Is it safe to breastfeed while taking methylphenidate?

QUESTION: My patient has narcolepsy and is currently breastfeeding her 3-month-old infant. Lately she has had difficulties adjusting to caring for her baby, especially staying alert with the demands of breastfeeding. If she starts taking methylphenidate again, should I advise her to switch to formula? ANSWER: Methylphenidate is excreted in breast milk only in small amounts, and to date there have been no reports of breastfed infants demonstrating any adverse effects. Based on the available data, methylphenidate appears to be compatible with breastfeeding; however, the long-term neurodevelopmental effects have not been adequately studied.

Fluconazole exposure during pregnancy.

QUESTION: One of my patients has just learned that she is 8 weeks pregnant. She took a 150-mg dose of fluconazole 2 weeks ago for the treatment of vaginal candidiasis and she is worried about the effect on her child and pregnancy. Can I reassure her? ANSWER: Short-term and low-dose fluconazole exposure, such as that indicated in the treatment of vaginal candidiasis, is not expected to increase the overall risk of major congenital malformations.

Fluconazole use during breastfeeding.

QUESTION: I have a patient with persistent breast and nipple thrush. Other therapies have failed, so I have decided to treat her with a loading dose of 400 mg of oral fluconazole followed by 100 mg twice daily for at least 2 weeks. Is there any need for her to interrupt breastfeeding during this treatment? ANSWER: Available data regarding fluconazole use during breastfeeding are reassuring. Fluconazole is also used in the treatment of fungal diseases in infants and has a good safety profile. Therefore, there is no need to interrupt breastfeeding when a mother is treated with fluconazole.

Cocaine abuse during pregnancy.

Cocaine abuse during pregnancy is a significant public health problem but is infrequently discussed between physicians and patients. The impact of in utero cocaine exposure on pregnancy and the baby has received significant media attention in preceding decades because of fears of teratogenicity, long-term health consequences, and poor cognitive and neurodevelopmental outcomes. We sought to review the medical literature examining these phenomena. We identified risks to the pregnancy and baby in women abusing cocaine during pregnancy. These include preterm birth, placenta-associated syndromes (e.g., placental abruption, preeclampsia, and placental infarction), and impaired fetal growth. Long-term neurodevelopmental and cognitive deficits include (but are not limited to) poorer language development, learning and perceptual reasoning, behavioural problems, and adverse effects on memory and executive function. However, these results should be interpreted cautiously because cocaine abuse may be accompanied by many other maternal and sociodemographic risk factors, so it is difficult to ascertain the effect of cocaine alone. Therefore, it is critical to counsel patients about potential risk, and perhaps more importantly, to treat addiction and to better understand, and advocate for improvements to, these patients' high-risk environment.

Bien que la consommation de cocaïne pendant la grossesse constitue un problème de santé publique considérable, elle ne fait que peu fréquemment l'objet de discussions entre les médecins et leurs patientes. Les effets de l'exposition in utero à la cocaïne sur la grossesse et l'enfant se sont mérités une attention médiatique considérable au cours des dernières décennies, en raison de préoccupations au sujet de la tératogénicité de la cocaïne, de ses conséquences à long terme sur la santé et de son influence sur l'obtention de piètres issues cognitives et neurodéveloppementales. Nous avons cherché à analyser la littérature médicale examinant ces phénomènes. Nous avons identifié des risques pour la grossesse et l'enfant attribuables à la consommation de cocaïne pendant la grossesse. Parmi ces risques, on trouve l'accouchement préterme, des syndromes associés au placenta (p. ex. décollement placentaire, prééclampsie et infarctus placentaire) et l'altération de la croissance fœtale. Parmi les déficits cognitifs et neurodéveloppementaux à long terme, on trouve (entre autres) des difficultés quant au développement langagier, à l'apprentissage et au raisonnement perceptif, des problèmes comportementaux et des effets indésirables sur la mémoire et la fonction exécutive. Toutefois, ces résultats devraient être interprétés avec prudence, puisque la consommation de cocaïne pourrait s'accompagner de nombreux autres facteurs de risque maternels et sociodémographiques; il est donc difficile de déterminer l'effet qui est seulement attribuable à la cocaïne. Ainsi, il est d'une importance cruciale de conseiller les patientes au sujet des risques potentiels d'une telle pratique et, ce qui est peut-être encore plus important, d'assurer la prise en charge de l'assuétude et de mieux comprendre les conditions de vie à risque élevé de ces patientes (et de promouvoir la mise en œuvre de mesures permettant de les améliorer).

