Breastfeeding - Complex medication history/severe car accident/brain trauma in 2012

[Chiara11]

Hi,

I need help please.. I had a severe car accident in 2012. I was a pedestrian hit at full speed from a taxi driver whilst crossing the road. I suffered multiple injuries, many fractures (shoulder, nose, 3 fracture of the jaw, skull, etc) and had a severe brain trauma with consequent 5 day coma. I have been on prescription medication since mainly to help with chronic pain and mood stabilizers. I have been experimented on with hundreds of different medicines until my asking to lower all my doses to the following:

• 20mg a day Brintellex
• 25mg per day Tryptizol.
• 5mg x day Diazepam
• 900mg x day Neurontin

I have been on the above meds throughout my pregnancy and i was told i could not breastfeed, so i had put my head to rest on this. However, my little girl decided to arrive 2 months earlier than expected, at 30 + 4 weeks and the lactation specialist at the hospital said that the benefits towards the risks of lactation for a premature baby were way higher so I have fed my baby with my milk since her arrival 4th of January 2018. I thought this would only be for the duration of her stay in NICU, but again the specialist there said that NO i could actually feed her until she was on solid food. I was ecstatic as i thought that i would not have had this opportunity. Following this though my psychiatrist and neonatal specialist spoke and decided for a straight NO to carrying on breastfeeding if i remain on this meds. Clearly i want ZERO risk for my baby, so i said ok that's fine, i want to come off all the meds (the only one ok is apparently the Brintellex) …again the answer of my psychiatrist is no, its not a good time, the birth of a baby, too stressful etc…then again is there ever a good time? Also if i had to listen to all the doctors have said in the past 5 years, i could have never conceived following my accident and…well my miracle baby is the proof doctors don't know everything all the time.

I have been working very hard with baby in NICU to pump as much milk as possible and although she is not with me im on approx 640ml production per day. The main question i have is:

• If i move the baby to formula how can i ensure to keep producing milk if i decide to go off my meds on my own anyway on my own and until i have done so, so that she can go back on my milk?
• Also what is the best organic formula on the market?
• How much milk do i need to ensure i keep expressing if i manage to remove all meds and put the baby back on my milk?
• How do i make sure that my baby doesn't forget how to feed from me whilst reducing all meds?

Thank you in advance for any help you can provide.
Chiara

[Sandra]

Chiara11,

Brintellix has changed it's name to Trintellix. It is rated an L3-no data-probably compatible."This medication has a small molecular weight and long half-life; however, its large volume of distribution (37 L/kg) and high protein binding (98%) suggest it will most likely enter milk at levels similar to other antidepressants. In the absence of specific data regarding this medication or its antidepressant class (SMSs) in breastfeeding mothers, we recommended to use medications with more extensive clinical experience and research in lactation (e.g. SSRIs, SNRIs)." (Medications and Mothers' Milk database, Dr Thomas Hale, PhD). Since your infant was exposed in utero we would say you could continue to nurse as long as you infant is not symptomatic. Monitor your infant for sedation or irritability, not waking to feed/poor feeding and poor weight gain.


Tryptizol (amitriptyline) is rated an L2-limited data-probably ok. The amount that transfers into breast milk is only 1.08-2.8% of your dose. The infant is probably exposed to more in utero than through breast milk. We think this medication is probably ok to continue to nurse on as long as your infant is not symptomatic. Monitor for sedation or irritability, dry mouth, not waking to feed/poor feeding, constipation, urinary retention, poor weight gain.


Neurontin is rated an L2-limited data-probably compatible. The amount that transfers into breast milk is 6.6% of your dose. The infant is probably exposed to more in utero than through breast milk. This medication is probably ok to nurse on as long as your infant is not symptomatic. Monitor for sedation or irritability, not waking to feed/poor feeding, vomiting, tremor.


Valium is rated an L3-limited data-probably compatible. The amount that transfers into breastmilk is 0.88-7.14% of your dose. This medication is not recommended for daily use especially in young infants as it has a long half-life of 43 hours and it takes 6 half-lives to be completely out. This medication could build up in the infant and cause over sedation, slowed breathing rate, apnea, not waking to feed/poor feeding and poor weight gain.

If you would be able to wean off the valium and stop it completely, you could probably continue to nurse on the other medications as long as your infant was not symptomatic. Since your infant is a premie you may want to supplement every other feeding with an hydrolyzed formula like Alimentum or Nutramigen, (each company has its own brand, all probably ok) until your infant is older and better able to metabolize these medications, then you could slowly increase to full feedings as long as your infant is tolerating them.


Sandra Lovato R.N.
InfantRisk Center
806-352-2519

[Chiara11]

Dear Sandra,

your reply is highly appreciated. I live in Dubai, where I am afraid to say, competent healthcare and knowledge is not always available.
I read your reply with much interest especially considering that I was told by my treating psychiatrist and neurologist that the only safe medication was Brintellix, whereas it does not appear to be the case.
You also mention that most medicines would have created more risk in uterus than through breastmilk which was exactly my thought and my question to the doctors when i was told i could not breastfeed, although being told that the meds were safe in pregnancy at those doses.

Could I ask which other SSRIs, SNRIs you'd recommend instead which would be safer for the baby? I was given different medications during the years all with their own side effects. Brintellix has worked but then again there are hundreds of medication on the market that i might not be aware of in this particular circumstance

I am already trying to wear myself off it of it and i have been on half the dose - so 2.5mg - for a week now.

The baby was discharged from NICU this past Monday and she is at home now. She has been completely switched to formula as I didn't want to take any risk with her until I got more clarity on the matter. I have not tried to have her latch any longer for the same reason.
I would love to know your take on breastfeeding vs formula. I have a strong desire to breastfeed her and my research tells me that the benefits of breastfeeding are multiple, however, i do not want to expose the baby to any risks.

The baby has been not symptomatic so far to any of the medications or at least nothing apparent to me or the various specialists involved with a premature baby. She was a bit sleepy during the very 1st few weeks, but she was also very very small so who knows. She is eating every 3 hrs and gaining weight regularly. She is just perfect :-)

Thank you again
Chiara

[Sandra]

Chiara11,

If your medications are working for you and you did not notice any negative side effects in your infant then you could continue to nurse if you are able to wean off the valium. When the infant is exposed in utero they become accustom to metabolizing the medications. Switching medications can also have it's draw backs as some medications do not work well for certain people. If you are concerned on how much medication your infant is exposed to another option would be half breast milk and half formula. If you are putting your infant to breast then alternate every other feeding with a bottle, or if you are strictly pumping you could mix half and half.

If you want to switch you need to discuss other options with your Dr and see what they think would be helpful for your condition.

Many of the SSRI's are rated L2's such as Prozac, Celexa, Lexapro, Zoloft and Paxil. Some of the preferred SSRI's are Zoloft, Lexapro and Paxil, but Paxil is not recommended in pregnancy so if you are planning on having more children this is not a good option. Possible side effects to monitor for include sedation or irritability, not waking to feed/poor feeding and weight gain.


The preferred SNRI's are probably Cymbalta or Effexor. Possible side effects to monitor for include sedation or irritability, not waking to feed/poor feeding and weight gain.


Sandra