Maternal medication, drug use, and breastfeeding

Concentrations of remdesivir and GS-441524 in human milk from lactating individuals diagnosed with COVID-19

IMPACT

Findings from this study provide further reassuring evidence that infant exposure through human milk received from lactating individuals who require treatment with remdesivir is negligible.

Controversies and Conundrums in Newborn Feeding

Breastfeeding is the biologic norm for newborn feeding, and exclusive breastfeeding for the first 6 months of life is universally endorsed by leading global and national organizations. Despite these recommendations, many people do not meet their breastfeeding goals and controversies surrounding breastfeeding problems exist. Medical issues can present challenges for the clinician and parents to successfully meet desired feeding outcomes. There are studies evaluating these common controversies and medical conundrums, and clinicians should provide evidence-based recommendations when counseling families about newborn feeding.

Prenatal Exposure to Tobacco and Childhood Cognition and Behavior: Effect Modification by Maternal Folate Intake and Breastfeeding Duration

In this exploratory analysis, we assessed whether nutrition modified the association between prenatal exposure to tobacco and childhood cognition/behavior among 366 Colorado-based mothers and their offspring (born ≥ 37 weeks with birthweights ≥ 2500 g). Interaction by folate ( 5 months, but not for shorter durations. Our findings support the need for smoking cessation campaigns throughout pregnancy and throughout the postpartum period breastfeeding to reduce neurobehavioral risks in the offspring.

Psychotropic medication in pregnancy and lactation and early development of exposed children

There is still limited knowledge about alterations of blood concentrations of psychotropic drugs during pregnancy, the transfer of psychotropic drugs into breastmilk and the effects on exposed children. We investigated changes in concentrations of psychopharmacological medication during pregnancy and lactation in serum and breastmilk at different time points in a naturalistic sample of 60 mothers and observed the development of the exposed children in the first 12 months. We found a decrease in serum concentrations from the first to the second trimester of amitriptyline, duloxetine, escitalopram, quetiapine and sertraline. Citalopram stayed rather stable during pregnancy, sertraline levels interestingly increased again from the second to the third trimester. High concentration-by-dose ratios in breastmilk were found for venlafaxine as well as lamotrigine, low for quetiapine and clomipramine. Similarly, clomipramine and quetiapine showed low milk/serum-penetration ratios. Regarding the birth outcome measures in children, we found no significant differences between in utero exposed compared to nonexposed newborns. There were no significant differences in the development in the first 12 months. Psychotropic medication in the peripartum needs a balancing of risks and benefits and a continuous therapeutic drug monitoring can be a guidance for clinicians to monitor drug alteration patterns, which are likely to occur due to physiological pregnancy-associated changes in pharmacokinetics. Accordingly, therapeutic drug monitoring can optimize a medication in pregnancy and lactation with the lowest effective dose.

Allopregnanolone Concentrations in Breast Milk and Plasma from Healthy Volunteers Receiving Brexanolone Injection, With Population Pharmacokinetic Modeling of Potential Relative Infant Dose

Background and Objective

Women with postpartum depression (PPD) may expose their infants to antidepressants via breast milk. Brexanolone is the only FDA-approved antidepressant specifically indicated for the treatment of PPD. This open-label, phase Ib study of healthy lactating volunteers assessed pharmacokinetic (PK) properties of brexanolone and a population PK (PopPK) model determined the relative infant dose (RID) in breastfeeding mothers.

Methods

Twelve participants received a 60-h infusion of brexanolone (titration up to 90 µg/kg/h). Allopregnanolone concentration was measured in breast milk and plasma. The RID was computed using a nonlinear mixed-effects PopPK model of patients with PPD and healthy women (N = 156). Model results were extended across an integrated dataset of participants through day 7.

Results

Allopregnanolone concentration–time profiles were similar between breast milk and plasma (partition coefficient for concentration gradient [milk : plasma] 1.36). Mean (95% CI) C_max was 89.7 ng/mL (74.19–108.39), and median (95% CI) t_max was 47.8 h (47.8–55.8) in plasma. The overall PK profile was best described by a two-compartment model with linear elimination and distribution. Body weight was the only significant covariate identified. There were no apparent differences in PopPK AUC and C_max between participants with or without concomitant antidepressant treatment. Maximum RID was 1.3%.

