Journal of Human Lactation

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Studying Drugs in Human Milk: Time to Unify the Approach

Evan J. Begg, Stephen B. Duffull, L. Peter Hackett and Kenneth F. Ilett
J Hum Lact 2002 18: 323
DOI: 10.1177/089033402237904

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 10.1177/089033402237904
Begg et alJ Hum Lact 18(4), 2002 J Hum Lact 18(4), 2002Drugs in Human Milk

Clinical Perspectives

Studying Drugs in Human Milk: Time to Unify the Approach

Evan J. Begg, MB, ChB, FRACP, Stephen B. Duffull, PhD, DipPharm, MPharm(Clin),
L. Peter Hackett, MRSC, and Kenneth F. Ilett, PhD, BPharm

Abstract
The trend globally for mothers to breastfeed has highlighted the need for information on drug
transfer into breast milk and the extent to which the suckling neonate may be exposed and af-
fected. This review discusses robust study methodologies that will yield high-quality informa-
tion on all aspects of this process. Methods for assessing drug transfer into breast milk are ex-
amined. The place of the milk/plasma ratio, the amount of drug in breast milk, and the volume
of milk produced are discussed in the context of their utility in estimating both absolute and
relative infant dose. The measurement of plasma drug concentrations and pharmacodynamic
effects in the breastfed infant exposed to drugs are identified as important factors that can as-
sist in deciding whether drug present in breast milk is a significant risk for the nursing infant. J
Hum Lact. 18(4):323-332.
Keywords: human milk, drug distribution and excretion, relative infant dose, absolute
infant dose, milk/plasma ratio

The trend globally for an increased percentage of moth- volume of milk produced, since this may indirectly
ers to breastfeed has highlighted the need for informa- affect infant growth and development. The ultimate test
tion on drug transfer into human milk and the extent to is the measurement of infant plasma drug concentration
which the suckling neonate may be exposed to, and and any pharmacodynamic effects on the infant.
affected by, unwanted xenobiotics. After excluding In this review, we summarize the methodology used
drugs that have an unacceptable risk of toxicity at any in studies of drug transfer into breast milk, assessment
dose, the primary consideration is the “dose” the infant of the infant dose, and the extent of exposure. Our aim is
will receive and how that dose is reflected in the infant in to encourage robust experimental designs that will facil-
terms of concentration and effect. For some drugs, con- itate evaluation of both risk and benefit for breastfed
sideration should be given as to how they might alter the infants whose mothers may need to use drugs during
lactation.
Received for review, December 10, 2001; revised manuscript accepted for Quantitation of Drug Transfer Into Human Milk
publication, June 6, 2002.
Evan J. Begg is a professor in the Department of Clinical Pharmacology at Measurement of Drug
Christchurch Hospital, Christchurch, New Zealand. Stephen B. Duffull is a Concentrations in Milk and Plasma
senior lecturer in the School of Pharmacy at the University of Queensland, St.
Lucia, Australia. L. Peter Hackett is a research scientist in the Clinical Phar- Measurement of drug concentrations in maternal
macology and Toxicology Laboratory at the Western Australian Center for plasma and/or milk provides useful information that
Pathology and Medical Research, Nedlands, Western Australia. Kenneth F. assists in evaluating drug transfer to the infant. Maternal
Ilett is an associate professor in the School of Medicine and Pharmacology at
the University of Western Australia, Crawley, Western Australia. Address
plasma concentrations of most drugs show wide
correspondence to Kenneth F. Ilett, School of Medicine and Pharmacology, intersubject variability as a result of varying doses and
University of Western Australia, Crawley, 6009, Western Australia. interindividual variability in clearance. As a matrix for
J Hum Lact 18(4), 2002 drug assay, plasma is generally uniform and the accu-
DOI: 10.1177/089033402237904
 Copyright 2002 International Lactation Consultant Association

323

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324 Begg et al J Hum Lact 18(4), 2002

racy and precision of measurements made by common

200 10
analytical methods is good.
Breast milk can be thought of as a special tissue com- 175
partment linked closely to plasma. It is not surprising, 8
150
therefore, that drug concentrations in human milk also

