Lecture Titles Provided by Dr. Hale

    Some Typical Lectures Provided Include
    • 1. Using Medications in Breastfeeding Mothers (Time requested 1.5 hrs)
    • 2. Anesthetic and Epidural Medications in Breastfeeding Mothers (1.0 hrs)
    • 3. Antidepressant Medications and Breastfeeding (45 min - 1 hour)
    • 4. Pharmacotherapy in Breastfeeding Mothers
    • 5. Drugs of Abuse and Breastfeeding
    • 6. Drugs and Milk Production
    • 7. The Control and Production of Human Milk

    Lecture Descriptions

Using Medications in Breastfeeding Mothers


      Session Objectives:

      1. Describe the transmission of drugs into breast milk and how to breast feed
      away from peak levels.
      2. Provide information on continuing breastfeeding afterdiagnostic procedures.
      3. Provide skills on communicating with health care providers.

      Session Outline:

        I. Review of physiology and endocrinology of breast milk production.

        II. Review of drug entry into breast milk.
          A. Entry and exit of medication.
          B.Characteristics of medications required for transport.
          C.Milk to Plasma Ratio
          D.Medication Kinetics
            1.Half-life
            2.Protein binding
            3.Timing of feeds.
            4.Side effects of some medications.
        III. Review of various medications
          A.Galactogogues
          B.Antibiotics
          C.Antidepressants
          D.Antihistamines
          F.Birth Control Preparations
          G. Analgesic medications.
          H. Anesthetic agents.
          I. Antifungal agents
          J. Radiocontrast agents

      References:

        1. Anderson PO. Drug use during breast-feeding. Clin Pharm. 1991; 10:594-624
        2. Anderson PO. Medication use while breast feeding a neonate. Neonatal Pharmacology Quarterly 2(2):3-14, 1993
        3. Rivera-Calimlim, L. The significane of drugs in breast milk. Clinics in Perinatology 14(1):51-69, 1987.

    Anesthetic/Epidura Medications and their Impact on Breastfeeding 

      Session Objectives:

        The trainee will be able to:
          1. Describe the transmission of drugs into the fetus and the consequences of prenatal medications.
          2. Provide information on continuing breastfeeding after prenatal anesthetic/analgesic medications.
          3. Provide skills on determining the timing of administration of medications and
          their likely impact on breastfeeding following anesthesia.

      Session Outline:


        I. Review of physiology of anesthetic and analgesic medications
        II.Review of drug transmission to the fetus and subsequently into breast milk.
          A.Entry and exit of medication.
          B.Pharmacology and kinetics of anesthetic and analgesic medications.
          C.Implication of metabolites.
        III. Medication Kinetics
          A.Half-life
          B.Protein binding
          C.Timing of feeds.
          D.Side effects of some medications.
        IV.Review of various medications
          A.Benzodiazepines
          B.Antibiotics
          C.Local anesthetics
          D.Epidural anesthetics
          E.Intrathecal medications
          F.Opiate analgesics
          G.Kappa opiate-like analgesics

      References:


        1. Spigset O: Anaesthetic agents and excretion in breast milk. Acta Anaesthesiologica
        Scandinavica 1994; 38:94-103.
        2. Shafer SL, Varvel JR: Pharmacokinetics, Pharmacodynamics,and Rational Opioid
        Selection.Anesthesiology 1991; 74:53-63.
        3. Scanlon JW, Brown WU Jr, Weiss JB, Alper MH: Neuro behavioral responses
        of newborn infants after maternal epidural anesthesia. Anesthesiology 1974; 40:121-128.

    Using Antidepressants in Breastfeeding Mothers

      Session Objectives:


        The trainee will be able to:
          1. Describe the clinical symptoms and pathogenesis of depression.
          2. Provide information on the best use of antidepressants in this syndrome.
          3. Learn to evaluate the problems associated with antidepressant use.

      Session Outline:


        I.Review of physiology and pharmacology of depression.