Conclusion

The PopPK model successfully described the variability and concentration–time profiles of allopregnanolone in breast milk and plasma in healthy participants and in the plasma of brexanolone-treated patients with PPD. The rapid elimination of allopregnanolone from plasma and breast milk, and low RID, suggests the appropriateness of brexanolone weight-based dosing and supports other PK-related labeling recommendations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40262-022-01155-w.

Acetaminophen and Xenobiotic Metabolites in Human Milk and the Development of Bronchopulmonary Dysplasia and Retinopathy of Prematurity in a Cohort of Extremely Preterm Infants

This retrospective cohort study sought to identify the association between certain xenobiotic metabolites in maternal breast milk and the diagnoses of bronchopulmonary dysplasia and retinopathy of prematurity in extremely preterm infants. Several acetaminophen metabolites were associated with a 3- to 6-fold increased odds of these disorders, and metabolites of certain food products, benzoate, and caffeine were associated with decreased odds.

Disease-Modifying Drugs and Breastfeeding in Multiple Sclerosis: A Narrative Literature Review

Pregnancy-related issues in women with multiple sclerosis (MS) have been receiving increasing attention, with particular interest for the use of disease-modifying therapies (DMTs) before conception, during pregnancy, and postpartum, including breastfeeding. The risk of relapse is higher in the early postpartum period, especially in cases of significant disease activity prior to pregnancy, and thus treatment resumption and/or switching strategies might be necessary. Moreover, breastfeeding provides unmatched health benefits for babies and mothers, and is recommended as the best source of nutrition for infants. Furthermore, a protective role of breastfeeding on MS disease course has not been fully demonstrated and it remains debatable. At the same time, a source of concern is the potential transfer of DMTs into breastmilk and the resulting infant exposure. The use of most DMTs is unlicensed during breastfeeding mainly due to the limited data available on the excretion in human milk and on the effects on infants' exposure. Consequently, women have to face the difficult challenge of choosing between breastfeeding and DMT resumption. The present narrative review summarizes and discusses the available evidence on the safety of DMTs during breastfeeding and the relative approved labels. At the time of diagnosis of MS, specific counseling should be offered to women of childbearing age, making them aware of the possible therapeutic options and their impact on pregnancy and breastfeeding. Women can be encouraged to breastfeed, if clinically feasible, following a review of their medications and clinical status, with a personalized approach.

Breastfeeding and drug use: what is the orientation found in drug package inserts of contraceptives and anti-infective agents?

This article aims to evaluate the conformity between drug package inserts (DPIs) and evidence-based bibliographic sources regarding the presence of contraindications to the use of contraceptives and anti-infective agents during breastfeeding. Contraceptive and anti-infectives were selected, according to ATC, with the updated record in the ANVISA and present in the bibliographic sources Breastfeeding and Use of Medicines and Other Substances, Medications and Mother's Milk, LactMed®, Micromedex® and UpToDate®. Information was extracted from the DPI "Contraindications" and "Warnings and precautions" sections and compared with the information in the bibliographic sources. The contraindication of the drug during breastfeeding was evaluated. Contraindications were found in the DPIs of five (55.5%) of the nine contraceptives. The contraindication percentage ranged from 0 to 55.5% among the bibliographic sources, depending on the source. The percentage was 46.3% in the DPIs, ranging from 0 to 12.9% in the bibliographic sources for anti-infectives. There is an agreement between the DPIs and the bibliographic sources regarding contraceptives; regarding anti-infectives, the DPIs are more often contraindicated for use during breastfeeding.