Bupropion (µg/l)
125
show wide interindividual variability. Human milk is 6

subject to significant time-dependent changes in lipid
1
and protein content. In turn, these changes influence
the extent of drug transfer into milk and may cause vari-
ability in the measurement of drug content. For exam-
ple, drug assay precision at comparable concentrations
2-4
is generally lower for milk than for plasma. The lipid
content of breast milk is probably the cause of this vari-
ability, since it can vary 2-fold, and many drugs have
significant lipid solubility. A comprehensive discussion
of the problems of drug assay in human milk was pub-
5 Figure 1. Data for a single 100 mg oral dose of bupropion showing
lished by Rossi and Wright.
There are 2 general approaches to optimizing the
analytical procedures used to measure drugs in human
milk. The first involves the validation of the assay
method, mainly in terms of both recovery (the amount
of drug that is successfully extracted from the milk) and
precision (the reproducibility of the overall analytical
procedure measured as the coefficient of variation
[CV]) at extremes of milk composition (JC Ritchie, per-
sonal communication, September 5, 2001). An example
of this approach can be found in the quantification of
naltrexone and its metabolite 6-β-naltrexol from human
6
milk and sheep milk. Recovery and CV were similar
over a wide concentration range, despite widely differ-
ing milk lipid contents (5% and 15%, respectively).
This approach involves significantly more assay devel-
opment time than is required for plasma. The second
approach uses the “method of addition” in which indi-
vidual breast milk samples are also used to construct the
assay standard curve. Drug concentrations in milk are
determined by taking 4 equal aliquots of each sample
(with internal standard added), and spiking 3 of these
with increasing concentrations of authentic drug stan-
dard. The samples are then extracted and analyzed, a
standard curve (peak height ratio for “drug: internal
standard” vs “added drug concentration”) is con-
structed, and drug concentrations in milk are deter-
mined from the negative x-axis intercept of the plot.
This method, which has been used widely in our labora-
2-4,7-11
tories, is very labor intensive, but it overcomes
problems of analytical variability. Both of the above
methods can yield quality data, and the choice is prag-
matically based on economic considerations.
M/P
100
75 4
50
2
25
0 0
0 1 2 3 4 5 6
Time (h)
the drug concentration in plasma (solid circles) and
breast milk (open circles), and milk-to-plasma ratio (M/
P) (solid squares) calculated from single points along a
simple spline curve fitted to the data. An M/P of 4 also
can be calculated by using the ratio of the area under the
curve (AUC) for the milk-concentration time curve di-
vided by that for the plasma-concentration time curve.
Measurement of the Milk-
to-Maternal Plasma Ratio
The milk-to-maternal plasma (M/P) ratio gives an es-
timate of the distribution of drug between the maternal
milk and plasma and provides an understanding of the
mechanisms involved. In addition, the M/P ratio is used
as an integral part of the calculation of infant dose12 ac-
cording to equation (1):
(1) Infant dose = M/P × Cav × Vmilk,
where Cav is the average maternal plasma drug concen-
tration and Vmilk is the average daily volume of milk in-
take.
Unfortunately, the M/P ratio may be misleading
because it is subject to variability. Single paired milk
and plasma concentration measurements have often
been used to calculate the M/P ratio. However, this
assumes that milk and plasma concentrations change in
parallel, which is not necessarily the case, as illustrated
13
for the antidepressant bupropion (Figure 1). The M/P
ratio at different time points can vary over a 2- to 3-fold
8 4
range as has been shown for sumatriptan, sertraline,
14 13
paroxetine, and bupropion. The problem of variation
can be avoided by measuring the M/P ratio using mea-

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J Hum Lact 18(4), 2002 Drugs in Human Milk 325

surements of the areas under the maternal plasma- and

100 35
milk-concentration time curves (AUCs) after a single
dose (AUC0 – ∞) or over a dose interval (τ) at steady state 30

Cumulative amount of drug (µg)

