No announcement yet.

re: AAP update "Transfer of Drugs and Therapeutics Into Human Breast Milk"

  • Filter
  • Time
  • Show
Clear All
new posts

  • re: AAP update "Transfer of Drugs and Therapeutics Into Human Breast Milk"

    I'm wondering if you guys have any helpful commentary on the AAP update "Transfer of Drugs and Therapeutics Into Human Breast Milk", particularly in reference to the sections on pain meds?

    Maybe I don't understand the paper well, but it seems to me they are basically eliminating many postpartum pain relief options.
    We currently use mostly percocet (oxycodone) for post cesarean pain relief, but it seems that the AAP is advising against its use:
    "Other narcotic agents, such as oxycodone, pentazocine, propoxyphene, and meperidine, are not recommended in the lactating mother. Relatively high amounts of oxycodone are excreted into human milk, and therapeutic concentrations have been detected in the plasma of a nursing infant. Central nervous system depression was noted in 20% of infants exposed to oxycodone during breastfeeding. Thus, use of oxycodone should be discouraged."

    They also write "... when narcotic agents are needed to treat pain in the breastfeeding woman, agents other than codeine (eg, butorphanol, morphine, or hydromorphone) are preferred. ...Given the reduced
    clearance of hydrocodone in neonates and the adverse events observed in ultrarapid metabolizers of codeine,
    caution is advised for use of codeine and hydrocodone in both the motherand nursing infant."

    So no percocet (oxycodone), no codeine, no vicodin (hydrocodone), no toradol (which we also use and seems to work pretty well).

    They prefer butorphanol (stadol), morphine, or hydromorphone. BUT -->

    -Are these meds relatively "equal" options to Percocet (oxycodone)?
    -Would morphine or hydromorphone be stronger than necessary if good pain relief is being achieved with something like Percocet (oxycodone)?
    -I find that IV butorphanol (Stadol) only gives moms relief for about an hour, which is not really a good option when it is only prescribed for q 2 or 3h. We only use it during labor at this time and not for postpartum. Should we reconsider it as an option?
    I think it helps to give 1mL IM and one 1mL IV concurrently - it helps it last longer. But I'm not sure if postpartum moms would like all those shots!
    -Also, the percocet we curently us is available PO - what's the best equal-strength pill option to percocet?

    SOOO... I'm very curious what your thoughts are on this.
    With these AAP recommendations & the weight they carry in mind, I would love to see some kind of hierarchy (by pain level), particularly with post cesarean/surgical pain relief in mind. I want our patients to be able to have the best balance for pain relief with least effect on breastfeeding that is possible & I feel like it's pretty muddled right now.

    Thanks in advance!

    PS - would also LOVE LOVE LOVE an updated hierarchy in order of preference for depression meds!!!!!!!
    I know that all situations are unique, but an inclusion of these two hierarchies in the next M&MM would be soooooo helpful. Probably and antibiotic one, too, although I realize that might be more complex.