Use of Antibiotic and Analgesic Drugs during Lactation

The Safety of Amoxicillin/Clavulanic Acid and Cefuroxime During Lactation

Breast-feeding is considered the gold standard for infant nutrition. In spite of statements about the safe use of drugs in lactation by the American Academy of Pediatrics, medical professionals remain confused regarding the management of drug therapy in nursing mothers, and this can lead to suboptimal prescribing and poor compliance. The aim of our study was to evaluate the safety of 2 of the newer antibiotics, amoxicillin/clavulanic acid and cefuroxime, during lactation. Breast-feeding women who called a drug consultation center to obtain information about the potential risks of amoxicillin/clavulanic acid (67 women) and cefuroxime (38 women) were prospectively recruited. As a control group, women who were treated with antibiotics known to be safe during lactation were recruited: amoxicillin (n = 40) for the amoxicillin/clavulanic acid group and cephalexin (n = 11) for the cefuroxime group. Women in the control group were matched for indication for antibiotic therapy, duration of treatment, and maternal age. Participants were interviewed after treatment termination regarding adverse reactions during therapy. In the amoxicillin/clavulanic acid group, 15 infants (22.3%) had adverse effects, and the rate increased with dosage (P = 0.0139). This was significantly higher than the amoxicillin group, where 3 infants (7.5%) had adverse effects (P = 0.046, relative risk (RR) = 2.99, 95% confidence interval (CI) 0.92-9.68). However, there were no significant differences between rates of specific events. The rate of adverse effects in the cefuroxime group (2.6%) was not significantly different from that in controls (9%) (P = 0.58, OR = 0.92, 95% CI 0.94-1.06). All adverse effects were minor, self-limiting, and did not necessitate interruption of breast-feeding. Our data suggest that amoxicillin/clavulanic acid and cefuroxime may be safe during lactation. Larger studies are needed to confirm these findings.

Drug use and breastfeeding

Section 1 describes the benefits of breastfeeding to both mother and infant as well as the potential risks to the infant from maternal drug use. The extent of adverse drug-related events and the need for quality information on drug transfer is stated. Section 2 describes the physiology of lactation and the effects of drugs that stimulate or decrease milk production. Section 3 deals with transport mechanisms for drug passage into milk and factors that may modify the infant's exposure to drugs. The critical descriptors of 'absolute' and 'relative' infant dose are defined to give an objective measure of infant exposure to drugs in milk. Section 4 reviews new or commonly used drugs under the headings of analgesics and anti-inflammatory agents, neurological, endocrine, psychotropic and antihypertensive drugs. Section 5 concludes with an expert opinion of the drug industry and drug use in lactation, herbal preparations, the process of 'risk-benefit' analysis, minimising infant exposure, understanding drug-related adverse events and fostering good experimental design for drugs in lactation studies.

Pregnancy and stroke

The risks of ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage are not increased in the 9 months of gestation except for a high risk in the 2 days prior and 1 day postpartum. The remaining 6 weeks postpartum also have an increased risk of ischemic stroke and intracerebral hemorrhage, though less than the peripartum period. Although there are some rare causes of stroke specific to pregnancy and the postpartum period, eclampsia, cardiomyopathy, postpartum cerebral venous thrombosis, and, possibly, paradoxical embolism warrant special consideration. The diagnostic and therapeutic approaches to stroke during pregnancy and the postpartum period are similar to the approaches in the nonpregnant woman with some minor modifications based on consideration of the welfare of the fetus. There is a theoretical risk of magnetic resonance imaging exposure during the first and second trimester but the benefit to the mother of obtaining the information may outweigh the risk. Available evidence suggests that low-dose aspirin (<150 mg/day) during the second and third trimesters is safe for both mother and fetus. Postpartum use of low-dose aspirin by breast-feeding mother is also safe for infant. While proper counseling is imperative, a history of pregnancy-related stroke should not be a contraindication for subsequent pregnancy.

Transfer of rofecoxib into human milk

OBJECTIVE

To determine the milk-to-plasma (M/P) concentration ratio of rofecoxib in lactating mothers and estimate likely infant exposure.

METHODS

Rofecoxib 25 mg was given to six lactating women at weaning. Blood and milk were sampled up to 72 h post-dose for determination of rofecoxib concentrations. M/P ratios were derived from the respective area under the concentration-time curves. The infant 'dose' in milk was estimated and expressed as a percentage of the maternal dose, corrected for weight.

RESULTS

The median (range) M/P ratio and infant 'dose' were 0.25 (0.16-0.32) and 2.1% (1.8-3.2%), respectively.

CONCLUSIONS

The use of rofecoxib during breastfeeding is unlikely to pose harm to the suckling infant on the basis of low transfer into human milk.

Challenging scenarios in a travel clinic: advising the complex traveler

With adequate preparation and in consultation with a travel medicine expert, most travelers today can travel safely regardless of their age and health status. The few instances when it is prudent to alter travel plans or postpone travel altogether are not to be taken lightly. For the most part, however, most complex travelers can enjoy a healthy and rewarding travel experience.

Endogenous opiates and behavior: 2003

This paper is the 26th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2003 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).