80
(AUC0 – τ). 25
Milk is not as easy as plasma to sample “instanta-

Drug (µg/L)
60
20
neously,” as sample collection takes time. In addition,
15
milk production and composition can be highly vari- 40

able, and are dictated by infant-feeding patterns that 10

cannot easily be simulated by expression. The average 20

5
concentration for a complete expression of milk from
0 0
both breasts is arguably the best representation of drug 0 4 8 12 16 20 24
content. Time (h)
The M/PAUC ratio itself may also be influenced by the
method of calculation of AUCmilk. This can be achieved Figure 2. Simulated steady-state breast milk concentration data
either by summation of rectangular areas under the con- and cumulative excretion data for a dose of 20 mg to a
centration time curve (assuming the concentration mea- 65 kg mother. The solid line with circles represents
concentration versus time as a rectangular area plot. The
sured represents the midpoint of the time between milk dashed line with circles represents concentration versus
expressions) or by application of the log or linear trape- time of collection as a line plot. The solid line with
zoidal rule referenced to the end point of the collection squares represents cumulative excretion versus time.
period. A theoretical example of both methods is shown
in Figure 2, using the simulated data set presented in Table 1. Simulated Steady-State Breast Milk Concentration Data
Table 1. In theory, the rectangular area method may be and Amount Excreted in Breast Milk Over a 24-Hour Dose
preferable when collection times are widely spaced. Interval Following the Administration of 20 mg of a Drug
Compared to an AUC determined by rectangular area to a 65 kg Breastfeeding Mother With a 5-kg Infant
summation, the trapezoidal rule generally underesti- Cumulative
Volume of Excretion of
mates AUC in the absorption phase and overestimates it Collection Drug Milk Drug Into
in the elimination phase. The overall difference in AUC Time Concentration Expressed Breast Milk
between methods depends largely on the number of col- (h) ( g/L) (mL) ( g)

lections and the interval between them. Nevertheless, 0 (immediately predose) 40 60 0

both methods generally give similar results. For the 2 50 60 3
example in Table 2, the log trapezoidal AUC is 1296 µg 4 90 50 7.5
6 80 70 13.1
× h/L, whereas that calculated using rectangular areas 8 65 50 16.35
is 1283 µg × h/L. AUCplasma is best calculated using the 12 50 90 20.85
trapezoidal rule. 16 45 80 24.45
20 42 100 28.65
There are other sources of variability in the M/P ratio. 24 40 90 32.25
The variation in milk lipid content between foremilk
and hindmilk15 has been shown to be associated with
significant variability in M/P ratios for drugs such as state. For drugs studied under steady-state dosing, col-
doxepin,16 dothiepin,17 methadone,9 and paroxetine.14,18 lecting a minimum of 5 to 6 samples is sufficient.
The extent of partitioning of drug into the lipid phase of
milk is proportional to the drug’s octanol:buffer (pH Assessment of Maternal Milk
7.2) partition coefficient19 (usually expressed as log10P),
and it may be necessary to collect both foremilk and Sample Collection Methods
hindmilk samples for drugs with high log10P values to The preferred method of milk expression is use of an
ensure that the concentration is representative. 20
electric breast pump, since this provides a degree of
The number of samples (milk or plasma) that should sampling reproducibility that is difficult to achieve with
be collected over a dose interval should also be consid- manual expression. However, it is more important to be
ered. Generally, more samples are necessary for an pragmatic and obtain any milk sample by whatever
AUC0 – ∞ after a single dose than for an AUC0 – τ at steady method than to achieve perfection. Note that the method

