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Mother with CRPS

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  • Mother with CRPS

    I have a permission to post. A mother of the first child is having a severe case of CRPS and have not been able to walk. The pain is affecting her whole body. Prior pregnancy she used Norspan (buprenorphine), Cymbalta (duloxetine), Topimax (topiramate) and Lyrica (pregabaline) to control the pain but all the medication has been stopped for pregnancy except Norspan 20mg (1 in 7 days). The c-section is going to be 15.2. and the mother have been discussing about her medication with the Finnish Teratologic Info Service (run by the Helsinki University Hospital). The Norspan has been said to be acceptable with the breastfeeding from the Info Service (The service is nationwide and highest information about medications during pregnancy and breastfeeding). Now some of the doctors are not happy with the medication and have said mother that she is not allowed to breastfeed.

    What is the recommendation with Norspan while breastfeeding? How about the other medication the mother used prior pregnancy, is it possible to combine one or two of them to Norspan if needed while breastfeeding? The pregnancy eased her symptoms and she is managing with only Norspan for now on. She is very determined to breastfeed her child if it is considered safe with the medication she needs.

    The baby is going to be admitted to Special Care Nursery for a day or two to see how she / he adapts and if the baby will need something treatment during neonatal period right after birth because of mother's medication. If breastfeeding is acceptable, what follow-up the baby would need? All Finnish babies have regular follow-up at well baby clinics so that would not be a problem.

    On the other hand we have mothers with drug abuse who are in drug withdrawal therapy and they are using buprenorphine and other drugs to control symptoms and they are usually breastfeeding and breastfeeding is accepted by the hospital protocol.

    I am happy to have any information!

    Pia Ruohotie
    From Helsinki Finland

  • #2
    Pia Ruohotie,

    Buprenorphine is rated an L2-limited data-probably compatible. The amount transferred into milk is 0.09-1.9% of moms dose. [COLOR=#333333][FONT=lucida grande]Studies thus far clearly show buprenorphine levels in milk are fairly low. Less than 2% of the dose transfers into milk and less than a third of this would be absorbed orally. Monitor the infant for sedation, slowed breathing rate/apnea, pallor, constipation and not waking to feed/poor feeding, and possible withdrawal since the infants are exposed to more of the medication in utero than through breast milk.

    Cymbalta (duloxetine) is rated an L3-limited data-probably compatible. The amount transferred in breast milk is 0.1-1.1% of moms dose. New data suggest that the milk/plasma ratio is low, and the RID is low as well. This is too low to have clinical effects on an infant. Monitor the infant for s[/FONT][/COLOR][COLOR=#333333][FONT=lucida grande]edation or irritability, not waking to feed/poor feeding and weight gain.

    Topamax (topiramate) is rated an L3-limited data-probably compatible. The amount transferred in breast milk is high 24.68-55.65% of moms dose. Topiramate may be used during breastfeeding with close monitoring. The amount transferred into milk is relatively high. There has also been one case report of an infant with persistent diarrhea. Plasma levels in two infants were 10-20% of maternal plasma levels. Topiramate has become increasingly popular due to its lower adverse effect profile in relation to other treatment options. Due to the fact that the plasma levels found in breastfeeding infants were significantly less than in maternal plasma, the risk of using this product in breastfeeding mothers is probably acceptable. Monitor the infant for sedation or irritability, not waking to feed/poor feeding, diarrhea, weight loss and over heating.

    Lyrica (pregabalin) is rated an L3-no data-probably compatible. While there are no data on its transfer into human milk, it should be expected. Due to the kinetics of the drug, its passage into the milk compartment is probable, and its oral bioavailability to the infant would be high. Therefore, nursing mothers should use caution in taking pregabalin while nursing. Monitor the infant for Sedation, slowed breathing rate/apnea, constipation and not waking to feed/poor feeding.[/FONT][/COLOR]

    We would say the use of buprenorphine in breastfeeding is acceptable, the infant is exposed to more in utero than through breast milk, just monitor for side effects. The Cymbalta is also considered safe if the infant is not symptomatic. The use of topamax or lyrica should be done so with caution and the infant needs to be monitored closely for side effects.

    I hope this helps.

    Sandra Lovato R.N.
    InfantRisk Center