Australian Foster Carers' Views and Concerns Regarding Maternal Drug Use and the Safety of Breastmilk

Parental substance misuse and mental health issues are major factors associated with infant placement into out-of-home care. Such placements may result in disruption and/or cessation of breastfeeding. Provision of breastmilk to infants in out-of-home care (OOHC) is desirable in terms of infant health and development, and also in supporting maternal caregiving. However, little is known about how breastfeeding is supported for infants in out-of-home care. This study used an online survey to explore the facilitation of breastfeeding in the context of OOHC and foster carers' management of expressed breastmilk (EBM). Foster carers were generally open to the idea of maternal breastfeeding and infants in their care receiving EBM from their mothers. However, the majority of respondents expressed concern regarding the safety of EBM for infant consumption due to the possibility of harmful substances in the milk. Concerns regarding the safety of handling EBM were also prevalent. These concerns caused foster carers to discard EBM. Findings suggest foster carers' may lack knowledge related to maternal substance use and breastmilk. Better integration between health care and social service systems, where the voices of mothers, foster carers and child protection workers are heard, is necessary to develop solutions enabling infants living in OOHC access to their mother's breastmilk.

Antioxidative Molecules in Human Milk and Environmental Contaminants

Breastfeeding provides overall beneficial health to the mother-child dyad and is universally recognized as the preferred feeding mode for infants up to 6-months and beyond. Human milk provides immuno-protection and supplies nutrients and bioactive compounds whose concentrations vary with lactation stage. Environmental and dietary factors potentially lead to excessive chemical exposure in critical windows of development such as neonatal life, including lactation. This review discusses current knowledge on these environmental and dietary contaminants and summarizes the known effects of these chemicals in human milk, taking into account the protective presence of antioxidative molecules. Particular attention is given to short- and long-term effects of these contaminants, considering their role as endocrine disruptors and potential epigenetic modulators. Finally, we identify knowledge gaps and indicate potential future research directions.

Early Life Exposure to Nicotine: Postnatal Metabolic, Neurobehavioral and Respiratory Outcomes and the Development of Childhood Cancers

Cigarette smoking during pregnancy is associated with numerous obstetrical, fetal, and developmental complications, as well as an increased risk of adverse health consequences in the adult offspring. Nicotine replacement therapy and electronic nicotine delivery systems (e-cigarettes) have been developed as a pharmacotherapy for smoking cessation and are considered safer alternatives for women to smoke during pregnancy. The safety of nicotine replacement therapy use during pregnancy has been evaluated in a limited number of short-term human trials, but there is currently no information on the long-term effects of developmental nicotine exposure in humans. However, animal studies suggest that nicotine alone may be a key chemical responsible for many of the long-term effects associated with maternal cigarette smoking on the offspring and increases the risk of adverse neurobehavioral outcomes, dysmetabolism, respiratory illness, and cancer. This review will examine the long-term effects of fetal and neonatal nicotine exposure on postnatal health.

Psychoactive substances in human breast milk: a review of analytical strategies for their investigation

WHO recommends breastfeeding for the first 6 months of newborn's life. Due to its physicochemical properties, breast milk may contain undesirable components originated from mother's feeding, medication and illicit drugs consumption. Some of these substances transferred from bloodstream to milk and delivered to the infant can cause harmful effects. For the last decades, analytical advances enabled the analysis of several substances in milk using different techniques. Thereby, it is possible to evaluate infant's level of exposure to these substances. This review presents the information published in the main scientific dissemination media about psychoactive drugs investigation in human breast milk, involving the sample preparation techniques and chromatographic validated methods developed in the past 10 years.

Use of Medications by Breastfeeding Women in the 2015 Pelotas (Brazil) Birth Cohort Study

Background: This study describes medication use by women up to 3 months postpartum and evaluates the association between medication use by women who were still breastfeeding at 3 months postpartum and weaning at 6 and 12 months. Methods: Population-based cohort, including women who breastfed (n = 3988). Medications were classified according to Hale's lactation risk categories and Brazilian Ministry of Health criteria. Duration of breastfeeding was analysed using Cox regression models and Kaplan-Meier curves, including only women who were still breastfeeding at three months postpartum. Results: Medication use with some risk for lactation was frequent (79.6% regarding Hale's risk categories and 12.3% regarding Brazilian Ministry of Health criteria). We did not find statistically significant differences for weaning at 6 or 12 months between the group who did not use medication or used only compatible medications and the group who used medications with some risk for lactation, according to both criteria. Conclusions: Our study found no association between weaning rates across the different breastfeeding safety categories of medications in women who were still breastfeeding at three months postpartum. Therefore, women who took medications and stopped breastfeeding in the first three months postpartum because of adverse side-effects associated with medications could not be addressed in this analysis.