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326
20
of milk collection may alter the completeness of breast
21
emptying and the milk composition.
Collecting the entire volume of milk from both
breasts at each of several collection intervals over 24
hours is optimal. However, if this is not practical, mea-
suring concentrations in representative milk samples
(equal volumes collected pre- and postfeed) collected at
several points over a dose interval can still be highly
informative.
Milk Production
The volume of milk that is available to the nursing
infant can influence growth and development. It is well
recognized that a select group of medications can
increase (dopamine antagonists) or decrease (dopamine
22
agonists, steroid hormones) milk production, and
hence for some drugs it may be appropriate to measure
milk production as well as drug content. For example,
the selective serotonin reuptake inhibitor sertraline has
been reported to lower mean milk volumes (probably
4
through indirect dopamine antagonism) by 56%. In
addition, fluoxetine has been shown to reduce postnatal
weight gain in breastfed infants by a mean of 392 g
23
between the ages of 2 weeks and 6 months. Because
some drugs in this category may alter the secretion of
prolactin in the anterior pituitary, measurement of the
size of the postfeed surge in maternal plasma prolactin
may also be informative.
Milk production at fixed times over a dose interval
may be measured by collecting as much milk as possible
24
using an electric breast pump. A more physiological
alternative is to measure infant intake by weighing the
breastfed infant before and after each feed in order to
obtain the volume of milk consumed by the weight dif-
25
ference. The latter requires that the infant’s clothing be
the same at the start and end of the feed. Short-term rates
of milk synthesis can also be estimated by computerized
26,27
3-dimensional measurements of breast volume,
this method requires specialized equipment.
Milk pH
The pH of human milk (7.2) is generally accepted to
be about 0.2 units lower than that of plasma. The differ-
28
ence is influential in drug transfer into the milk, partic-
ularly for weak bases with susceptible pKa values.
Allen et al1 have shown that pH can be low in early lacta-
tion but is relatively stable from day 100 to day 450. In
addition, we have recently shown that the pH of mature
milk was remarkably stable (mean ± SD = 7.23 ± 0.27)
10
over a 24-hour dose interval. Hence, routine measure-
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Begg et al J Hum Lact 18(4), 2002
ment of milk pH is probably unnecessary, except per-
haps in studies conducted very early in lactation. Milk
pH should be measured immediately after sample col-
lection, since pH may decrease significantly because
samples rapidly lose dissolved carbon dioxide. Alterna-
tively, collection into pediatric blood gas syringes
(stored at 4°C) allows measurements to be made in the
10
laboratory up to 9 hours after collection.
Creamatocrit
For some drugs, the fat content of milk is an impor-
tant determinant of drug transfer. Hence, measurement
of fat content is sometimes useful, and it is readily mea-
29
sured as the creamatocrit.
Infant Dose
Calculation of Infant Dose
The main objective of studying drugs in human milk
is to assess safety during breastfeeding. From the clini-
cal perspective, it is the dose that the infant receives that
is important, along with the resulting concentrations
and the effects on the infant. The ideal assessment of
infant exposure is the measurement of drug concentra-
tion in their plasma.
Calculation of Absolute Infant Dose
An informative and practical endpoint is the esti-
mated dose received by the infant. In this context, it is
important to estimate the “absolute” dose received by
the infant:
(2) Doseabsolute = Cmilk × Vmilk,
where Doseabsolute = absolute infant dose, Cmilk = drug con-
centration in milk (Cmax or Cav), and Vmilk = volume of
milk ingested.
but The estimate of absolute infant dose involves mea-
suring the actual amount (concentration × volume) of
drug excreted in the milk from the time of ingestion of a
single dose by the mother until the drug can no longer be
detected in the milk (essentially to ∞). Alternatively, the
amount of drug in the milk can be measured using sev-
eral collection times spread evenly between 2 consecu-
tive maternal drug doses during a dose interval at steady
state (ie, regular dosing during chronic therapy).
As outlined above, we generally prefer a strategy of
“total” milk collection at an appropriate number of fixed
intervals (about 2 to 4 hours each) after the dose. At the
end of each collection interval, the sample volume is
J Hum Lact 18(4), 2002 Drugs in Human Milk 327

