198418(1):915.
136. HardeeGE,StewartT,CapomacchiaAC.Tobaccosmokexenobioticcompoundappearanceinmothers'milk
afterinvoluntarysmokeexposures.I.Nicotineandcotinine.ToxicolLett198315(23):10912.
137. HopkinsonJM,SchanlerRJ,FraleyJKetal.Milkproductionbymothersofprematureinfants:influenceof
cigarettesmoking.Pediatrics199290(6):9348.

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