Pharmacogenomic Testing In Pediatrics: Navigating The Ethical, Social, And Legal Challenges

For the past several years, the implementation of pharmacogenetic (PGx) testing has become widespread in several centers and clinical practice settings. PGx testing may be ordered at the point-of-care when treatment is needed or in advance of treatment for future use. The potential benefits of PGx testing are not limited to adult patients, as children are increasingly using medications more often and at earlier ages. This review provides some background on the use of PGx testing in children as well as mothers (prenatally and post-natally) and discusses the challenges, benefits, and the ethical, legal, and social implications of providing PGx testing to children.

Negligible exposure to nifurtimox through breast milk during maternal treatment for Chagas Disease

BACKGROUND

Treatment with nifurtimox (NF) for Chagas disease is discouraged during breast-feeding because no information on NF transfer into breast milk is available. NF is safe and effective for paediatric and adult Chagas disease. We evaluated the degree of NF transfer into breast milk in lactating women with Chagas disease.

PATIENTS AND METHODS

Prospective study of a cohort of lactating women with Chagas disease. Patients were treated with NF for 1 month. NF was measured in plasma and milk by high performance liquid chromatography (HPLC). Breastfed infants were evaluated at admission, 7th and 30th day of treatment (and monthly thereafter, for 6 months).

RESULTS

Lactating women with chronic Chagas disease (N = 10) were enrolled (median age 28 years, range 17-36). Median NF dose was 9.75 mg/kg/day three times a day (TID). Six mothers had mild adverse drug reactions (ADRs), but no ADRs were observed in any of the breastfed infants. No interruption of breastfeeding was observed. Median NF concentrations were 2.15 mg/L (Inter quartil range (IQR) 1.32-4.55) in milk and 0.30 mg/L (IQR 0.20-0.95) in plasma. Median NF milk/plasma ratio was 16 (range 8.75-30.25). Median relative infant NF dose (assuming a daily breastmilk intake of 150 mL/kg/day) was 6.7% of the maternal dose/kg/day (IQR 2.35-7.19%).

CONCLUSIONS

The low concentrations of NF in breast milk and the normal clinical evaluation of the breastfed babies imply that maternal NF treatment for Chagas disease during breastfeeding is unlikely to lead to clinically relevant exposures in the breastfed infants.

TRIAL REGISTRATION

Clinical trial registry name and registration number: ClinicalTrials.gov NCT01744405.

The Prevalence of Anxiety Disorders During Pregnancy and the Postpartum Period: A Multivariate Bayesian Meta-Analysis

OBJECTIVE

To estimate the prevalence of anxiety disorders in pregnant and postpartum women and identify predictors accounting for variability across estimates.

DATA SOURCES

An electronic search of PsycINFO and PubMed was conducted from inception until July 2016, without date or language restrictions, and supplemented by articles referenced in the obtained sources. A Boolean search phrase utilized a combination of keywords related to pregnancy, postpartum, prevalence, and specific anxiety disorders.

STUDY SELECTION

Articles reporting the prevalence of 1 or more of 8 common anxiety disorders in pregnant or postpartum women were included. A total of 2,613 records were retrieved, with 26 studies ultimately included.

DATA EXTRACTION

Anxiety disorder prevalence and potential predictor variables (eg, parity) were extracted from each study. A Bayesian multivariate modeling approach estimated the prevalence and between-study heterogeneity of each disorder and the prevalence of having 1 or more anxiety disorder.

RESULTS

Individual disorder prevalence estimates ranged from 1.1% for posttraumatic stress disorder to 4.8% for specific phobia, with the prevalence of having at least 1 or more anxiety disorder estimated to be 20.7% (95% highest density interval [16.7% to 25.4%]). Substantial between-study heterogeneity was observed, suggesting that "true" prevalence varies broadly across samples. There was evidence of a small (3.1%) tendency for pregnant women to be more susceptible to anxiety disorders than postpartum women.