measured and an aliquot is reserved for the measure- Method D—Estimate from Cmax:
ment of drug concentration. When appropriate, the (Cmax × 0.15 L/kg/day) using the measured Cmax
remainder of the milk can be fed back to the infant. The (90 µg/L) in the calculation gives a somewhat
total amount of drug (absolute infant dose) in each col- higher absolute dose estimate of 13.5 µg/kg/day.
lection period is equal to the drug concentration multi-
plied by the volume of milk. The total (cumulative) dose As can be seen, estimates using Cav or cumulated drug
can then be estimated by summing all the amounts for excretion in milk give very similar results, whereas
each period over the duration of the study (Table 1, Fig- those using Cmax are approximately 2-fold greater. Our
ure 2). preference is to use the average concentration calcu-
Absolute infant dose estimated in this way represents lated from the AUC, as it gives the most accurate repre-
a “maximum” dose. In the case of our simulated drug sentation of infant dose across the dose interval. How-
administration (Table 1), the total infant dose is 32.3 µg ever, it can be argued that use of the maximum milk
or 6.45 µg/kg/day. It is very likely that the infant may concentration gives an answer with a higher margin of
not always empty each breast. However, variations in safety.
infant suckling are likely to be in the direction of a lower
dose. Thus, the maximum dose provides a safe yard- Calculation of Relative Infant Dose
stick. The relative infant dose can be derived and compared
When it is not practical or possible to measure total with the dose received by the mother (usually as a per-
available milk volume as described above, a strategy of centage) after normalizing the maternal dose to body
collecting samples (10 mL) at intervals of about 2 to weight:
4 hours can be used. For such a sampling protocol,
30
Bennett recommended the use of an average milk Relative infant dose(%) =
intake value of 0.15 L/kg/day for the calculation of (3) Absolute infant dose (µg kg day) × 100
.
infant dose. Although this is representative of milk Maternal dose (µg kg day
intake for a neonate, it may overestimate intake in an
older infant who is also receiving supplementary feed- Again, using the data set from Table 1 and the maternal
ing. Nevertheless, the infant dose calculated in this man-
ner provides a generous (safe) estimate of absolute
(
weight-adjusted dose 65kg = 307.7 µg kg day , the
20mg
)
infant dose. calculated relative weight-adjusted infant doses are as
The data from Table 1 can be used to illustrate the es- follows:
timation of the absolute infant dose as follows. 8.03 × 100
Method A—Estimate using rectangular AUC = = 2.61%
307.7
Method A—Estimate using rectangular AUC:
(Cav × 0.15 L/kg/day) using Cav from the rectangu- . × 100
81
= 2.63%
)
Method B—Estimate using trapezoidal rule =
lar AUC summation (
1283 µg × h L
24h
= 53.5 µg L 307.7

gives an absolute dose estimate of 8.03 µg/kg/day. Method C—Estimate using cumulative dose =
6.46 × 100
= 210
. %
307.7
Method B—Estimate using trapezoidal rule:
(Cav × 0.15 L/kg/day) using Cav from the log trape- 13.5 × 100
= 4.39%.
)
Method D—Estimate from Cmax =
zoidal AUC (
1296 µg × h L
24h
= 54.0 µg L gives an 307.7

absolute dose estimate of 8.1 µg/kg/day. Interpretation of Results

Method C—Estimate using cumulative dose:
(cumulative dose of the drug milk divided by
infant body weight) using a measured cumulative
amount of 32.3 µg divided by the infant’s actual
body weight of 5 kg gives an absolute dose esti-
mate of 6.46 µg/kg/day.
Because the breastfed infant is not supposed to be
receiving any drug at all, a decision has to be made as to
what dose can be considered safe. There are many fac-
tors to be taken into account, including the therapeutic
index of the drug, any specific effects in children, the
absolute dose, the duration of exposure, and possible so-

