Pharmacists can refer patients to their health-care professional and/or to a lactation consultant to review the patient’s technique and provide additional education. Pharmacists should assess the patient’s OTC and prescription medication lists associated with reduced milk supply. These could include estrogen-containing contraceptives, oral decongestants and antihistamines, nicotine use, and diuretics.9 Although complementary herbal products such as fenugreek and milk thistle to boost milk production are used by many patients, safety data on them is limited and their use should be discouraged.7-9 Furthermore, some herbal products may contain pesticides that may be harmful to the infant.
Pharmacists should encourage patients to apply a few drops of expressed breast milk to nipples after feeding and allowing the area to air dry. Over the counter options that can be applied directly to the nipples after feeding include purified lanolin and hydrogel dressings to promote healing. Patients should be triaged for self-care exclusions such as bacterial or fungal infection. Red flags for infection include fever, breast pain, and burning nipples with pain and redness. These patients should be referred to their health-care professional for evaluation.
Although mothers may be advised to discontinue breastfeeding if they are taking some medications or to stop taking medications while they breastfeed, this is not always necessary.5,8 The benefits of nursing need to be considered along with any risks associated with medication exposure. Pharmacists are best equipped to assess drug properties associated with increased exposure in breast milk, such as high bioavailability, small molecular weight, low serum protein binding, lack of ionization, high lipid solubility, or a long half-life.8-11 The timing and duration of the medication regimen also influences exposure to the infant. For example, the risk associated with a single dose treatment is much less than if the same product was administered daily for a week.
Pharmacists can develop a medication schedule for the patient that can minimize systemic infant exposure (Table 1). Patients can be instructed to take their medication immediately after feeding the baby so that the baby’s exposure is minimized. They can also collaborate with the mother’s health-care provider to identify medication formulations that minimize risk, such as switching from sustained release to immediate release or choosing a formulation with less systemic absorption such as a topical or inhaled product. Systemic exposure is also influenced by the infant’s age. Premature infants and or those with organ dysfunction may be more prone to systemic exposure compared to those born full-term.