CONCLUSIONS

Peripartum anxiety disorders are more prevalent than previously thought, with 1 in 5 women in a typical sample meeting diagnostic criteria for at least 1 disorder. These findings highlight the need for anxiety screening, education, and referral in obstetrics and gynecology settings.

Pharmacologic Management of Common Ailments in Women Who Are Breastfeeding

According to the Centers for Disease Control and Prevention, the rate of breastfeeding in the United States has increased 34% between 2005 and 2015. Women who breastfeed can require treatment of various common illnesses. When caring for women who are breastfeeding, health care providers may unnecessarily discourage them from breastfeeding during treatment. Choosing the appropriate medications for these individuals is critical to ensure the woman is effectively treated, infant exposure to medication is minimized, and the breastfeeding relationship is preserved. This article provides an overview of essential principles for prescribing medications for women who are lactating. Recommendations for the management of common illnesses seen in the outpatient setting are suggested and resources that can help guide therapeutic decision making are offered.

[Medications in breastfeeding: what evidence is there?]

Breastfeeding plays a fundamental role in the benefits for the health of the newborn child and the nursing mother. The use of medications during breastfeeding is a relevant issue, by virtue of the frequent need for pharmacological treatment in the postpartum period. The scope of this article was to conduct a review of the literature regarding the efficacy and safety of medications used during the breastfeeding period. A search was conducted in the PubMed (National Library of Medicine), ScienceDirect and Biblioteca Virtual em Saúde (BVS) databases for articles published in Portuguese, English and Spanish in the period from 1981 to 2016. This review discusses the risk of the use of medications during lactation and the effects that they may have on the breastfed infant. Few medications are contraindicated and others require care due the risk of adverse effects on breastfed infants or in the suppression of breast milk volume. Therefore, the dissemination of updated information for the health professional to adequately assess the risks and the benefits of the use of medications during breastfeeding is of vital importance, thereby contributing to avoid early weaning.

Uso de medicamentos antidepressivos na amamentação: avaliação da conformidade das bulas com fontes bibliográficas baseadas em evidências científicas

O objetivo deste artigo foi avaliar a conformidade entre as recomendações de uso de medicamentos antidepressivos durante a amamentação, presentes em bulas, e as recomendações de fontes bibliográficas baseadas em evidências científicas. Foram avaliadas as bulas padrão de 23 antidepressivos com registro ativo no Brasil. A presença de contraindicação do uso do antidepressivo durante a amamentação foi comparada com as informações presentes no manual técnico do Ministério da Saúde, no livro Medications and Mothers’ Milk e nas bases de dados LactMed, Micromedex e UpToDate. Na maioria das bulas (62,5%), o antidepressivo é contraindicado na amamentação. Entre as fontes bibliográficas, esse percentual variou de 0% a 25%. O estudo aponta para baixa conformidade entre bulas e fontes bibliográficas, alertando sobre a necessidade de revisão do conteúdo e forma de apresentação das informações presentes nas bulas dos antidepressivos no Brasil.

Factors influencing the recruitment of lactating women in a clinical trial involving direct oral anticoagulants: a qualitative study

Background Robust human data on medication use during lactation is scarce. With increasing medication use in postpartum women, it is important to conduct clinical lactation studies measuring the excretion of drugs in human milk and generate evidence. We plan to conduct a clinical lactation study, involving the direct oral anticoagulants (DOACs). Objective This study aimed to identify factors influencing lactating women's clinical trial participation and to improve the design of a proposed DOACs clinical lactation study. Setting Lactating women in London, UK. Methods Three focus groups were conducted in lactating women with differing experiences of being prescribed anticoagulants during puerperium. Main outcome measures Thematic framework approach was used to analyse and identify key themes, using NVivo version 11. Results Eight breastfeeding mothers participated. Women's decision-making on clinical trial participation was largely influenced by the lactation stage and previous breastfeeding experience. The concern of harm to their infant caused by the test medication or interruption of lactation were the predominant barriers to potential participation. Around 6 months following the birth of their infant and second-time mothers appeared to be more amenable to clinical trial participation. The provision of home visits for the execution of the study was highly recommended. Conclusion Our findings suggest that lactating women would participate in a clinical trial during the breastfeeding period, if the timing is right and if the woman is an experienced mother. Home visits will be provided in our proposed DOACs clinical lactation study.