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328
called dose-independent effects (eg, hypersensitivity
reactions).
Interpreting Absolute Infant Dose
When the drug has a recognized pediatric use, the
absolute infant dose (as calculated above) can be com-
pared directly to the normal therapeutic dose for an
infant of that age.
Interpreting Relative Infant Dose
For drugs that have no known inherent toxicity and
are being taken by a mother at usual therapeutic doses,
an arbitrary cutoff for infant dose has to be chosen. A
relative infant dose of 10% of the weight-adjusted ma-
ternal dose is the most commonly accepted cutoff.22
Knowledge of the pharmacokinetics of the drug in the
infant is also important, so that the plasma concentra-
tions achieved after a given dose can be calculated:
Drug concentration in plasma =
(4) Absolute dose × Oral availability
Clearance
Infants are born with immature clearance mecha-
nisms and hence have lower drug clearance values (cor-
rected for weight) than adults. In general, infant drug
clearance is particularly impaired in the premature neo-
nate and increases gradually to adult levels after about 6
months. The clearance has been estimated to be approx-
imately 5%, 10%, 33%, 50%, 66%, and 100% of adult
maternal values at 24-28, 28-34, 34-40, 40-44, 44-68,
31
and > 68 weeks postconceptual age, respectively. The
10% relative dose cutoff applies to infants with “nor-
mal” clearance (compared to adults) and should be
adjusted when there is impaired infant clearance.
Assessment of the Infant
Infant Plasma Drug Concentrations
Measurement of drug in the infant’s blood is an
excellent objective measure of drug exposure via milk.
Ethical concerns and parental cooperation usually dic-
tate that only one sample can justifiably be taken. A
realistic approach to measuring infant concentrations is
that any samples are a bonus. For drugs with long half-
lives and studied at steady state, it is probably unimpor-
tant to control the time at which infant plasma samples
are taken in relation to the last maternal dose. The tim-
ing of infant blood samples for single-dose studies is
more difficult, and a value judgment has to be made,
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Begg et al J Hum Lact 18(4), 2002
after considering factors such as the profile of the milk
concentration time curve, the milk ingestion pattern,
and the likely drug t1/2 in the infant.
Infant blood samples should be drawn by an experi-
enced pediatric phlebotomist, as this minimizes trauma
to the infant and also maternal anxiety. The measure-
ment usually gives parents an objective reassurance that
their baby is receiving an acceptable drug exposure.
Urine sampling in infants is of little use, as the result is
qualitative and merely confirms the passage of drug
through the infant.
Analysis of the drug concentration in infant plasma/
serum often needs thoughtful consideration, as the
small sample volumes available may raise the analytical
limit of detection. Interpretation of measured drug con-
centrations in the infant can be made by comparison
with known therapeutic concentrations in either adults
or infants.
Infant Well-Being
Assessment of the infant’s general health and well-
being is a difficult but nevertheless vital consideration,
as documented effects (or lack of same) on the infant are
an important adjunct measurement. Inquiry of the
mother and pediatrician should be made, while recog-
nizing that such reports are often subjective. A detailed
clinical assessment may be made by an experienced
pediatrician using a structured approach such as the
Denver Developmental Screening Test,
32,33
which
although fully validated in the context of assessing gen-
eral infant well-being, was not designed to test for
adverse effects of drugs. The place of the infant in popu-
lation-specific percentile distributions of weight for
age, as well as records from infant health clinic visits,
may also be of assistance in establishing general well-
being. Certainly, assessment of adverse pharmaco-
dynamic effects on the infant is an area where objective
methods are needed. An innovative example of assess-
ing the effects of the selective serotonin reuptake inhibi-
tor sertraline in breastfed infants has recently been pub-
34
lished. Using measurements of 5-hydroxytryptamine
uptake in platelets from both mother and baby, the
authors were able to show clear effects of the drug in the
mothers who took this antidepressant but no effect in
their breastfed infants.
What to Do If an Adverse Effect Is Observed
in the Infant
As with any adverse drug report, thorough investiga-
tion of the differential diagnosis is extremely important.
J Hum Lact 18(4), 2002 Drugs in Human Milk 329

Question:
What is the amount of drug in breast
milk and the infant dose/significance?

Single maternal dose Steady-state maternal dosing

Usual dose in therapeutic setting Usual dose regimen, at a time
when steady state achieved (≥ 4 x
t1/2 )

Data collection: Data collection:

