Medication Safety in Breastfeeding.

Breastfeeding is universally recognized as the preferred method of infant nutrition, but is sometimes abbreviated because of fear of harm to the infant from maternal medication. The amount of medication that enters breast milk varies based on the maternal serum concentration and the pharmacologic properties of the medication. When prescribing medications for a breastfeeding patient, those with the lowest risk to the infant should be selected, and dosing should be before the infant's longest sleep interval. Prescribers should use current, accurate resources. LactMed is a convenient, government-sponsored, authoritative resource that lists safety information for many medications and is available free online. When mental health conditions occur during lactation, priority should be given to effectively treating the mother, often with medications that were effective during pregnancy. Most antidepressants are compatible with breastfeeding. Stimulant medications may decrease milk supply. Insulin, metformin, and second-generation sulfonylureas are generally preferred to treat diabetes mellitus during breastfeeding, but newer agents require caution because they have not been studied in lactation. Inhaled and nasal treatments for asthma and allergic rhinitis are unlikely to affect breastfed infants. Acetaminophen and ibuprofen are preferred analgesics during lactation. Maternal opioid use can cause infant sedation. Herbal supplements are concerning for risk of impurities and lack of study of effects on breastfed infants. Nonhormonal and progestin-only contraceptives are preferred over combination oral contraceptives. Contrast for computed tomography or magnetic resonance imaging is not concerning during lactation, but use of radiopharmaceuticals, such as iodine 131, can accumulate in the lactating breast and increase risk to the infant.

Vaccine Adverse Events: Separating Myth from Reality.

Vaccines are one of the most successful medical advances in modern times. Most vaccine-preventable illnesses are unfamiliar to modern parents. Because of this, parents are increasingly questioning the necessity of immunizing their children, especially because no vaccine is completely free of adverse effects or the risk of complications. Family physicians should be aware of the risks and benefits of recommended immunizations. Thimerosal is currently used only in multidose vials of influenza vaccine, and exposure through vaccines is not associated with adverse neurologic outcomes. The measles, mumps, and rubella vaccine is not associated with autism. Vaccines are associated with local reactions, such as pain and erythema. The rotavirus vaccine minimally increases the rate of intussusception, whereas other vaccines minimally increase the risk of syncope. Although immunization with the human papillomavirus vaccine is recommended for all boys and girls, vaccination rates remain low. Physicians should guide parents to credible resources if they are considering vaccine refusal. If a recommended vaccine is refused, proper documentation is essential. The Vaccine Adverse Event Reporting System and National Vaccine Injury Compensation Program track adverse events and allow compensation for documented harms from vaccinations.

Office-based patient education decreases non-emergent emergency department visits.

Emergency department (ED) utilization for non-emergent conditions is costly and inefficient. We evaluated whether a simple office-based intervention could encourage patients with non-emergent conditions to be seen in the office instead of in the ED. The study compared ED utilization of patients of the intervention family medicine clinic to those of the nearby internal medicine clinic. The intervention consisted of educational posters in the family medicine clinic and follow-up letters after non-emergent ED visits. We measured ED use for the two clinics before, during, and after the intervention. We found a statistically significant decrease in ED utilization for the patients of the intervention clinic. For the intervention office with approximately 1100 patient encounters per month, this resulted in a reduction of approximately 40 ED visits per month. If these results are replicated, this simple intervention could result in cost savings and more efficient patient care.

Management of mastitis in breastfeeding women.

Mastitis occurs in approximately 10 percent of U.S. mothers who are breastfeeding, and it can lead to the cessation of breastfeeding. The risk of mastitis can be reduced by frequent, complete emptying of the breast and by optimizing breastfeeding technique. Sore nipples can precipitate mastitis. The differential diagnosis of sore nipples includes mechanical irritation from a poor latch or infant mouth anomalies, such as cleft palate or bacterial or yeast infection. The diagnosis of mastitis is usually clinical, with patients presenting with focal tenderness in one breast accompanied by fever and malaise. Treatment includes changing breastfeeding technique, often with the assistance of a lactation consultant. When antibiotics are needed, those effective against Staphylococcus aureus (e.g., dicloxacillin, cephalexin) are preferred. As methicillin-resistant S. aureus becomes more common, it is likely to be a more common cause of mastitis, and antibiotics that are effective against this organism may become preferred. Continued breastfeeding should be encouraged in the presence of mastitis and generally does not pose a risk to the infant. Breast abscess is the most common complication of mastitis. It can be prevented by early treatment of mastitis and continued breastfeeding. Once an abscess occurs, surgical drainage or needle aspiration is needed. Breastfeeding can usually continue in the presence of a treated abscess.

The newborn foot.

An examination of the feet is an essential component of an evaluation of a newborn. A thorough examination can be performed quickly. Despite its small size, the newborn foot is a complex structure. Most deformities can be diagnosed easily with physical examination alone, using few diagnostic studies. A thorough examination includes assessment of vascular, dermatologic, and neurologic status of the lower extremities, and observation, palpation, and evaluation of joint range of motion in both feet. Common newborn foot abnormalities include metatarsus adductus, clubfoot deformity, calcaneovalgus (flexible flatfoot), congenital vertical talus (rigid flatfoot), and multiple digital deformities-polydactyly, syndactyly, overlapping toes, and amniotic bands. Most treatments include conservative measures, such as observation, stretching, and splinting, which can be performed easily in the family medicine setting. Cases that require surgical correction should be referred to a subspecialist with expertise in correcting lower extremity deformities in children. When surgery is indicated, procedures generally are postponed for six to nine months so that the child will better tolerate anesthesia.

Heparin-induced thrombocytopenia occurring after discontinuation of heparin.

BACKGROUND: Heparin-induced thrombocytopenia is caused by antibody formation to heparin-platelet factor 4 complexes. It typically develops 5 to 14 days after the initiation of heparin, but it can occur up to 3 weeks after the patient stops taking it. Early recognition by monitoring platelet counts during heparin therapy can decrease associated mortality and morbidity. METHODS: A case is described of a patient with severe morbidity as a result of heparin-induced thrombocytopenia. The medical literature was searched using the key words "heparin/adverse effects" and "thrombocytopenia." RESULTS AND CONCLUSIONS: The severe morbidity and potential mortality associated with heparin-induced thrombocytopenia are caused mainly by thrombosis. If it is suspected, all heparin products should be immediately stopped. Platelet counts usually return to normal after the heparin is discontinued. Approximately 50% of patients with heparin-induced thrombocytopenia develop thrombotic events. Patients should receive anticoagulation with agents other than heparin or low molecular weight heparin. As early detection of heparin-induced thrombocytopenia seems to improve outcome, it is recommended that all patients on heparin should have frequent monitoring of platelet counts.