Breastfeeding Fundamentals

Motherhood is an exciting time, especially for first time mothers. However, with all the excitement comes a lot of questions. Pharmacists are the most accessible healthcare providers for patients and especially nursing mothers who are seeking information on medication use while breastfeeding. Below are breastfeeding basics and guidance on how to approach drug therapy in breastfeeding women.

1. World Health Organization recommendations for breastfeeding

  • For the first six months of life, infants should be exclusively breastfed.
  • Beyond six months to two years of age or older, breastfeeding should be complemented with other foods.
  • Infants should be fed on-demand as often as they need, night and day.

Counselling tip: Advise mothers to avoid using bottles and pacifiers in order to prevent nipple confusion (i.e., when babies struggle to suckle from the breast because they are used to feeding from a bottle or pacifier).

2. Active feeding

During the first weeks of life, infants will need to feed 8 or more times per day. This active feeding helps to establish regular milk production, which in turn supplies enough nourishment for infants to regain the 5-7% weight loss they tend to experience in the first 3-4 days of life. During the first few weeks, infants feed approximately once every 2 to 4 hours. If it has been more than 4 hours since the last feed, mothers should wake up their baby in order to feed.
Counselling tip: Advise mothers to monitor their baby’s wet and dirty diaper output as a measure of whether the baby is feeding enough.

  • Wet diapers: after the first week, an infant is expected to produce five to six wet diapers daily.
  • Dirty diapers: after the fourth day of life, an infant is expected to produce three to four dirty diapers daily.

3. Medication use and breastfeeding
A common question breastfeeding mothers may have is: “How much of my medication will reach my nursing baby?” The answer is that almost all medications get transferred to feeding infants in small quantities. However, this shouldn’t stop mothers from breastfeeding or taking their medications.
Use the following principles as a guide to making drug therapy decisions for breastfeeding mothers:

  • If the drug is okay for the baby to use, then it is okay for the mother to use.
  • An exposure index (EI), which is how much of the mother’s dose the infant is exposed to, of <10 % is generally considered clinically unimportant.
  • Consider how the medication may affect the milk supply. The following acronym lists some medications that decrease milk flow: ACE ADE: Amphetamines, Cabergoline, Ergots, Antihistamines, Diuretics and Estrogen
  • The following medications are incompatible with breastfeeding: NICE SR: Nicotine, Immune suppressants, Chemotherapy, Ergots, Statins, Radiopharmaceuticals

Counselling tip: Advise mothers, especially when taking medications, to monitor their baby for any unusual signs and symptoms such as reduced feeding, irritability, drowsiness, etc., and seek medical attention as necessary.
4. Contraceptive methods during breastfeeding

A common misconception is that you “can’t get pregnant while breastfeeding”. When breastfeeding, the chance of becoming pregnant is lower, but the risk is still there. Breastfeeding can inhibit ovulation and prevent pregnancy only when certain criteria are followed (see below). Different contraceptive options are available for nursing mothers; however, estrogen-containing products should be avoided during the first 6 weeks post-partum due to risk of clots and reduction in milk supply. The following are contraceptive methods that can be recommended to nursing mothers:
i) Lactation amenorrhea

  • Exclusive breastfeeding, not complemented by other sources of food, for the first six months postpartum with no feeding interval greater than five hours during this time.
  • If menses has returned, breastfeeding does not occur at the above frequency, other sources of food are introduced, or the baby turns six months of age or older, then this method is no longer reliable and another contraceptive measure should be used.

ii) Progestin-only hormonal contraceptives

  • Norethindrone 0.35 mg oral tablet
  • Medroxyprogesterone acetate injection
  • Progestin-only intrauterine system (IUS)

iii) Barrier methods

  • Condoms, diaphragms, cervical caps or sponges

iv) Copper IUD

Use this information to effectively advise nursing mothers on various issues surrounding breastfeeding. From general tips to medicinal-based knowledge, pharmacists can extend a comforting hand to ensure that the nursing process is both safe and successful.

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