Mother Mother
Milk (Until [drug] < milk MQC) Milk (Over one dose interval)
(i) Collect total milk produced every 2- (i) Collect total milk produced every 2-
4 h (record volume, keep 10mL 4 h (record mL volume , keep 10mL
sample), or sample), or
(ii) Representative sample (10mL) (ii) Representative sample (10mL)
every 2-4 h, or every 2-4 h, or
(iii) Weigh infant before & after each (iii) Weigh infant before & after each
feed and take representative feed and take representative
sample (10mL) sample (10mL)
Plasma (Until [drug] < plasma MQC) Plasma (Over one dose interval)
(i) If M/P is needed, collect sample (5 (i) If M/P is needed, collect sample (5
mL) every 2-4 h at same time as mL) every 2-4 h at same time as
milk milk
Infant Infant
(i) Plasma (1mL) at time of (i) Plasma (1mL) at time of peak
peak in maternal plasma in maternal plasma
(ii) History from mother, infant (ii) History from mother, infant
health clinic and pediatrician health clinic and pediatrician
(iii) Objective pharmacodynamic (iii) Objective pharmacodynamic
measures whenever measures whenever possible
possible

Calculation of infant dose

(i) [drug] x total volume milk
(ii) [drug] x 0.15 L/kg/d
(iii) [drug] x actual volume suckled

All quoted as absolute dose, or dose relative to maternal dose,

corrected for body weight.

Figure 3. Schema for studies involving assessment of the amount of drug in human milk, the calculated infant dose, and the extent of drug ef-
fect on the infant. MQC = minimum quantifiable concentration, M/P = milk-to-maternal plasma ratio.

A suitable time relationship of the effect in relation to Experimental Design

the time of drug administration, disappearance of the
effect upon discontinuation of the drug, and reappear-
ance on rechallenge all increase the likelihood that the
drug is causative. In this context, it is important not to
confuse drug effects attributable to drugs ingested in
milk with effects due to drug exposure in utero. Drugs
with long half-lives may affect the infant for a consider-
able time postpartum. Neonatal withdrawal syndromes
are well documented for methadone9,35,36 and may also
37 38,39
occur with fluoxetine and paroxetine.
Figure 3 summarizes study design factors that should
be considered for single and steady-state drug studies
where the primary aim is quantifying infant dose.
Studies should use the most common maternal dose reg-
imen and are best conducted when mature milk is being
produced so as to avoid the complications of the differ-
ent milk composition in early lactation. Where the focus
is on investigating an adverse event in a breastfed infant,
the study methodology would be similar to that in Fig-

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330 Begg et al J Hum Lact 18(4), 2002

ure 3, with additional emphasis being placed on
pharmacodynamic evaluation.
Conclusions
The primary aim of this review has been to examine
study methodology and experimental designs available
for the study of drugs and human milk. Because such
studies are usually of necessity carried out on small
numbers of mother-baby pairs, it is important that they
are comprehensive and robust. We hope that our deliber-
ations will provide a framework for future investiga-
tions. The major points can be summarized as follows.
• Milk is often a difficult matrix for the analyst be-
cause of its highly variable composition.
• The M/P ratio is really only of primary interest in
understanding the mechanisms of transfer. This
parameter is sometimes erroneously viewed as a
40
predictor of risk to the infant, but it is ultimately
the concentration of drug in milk, and not the M/
P ratio, that is critical to the calculation of infant
41
dose and the assessment of risk.
• Assessment of the milk intake by the infant is im-
portant. Milk production rate may also be of in-
terest when the primary effect of the drug is on
mediators that control milk secretion via central
or peripheral mechanisms.
• The calculation of absolute infant dose is the pri-
mary way in which a risk assessment can be
made.
• The absolute dose can be compared with normal
pediatric dose rates or with the maternal dose (as
dose relative to weight) to assess the level of ex-
posure and the potential risk to the infant.
• Arguably, the ultimate proof of infant exposure
lies in measuring pharmacodynamic effects (ad-
verse or otherwise) on the infant. Monitoring of
infant plasma drug concentrations is an excellent
surrogate for pharmacodynamic effects.