        II.Review of basic pharmacotherapy of depression.
            A.Entry and exit of antidepressants in breastmilk.
            B.Various families of antidepressants and their uses.
            C.Milk to Plasma Ratios
            D.Medication Kinetics
              1.Half-life of antidepressants
              2.Active metabolites
              3.Timing of feeds following therapy.
              4.Side effects of some medications.
        III. Review of various medications
          A.Tricyclic antidepressants-Amitriptyline, etc.
          B.Serotonin Reuptake Inhibitors
            1.Prozac
            2.Zoloft
            3.Paxil
            4.Effexor

          C.Monoamine Oxidase Inhibitors
          D.Buproprion (Wellbutrin)
          E.Lithium
        IV.Review of Side Effects
          A. Maternal Side Effects
          B. Pediatric Side Effects

        V.Techniques for Risk-Assessment
          A. Optimal development in healthy mothers
          B. Contraindications


      References:


        1. Matheson I, Skjaeraasen J.Milk concentrations of flupenthixol, nortriptyline, and
        zuclopenthixol and between-breast differences in two patients. Eur. J. Clin. Pharmacol.
        35:217-20,1988.
        2. Wisner KS and Perel J. Serum nortriptyline levels in nursing mothers and their infants.
        3. Brixen-Rasmussen L, Halgrener J, Jergensen a. Amitriptylineand nortriptyline
        excretion in human breast milk.Psychopharmacology 76:94-95, 1982.
        4. Altshuler LL.Breastfeeding and Sertraline: a 24 hours Analysis. J. Clin Psychiatry 56(6):243-245, 1995.
        5. Wisner KL, Perel JM, Findling RL: Antidepressant treatment during breast-feeding.
        Am J Psychiatry 153(9): 1132-1137, 1996.
        6. Mammen OK, Perel JM et.al: Sertraline and norsertraline levels in three breastfed
        infants. J. Clin. Psychiatry 58(3): 100-103, 1997.
        7. Isenberg KE.Excretion of fluoxetine in human breast milk. J Clin Psychiatry 51:169, 1990.
        8. Burch KJ, and Well BG. Fluoxetine/Norfluoxetine concentrations in human milk. Pediatrics 89:676, 1992.
        9. Taddio a, Ito S, Koren G.Excretion of fluoxetine and its metabolite in human breast milk.
        Pediatric Res 35(4, part 2): 149a, 1994. Abstract.
        10. Wisner KL, Perel JM, Findling RL:Antidepressant treatment during breast-feeding.
        Am J Psychiatry 153(9): 1132-1137, 1996.

    Pharmacotherapy in Breastfeeding Patients

    Session Objectives:


      The trainee will be able to:
        1.Describe the treatment of various syndromes with medications best for breastfeeding mothers and infants.
        2.Learn to evaluate infants, those more or less susceptible, to various drug treatment regimens.
        3.Learn to evaluate the problems associated evaluating medication use in various types of breastfeeding mothers.
        4.Evaluate drugs of abuse, and provide counseling concerning breastfeeding following their use.

      Session Outline:


        I.Review on how to evaluate the infant prior to giving advise on medications.
          A.Age
          B.Weight and prematurity.
          C.Medica condition of infant.
          D.Medications that the infant may be receiving.
          E.Timing postpartum.

        II.Review various medical conditions and their therapy in breastfeeding patients.
          A.Mastitis
          B.Treatment of Hypertension
          C.Hyperthyroidism and medications
          D.Hepatitis and breastfeeding
          E.Treatment of asthma in breastfeeding mothers
          F.Use of Radioactive medications
          G.Use of Radiocontrast agents in breastfeeding mothers
          H.Drugs of Abuse
          I.Lice and Scabies treatments
          J.Antidepressant therapy in breastfeeding patients

    Breastfeeding and Drugs of Abuse


      Session Objectives:

        The trainee will be able to:
          1. Describe the basic testing of drugs of abuse.
          2. Provide information on the transfer of drugs of abuse into human milk.
          3. Learn to evaluate the problems associated with drugs of abuse and their implication in breastfed infants.

