Wendy Jones explains that one of the biggest problems with medications for expectant and breastfeeding mothers, whose offspring may be affected by what they take, is that there is so little research done. It is almost impossible to set up an ethical trial that might affect the health and development of unborn babies and infants. As a result, manufacturers refuse to take responsibility for this research. We have all seen the disclaimer: "if pregnant or breastfeeding, consult your doctor or pharmacist." In this way the manufacturer passes the responsibility to the prescriber or retailer. This is confusing for a mother, when her doctor, pharmacist, and the patient information leaflet with her medicine all tell her something different. Dr Jones quotes studies that have shown that mothers are reluctant to believe reassurances about the safety of drugs in breastmilk. This leads to a blanket over-caution, which can harm the breastfeeding relationship, or mean the mother not receiving treatment, sometimes unnecessarily. This can have a negative impact on her health, or mean she stops breastfeeding when she wants to continue. Pregnant women are also often expected to go without help for various conditions, which treats them as reproductive vessels, rather than persons.
One problem is that sometimes health care professionals do not understand or appreciate the nature of breastfeeding. Over caution may lead them to tell a mother that she must stop breastfeeding altogether, or express and discard her milk for a period of time. While this may be the case, Dr Jones finds that this often happens when it is not necessary. We must not fail to understand that breastfeeding is not like formula feeding. Stopping breastfeeding can have a big impact on a mother and her child. buying artificial milk costs money. There will be an emotional impact for both parties. Treatment for post natal depression must take this into account: treatments such as CBT that require separation of mother and child are not suitable and might put the mother off getting help; breastfeeding itself has an impact on depression which should be taken into account. Artificial milk is not the same product as breastmilk, and the baby may not react well to it, as well as missing out on all of the advantages of breastmilk, such as immunological factors. A mother told to express and discard her milk may give her baby a bottle, which can lead to latch issues and nipple confusion, threatening the breastfeeding relationship. She may not have a store of expressed breastmilk, and may delay treatment until she has created one, which may affect her health. She would also be at risk of blocked ducts and mastitis because expressing is not he same as breastfeeding for her breasts, and she may not express frequently enough, as it is inconvenient. This could also create a supply problem. Where mothers hear poor information on breastfeeding from their care givers they come to doubt their medical opinion and look elsewhere for help, which could be dangerous. Appropriate breastfeeding knowledge from the HCP can prevent this.
There are several different situations in which mothers might need to know about the safety of their medication. Some are straightforward and predictable, such as in pregnancy and breastfeeding, but some are not. Mothers with preexisting conditions might arrive at their due date with no idea whether their medication is suitable for breastfeeding. As breastfeeding continues for longer, the issue of breastfeeding mothers receiving fertility treatment might arise. Tandem feeding mothers have babies who might be affected by medications in different ways. Some mothers have chronic conditions, and sometimes treatment is urgent. All of these are situations in which specialist information is required. Dr Jones quotes NICE Maternal and Child Nutrition Guideline PH11 (2008) recommending that prescribers/dispensers consult supplementary sources; support continuation of breastfeeding where possible; recognise the consequences of ending breastfeeding for mother and child. I.e. the BNF is not sufficient reference. Dr Jones points to the LactMed database and the UKMI specialist centre for addressing the safety of drugs in breastmilk, among others, as appropriate resources for HCPs. She finds that too many health professionals will not go beyond the BNF, partly because they do not value breastfeeding over artificial milk feeding. In practice most health care professionals receive very little training in this area, and their thoroughness tends to depend on their own experiences of breastfeeding. Additional training in this subject for GPs has had very low take up, and those who did take it up were mostly women and parents of breastfed children. Adult hospital wards are not set up to accommodate expression and milk storage, and may be hostile to it. I was particularly struck by Dr Jones example of hospital policies on MRIs and breastfeeding, which stipulate a 24 hour cessation of breastfeeding, directly opposing professional guidelines and the facts about the half lives of the medications.
So what are Dr Jones' conclusions? "When I think about what I want doctors to know about breastfeeding and the safety of drugs in breastmilk, it boils down to this:
- how to signpost to a local breastfeeding specialist
- how to access databases and expert books on the safety of drugs in breastmilk."