Resources for Psychiatric Clinicians Working With Breastfeeding Mothers

In today's health care-focused climate, in which encouraging breastfeeding is part of national and international health care initiatives, clinicians in any field should have resources available for breastfeeding mothers. The current article provides information for psychiatric clinicians on how breastfeeding may affect women with psychiatric conditions, the type of lactation counselor likely to be best prepared to collaborate with psychiatric clinicians, and resources available regarding maternal psychiatric medications safe for breastfeeding infants. These resources can assist informed choices that support the mother's breastfeeding goals while providing the psychological care the nursing mother requires. [Journal of Psychosocial Nursing and Mental Health Services, 56(8),37-46.].

Use of Psychotropic Medications in Breastfeeding Women

BACKGROUND

Breastfeeding women who are prescribed with psychotropic medications on a regular basis are often concerned, regarding the possible implications of such treatment on the breastfed infant. A mother's well-being has a direct influence on the well-being of the baby. However, the notorious reputation of psychotropic medications may lead to suboptimal prescribing by the physician and poor adherence by the mother.

METHODS

A PubMed search (from 1976 through February 2017) was conducted for commonly used psychotropic drug classes, as well as individual medications commonly prescribed in these classes, along with the MeSH terms "breastfeeding"/"lactation". In each case, we chose studies that describe the pharmacokinetics of passage into breast milk and/or adverse effects in breastfed infants.

RESULTS

No large-scale controlled studies regarding the safety of psychotropic medications in breastfeeding mothers were reported. Based on case reports and small studies, most psychotropic medications produce low milk levels and low plasma levels in the infant, while serious adverse effects in the breastfed infant are rarely reported. Safety data for some psychotropic medications are still unavailable.

CONCLUSION

According to the data available in the literature to date, most psychotropic medications are expected to produce low levels in breast milk with no clinical importance. Nevertheless, an individual risk-benefit assessment of a proposed treatment should always be performed, as inter-individual differences may have a substantial effect on the breastfeeding infant's response to the treatment. Further studies and additional objective data are needed to consolidate and improve our current knowledge of psychopharmacotherapy in breastfeeding women. Birth Defects Research 109:957-997, 2017. © 2017 Wiley Periodicals, Inc.

Controversies in Breastfeeding

When addressing the compatibility of breastfeeding with certain maternal conditions, we need to differentiate between "contraindication" and "obstacle." Failure to distinguish between the two confuses new mothers and their families, and engenders misconceptions about breastfeeding advice by health professionals. Health conditions that may simply impede the initiation and duration of breastfeeding are often wrongly referred to as true contraindications to breastfeed, under the assumption that they might harm the health of the mother and/or that of the nursing infant. Here, we discuss several topics, including breast surgery, prolactinoma, concurrent new pregnancy, hormonal contraception, and use of medications and contrast agents, that continue to raise controversy. While most conditions appear to be compatible with breastfeeding, the major determinants of a woman's final choice of whether to nurse her infant or not are the attitude of health professionals and the state of mind of being an informed mother.

Treating postpartum mood and anxiety disorders in primary care pediatrics

Postpartum psychiatric disorders represent a significant public health problem that has not been readily addressed, particularly in the primary care setting. As maternal mood and anxiety difficulties are associated with a number of adverse outcomes for the mother, her offspring and the family system, addressing these concerns during the perinatal period is of critical importance. Although researchers and clinicians have become increasingly aware of the problem, postpartum mood and anxiety disorders (PMADs) remain widely unrecognized and poorly understood by both patients and providers. As pediatric primary care providers encounter mothers repeatedly throughout the postpartum period, the pediatric clinician has the unique opportunity to intervene with mothers suffering from mental illness. Given the potentially devastating impact of PMADs across multiple domains, the purpose of this article is to provide guidelines for pediatric clinicians to better manage maternal mental illness within the primary care pediatric setting. As such, we review the categories and prevalence of PMADs and provide strategies for responding to a positive PMADs screen or concerns raised during surveillance of the mother-infant-dyad. In addition, we offer a summary of the literature on evidence-based treatments for PMADs to allow pediatricians to guide the parents of their patients towards the most effective interventions. Finally, we provide an overview of alternative treatment models that can facilitate the screening and treatment of behavioral health concerns within the primary care setting.