Glossary
Accuracy A measure of the ability of a drug assay method to estimate the true concentration of drug in
a milk or plasma sample. Established by comparing a quality control sample with a known
drug concentration with that predicted from the standard curve.
AUC Area under the curve—when it refers to the plasma concentration it is a reflection of the
total systemic exposure of an individual to a drug. The AUC is measured as the area under a
graphical plot of plasma or milk concentration (Y-axis) versus time (X-axis) after last drug
dose. For single doses of drug, AUC0-∞ is measured from the time of dose (zero) to when the
drug is no longer present in the body (infinity—in practice this is the last definable concen-
tration). For drugs given as multiple doses during chronic therapy, AUC is measured from
the time of the last dose (zero) to the end of that dose-interval (τ); ie time immediately prior
to the next dose being given—the AUC0-τ. AUC is usually measured by dividing the area
under the curve into a series of trapezoids whose area is calculated and summed. It can also
be measured as the sum of a series of rectangular areas where sampling is at discrete inter-
vals of several hours, as often occurs for milk.
Oral availability The extent to which an orally administered drug becomes available within the systemic
circulation (usually as compared with IV dosage).
Cav The average concentration of drug in milk, measured over a dose interval. Calculated
from AUC0-τ/τ, where τ = duration of the dose interval in hours
Cmax The maximum observed concentration of drug in milk over a dose interval.
Clearance A pharmacokinetic constant that describes the relationship between the dose and the
steady-state average concentration. Clearance of drugs is largely carried out by the liver
and kidneys.
Crematocrit A measure of the amount of lipid (fat) in a milk sample. Expressed as a percentage of the
total volume of the sample.
Dose interval (τ) The time between sequential doses of a drug when given as regular doses during chronic
therapy.
Half-life The time taken for the plasma concentration of a drug to decrease by one half.

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J Hum Lact 18(4), 2002 Drugs in Human Milk 331

Infant dose—absolute The dose of a drug received by the infant via breast milk. Usually expressed as µg/kg/day.
See Calculation of absolute infant dose section for a detailed explanation.
Infant dose—relative The dose of a drug received by the infant via breast milk in µg/kg/day expressed as a per-
centage of the maternal drug dose also in µg/kg/day. See Calculation of relative infant dose
section for a detailed explanation.
M/P ratio The ratio of the concentration of drug in milk to the concentration of drug in plasma. May
be estimated from measurements of drug in milk and plasma at a single time after dose, or
from AUC measurements for drug in milk and plasma over a dose interval.
Partition coefficient (P) A measure of the relative lipid and water solubility of a drug. Usually measured as the equi-
librium concentration of a drug in octanol (a lipid-like solvent) relative to that in an aque-
ous buffer (usually at a pH = 7.2). It is often expressed as log10P, as the value can range
over several orders of magnitude. Its value is proportional to the ability of a drug to move
from the maternal plasma into the milk.
Pharmaco-dynamics The pharmacological effects that a drug has in humans.
Pharmaco-kinetics The description of drug concentration in the human body over time following the adminis-
tration of single or multiple doses.
PKa A physicochemical constant for drugs having positively or negatively charged groups in
their structure. Its value gives information about the ability of a drug to move from the
maternal plasma into the milk. Strictly, it is the pH at which a drug is 50% ionized and 50%
un-ionized.
Precision A measure of the ability of a drug assay method to reproducibly measure drug concentra-
tion in a milk or plasma sample. It is measured as the coefficient of variation (CV), where
CV = standard deviation × 100/mean, for measurements in several samples containing the
same concentration of drug.
Recovery A measure of how much of the drug content of a milk or plasma sample is successfully
extracted from the sample. Extraction is necessary to separate the drug from other constitu-
ents in a milk or plasma sample, prior to its measurement.
Steady-state A time when the drug concentration in the body is no longer accumulating, during chronic
therapy with regular doses. All drugs accumulate in the body until steady state is reached
(approximately 4 to 5 half-lives).
Therapeutic index A measure of the overall safety of a drug. It is defined as the minimum dose that shows
toxic effects divided by the minimum dose that is effective. High values indicate safety.
Trapezoidal rule A method for estimating AUC by dividing the area under a drug concentration-time curve
into a series of trapezoids whose areas are calculated, and then summed across the total
time of the study. A trapezoid is a geometric shape that has one set of parallel sides—it
resembles a rectangle with a triangle on top.
Xenobiotic A chemical that is foreign to the human or animal body. Includes drugs, industrial chemi-
cals, chemicals present in plants, and environmental pollutants.

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