      Session Outline:

        I.Specifics of drug abuse testing
          1.Collection of samples
          2.Methods of testing
            a.Preliminary screening methods
            b.Gas chromatography
            c.Gas chromatography mass spectrometry
        II.Limitations of screening, what are you testing for?
        III.Timing of testing is of major importance
          a.  What does it mean?
        IV.Metabolism and plasma kinetics of drugs of abuse
          1.Cocaine
            a.Crack and cocaine HCL
            b.Benzoecgonine
          2.Amphetamines
          3.Marijuana
          4.Methadone and opiates
          5.Phencyclidine
          6.Hallucinogens
        V.Pharmacologic/Neuroleptic effects of drugs of abuse on infants
          1.Stimulants
          2.Depressants
          3.Hallucinogens
          4.Opiates
          5.In utero vs breast milk exposure

        VI.Transfer of DOA into human milk
          1.Published concentrations in breast milk
          2.Doses and possible neurologic effects on breastfed infants
          3.Long term outcome of infants

        VII.Should the mother breastfeed her infant?
          1.Suggested monitoring conditions of the mother
          2.Counseling the mother
          3.Counseling the physician
          4.Counseling Child Protective Services

    Pharmacology of Prolactin

      Session Objectives:


        The trainee will be able to:
          1. Describe the basic basic secretion of prolactin in breastfeeding mothers.
          2. Describe the implication of prolactin in breast milk production.
          3. Learn to evaluate levels of prolactin and their likely importance in lactation.

      Session Outline:

        I.Specifics of prolactin secretion in normal and breastfeeding mothers.
          1.Changes in prolactin levels as a function of pregnancy, and postpartum time periods.
          2.Effects of changes in prolactin levels and milk production.
            a.Management of insufficient prolactin level
            b.Learn medications that negatively effect milk prolactin release
        II.Describe the basic medications that effect prolactin release.
          1.Learn about metoclopramide (Reglan) and the studies on this medication.
          2. Learn about domperidone and the studies on this medication.
        III. Learn how to best manage a patient with insufficient prolactin levels.

      References:

      1. Brouwers JR, Assies J, Wiersinga WM, Huizing G, Tytgat GN. Plasma prolactin levels after acute and subchronic oral administration of domperidone and of metoclopramide: a cross-over study in healthy volunteers. Clin Endocrinol (Oxf) (1980) 12:435-440.
      2. Caminiti F, De Murtas M, Parodo G, Lecca U, Nasi A. Decrease in human plasma prolactin levels by oral prostaglandin E2 in early puerperium. J Endocrinol (1980) 87:333-337.
      3. Canales ES, Garcia IC, Ruiz JE, Zarate A. Bromocriptine as prophylactic therapy in prolactinoma during pregnancy. Fertil Steril (1981) 36:524-526.
      4. Canales ES, Garrido JT, Zarate A, Mason M, Soria J. Effect of ergonovine on prolactin secretion and milk let-down. Obstet Gynecol (1976) 48:228-229.
      5. Cox DB, Owens RA, Hartmann PE. Blood and milk prolactin and the rate of milk synthesis in women. Exp Physiol (1996) 81:1007-1020.
      6. Hill PD, Chatterton RT, Jr., Aldag JC. Serum prolactin in breastfeeding: state of the science. Biol Res Nurs (1999) 1:65-75.
      7. Hofmeyr GJ, Van Iddekinge B, Blott JA. Domperidone: secretion in breast milk and effect on puerperal prolactin levels. Br J Obstet Gynaecol (1985) 92:141-144.
      8. Webster J, Piscitelli G, Polli A, D'Alberton A, Falsetti L, Ferrari C et al. Dose-dependent suppression of serum prolactin by cabergoline in hyperprolactinaemia: a placebo controlled, double blind, multicentre study. European Multicentre Cabergoline Dose-finding Study Group. Clin Endocrinol (Oxf) (1992) 37:534-541.