Minimal to no transfer of certolizumab pegol into breast milk: results from CRADLE, a prospective, postmarketing, multicentre, pharmacokinetic study

Background

Women with chronic inflammatory diseases face uncertainty regarding the safety of biologics during breast feeding. CRADLE was the first industry-sponsored study to evaluate certolizumab pegol (CZP) concentrations in human breast milk and estimate average daily infant dose (ADID) of maternal CZP.

Methods

CRADLE (NCT02154425) was a pharmacokinetic study of lactating mothers receiving CZP. After ≥3 CZP doses, breast milk samples were collected across one dosing period (14 days for 200 mg every 2 weeks [Q2W]; 28 days for 400 mg every 4 weeks [Q4W]). Optimal analytical methods were developed to determine CZP and polyethylene glycol (PEG) levels in breast milk. ADID and relative infant dose (RID) were estimated. Safety events in mothers and infants were assessed.

Results

19 CZP-treated mothers were screened; 17 entered the sampling period: 16 on 200 mg Q2W, 1 on 400 mg Q4W. 77/137 (56%) breast milk samples had no measurable CZP. For 4/17 mothers, all samples were below the lower limit of quantification (LLOQ). Estimated ADID was 0–0.0104 mg/kg/day; median RID: 0.15%. PEG was undetectable in 134/137 samples (results could not be determined in three samples). Infants of CZP-exposed mothers had a safety profile consistent with that of unexposed similar-age infants.

Conclusion

When quantifiable, CZP concentrations were <3× LLOQ (<1% plasma concentration observed with therapeutic dose), indicating no/minimal CZP transfer from plasma to breast milk. RID was 0.15% of maternal dose; <10% is considered unlikely to be of clinical concern. No PEG transfer was observed. CZP absorption by infants via breast milk is unlikely due to its low oral bioavailability and Fc-­free molecular structure. These findings are reassuring and support continuation of CZP treatment during breast feeding.

Trial registration number

NCT02154425; Results.

Evaluation of the Safety of Drugs and Biological Products Used During Lactation: Workshop Summary

This report serves as a summary of a 2-day public workshop sponsored by the US Food and Drug Administration (FDA) to discuss the safety of drugs and biological products used during lactation. The aim of the workshop was to provide a forum to discuss the collection of data to inform the potential risks to breastfed infants with maternal use of medications during lactation. Discussions included the review of current approaches to collect data on medications used during lactation, and the considerations for future approaches to design and guide clinical lactation studies. This workshop is part of continuing efforts to raise the awareness of the public for women who choose to breastfeed their infants.

Mood stabilizers and antipsychotics during breastfeeding: Focus on bipolar disorder

Breast milk is considered the best source of nutrients and provides much better protection than immune modified milk. However, the postpartum period is a phase of increased risk for all women to experience psychiatric symptoms and recurrences or new episodes of bipolar disorder (BD), especially in those who have discontinued treatment. This is a systematic review of the risks and benefits of mood stabilizers and antipsychotics during breastfeeding as they relate to the health and well-being of mothers and their infants. Evidence-based treatment advice for women with BD during lactation is also provided. This systematic review has been conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. We included studies examining the exposure and the effects of antipsychotics and mood stabilizers used to treat BD on infants during breastfeeding clearly reporting the estimated amount of drug or effects on infants. The final selection included 56 studies. The available data supports the use of lithium as a possible treatment option during breastfeeding. Carbamazepine and valproic acid are also considered relatively safe. Lamotrigine can be used but at the lowest doses and considered for individual cases. Among the antipsychotics, quetiapine and olanzapine should be considered as first-line treatment options. Risperidone may be compatible with breastfeeding under medical supervision. Clozapine and amisulpiride are currently contraindicated. Long-term outcome studies evaluating the infant׳s health and psychosocial and cognitive functioning are needed.

Managing anesthesia for cesarean section in obese patients: current perspectives

Obesity is a worldwide epidemic. It is associated with increased comorbidities and increased maternal, fetal, and neonatal complications. The risk of cesarean delivery is also increased in obese parturients. Anesthetic management of the obese parturient is challenging and requires adequate planning. Therefore, those patients should be referred to antenatal anesthetic consultation. Anesthesia-related complications and maternal mortality are increased in this patient population. The risk of difficult intubation is increased in obese patients. Neuraxial techniques are the preferred anesthetic techniques for cesarean delivery in obese parturients but can be technically challenging. An existing labor epidural catheter can be topped up for cesarean delivery. In patients who do not have a well-functioning labor epidural, a combined spinal epidural technique might be preferred over a single-shot spinal technique since it is technically easier in obese parturients and allows for extending the duration of the block as required. A continuous spinal technique can also be considered. Studies suggest that there is no need to reduce the dose of spinal bupivacaine in the obese parturient, but there is little data about spinal dosing in super obese parturients. Intraoperatively, patients should be placed in a ramped position, with close monitoring of ventilation and hemodynamic status. Adequate postoperative analgesia is crucial to allow for early mobilization. This can be achieved using a multimodal regimen incorporating neuraxial morphine (with appropriate observations) with scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Thromboprophylaxis is also important in this patient population due to the increased risk of thromboembolic complications. These patients should be monitored carefully in the postoperative period, since there is increased risk of postoperative complications in the morbidly obese parturients.

Bioanalytical challenge: A review of environmental and pharmaceuticals contaminants in human milk

An overview of bioanalytical methods for the determination of environmental and pharmaceutical contaminants in human milk is presented. The exposure of children to these contaminants through lactation has been widely investigated. The human milk contains diverse proteins, lipids, and carbohydrates and the concentration of these components is drastically altered during the lactation period providing a high degree of an analytical challenge. Sample collection and pretreatment are still considered the Achilles' heel. This review presents liquid chromatographic methods developed in the last 10 years for this complex matrix with focuses in the extraction and quantification steps. Green sample preparation protocols have been emphasized.

Advising Mothers on the Use of Medications during Breastfeeding: A Need for a Positive Attitude

The use of medications by the nursing mother is a common reason for interrupting breastfeeding. Few drugs have been demonstrated to be absolutely contraindicated during breastfeeding. Excessive caution may lead health professionals to unnecessarily advise to interrupt breastfeeding, without assessing the latest evidence or considering the risk-benefit ratio of taking a medication versus terminating breastfeeding. To foster an appropriate approach toward the use of medications in breastfeeding women, the Italian Society of Perinatal Medicine created the following policy statement.

Clinical management of perinatal anxiety disorders: A systematic review

BACKGROUND

In the last few decades, there has been a growing interest in anxiety disorders (AnxD) in the perinatal period. Although AnxD are diagnosed in 4-39% of pregnant women and in up to 16% of women after delivery, evidence on their clinical management is limited.

METHODS

A systematic review was conducted on pharmacological and non-pharmacological treatment of AnxD in the perinatal period. Relevant papers published from January 1st 2015 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

RESULTS

18 articles met inclusion criteria. Selected studies supported the use of cognitive-behavioural therapy (CBT) for obsessive-compulsive disorder (OCD), panic disorder (PD) and specific phobia both in pregnancy and postpartum. Selective serotonin reuptake inhibitors (SSRIs) led to significant OCD and PD improvement both in pregnancy and postpartum with no side effects for the babies. In the largest clinical sample to date, 65% of postpartum patients who entered the open-label trial of fluvoxamine (up to 300mg/day) experienced a 30% or greater decrease in the total score of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). During pregnancy, SSRIs and tricyclic antidepressants (TCAs) led to remission of panic symptoms and healthy outcomes for the babies.

LIMITATIONS

Study design, mostly case reports, and enrolment of subjects mainly from outpatient specialty units might have limited community-wide generalisability.

CONCLUSIONS

Keeping in mind the scantiness and heterogeneity of the available literature, the best interpretation of the available evidence appears to be that CBT should be the first treatment offered to pregnant and breastfeeding women with AnxD. However SSRIs can represent a first line treatment strategy, and not exclusively in cases where AnxD is refractory to CBT.