Sugar substitutes during pregnancy.

QUESTION: I have a pregnant patient who regularly consumes sugar substitutes and she asked me if continuing their use would affect her pregnancy or child. What should I tell her, and are there certain options that are better for use during pregnancy? ANSWER: Although more research is required to fully determine the effects of in utero exposure to sugar substitutes, the available data do not suggest adverse effects in pregnancy. However, it is recommended that sugar substitutes be consumed in moderate amounts, adhering to the acceptable daily intake standards set by regulatory agencies.

Using nitrofurantoin while breastfeeding a newborn.

QUESTION: My patient has a urinary tract infection and is currently breastfeeding. Her son is only 3 weeks old. Is nitrofurantoin a safe antibiotic for treatment? ANSWER: The use of nitrofurantoin in breastfeeding mothers is generally safe, as only small amounts transfer into the breast milk. Despite the lack of documented reports, there is a risk of hemolytic anemia in all newborns exposed to nitrofurantoin owing to their glutathione instability, especially in infants with glucose-6-phosphate dehydrogenase deficiency. Although some suggest that nitrofurantoin be avoided in infants younger than 1 month, studies have noted that glutathione stability might be established by the eighth day of life. In infants younger than 1 month, an alternative antibiotic might be preferred; however, if an alternative were not available, the use of nitrofurantoin would not be a reason to avoid breastfeeding. In any such case the suckling infant should be monitored by his or her physician.

Safety of tacrolimus in pregnancy.

QUESTION: I have a 30-year-old patient who had a kidney transplant 2 years ago. She is now planning a pregnancy. She has been treated with tacrolimus since her transplant. Will it be safe for the fetus if she continues to take it during the pregnancy or should she switch to a different antirejection medication? ANSWER: If your patient is stable while taking tacrolimus, there is no reason to switch. The current available information does not suggest that tacrolimus increases the risk of major congenital malformations above the baseline risk in the general population. Premature birth and low birth weight are often reported in this population; however, these effects are frequently reported in pregnant transplant patients treated with other immunosuppressant agents and probably reflect the effects of the maternal condition. As there are some reports of hyperkalemia and renal impairment in infants exposed to tacrolimus in utero, kidney function and electrolytes should be monitored in exposed neonates.

Consuming non-alcoholic beer and other beverages during pregnancy and breastfeeding.

QUESTION: An increasing number of my patients are asking about the safety of consuming non-alcoholic beer and other alcohol-free versions of alcoholic beverages during pregnancy and breastfeeding, as they believe that these drinks might be a "safer" alternative to regular alcoholic beverages. What are Motherisk's recommendations regarding these products? ANSWER: Such drinks might contain higher ethanol levels than what is indicated on their labels. As there is no known safe level of alcohol intake in pregnancy, abstinence from non-alcoholic beverages would eliminate any risk of fetal alcohol spectrum disorder. Although it is likely that moderate intake of non-alcoholic beverages would pose no harm to breastfed infants, briefly delaying breastfeeding after consumption of such drinks would ensure that the infant is not exposed to alcohol.

Safety of the newer class of opioid antagonists in pregnancy.

QUESTION: I have a patient recently confirmed to be 6 weeks pregnant. For the past 6 months she has been treated for an opioid addiction with buprenorphine-naloxone combination. Should I be concerned about her exposure to this drug combination up to this point of the pregnancy? Should I switch her medication to methadone now that she is pregnant? ANSWER: The limited data on buprenorphine exposure during pregnancy show no increased risk of adverse outcomes in the newborn. There are limited data on naloxone exposure during pregnancy; however, oral use is not expected to be associated with an increased risk of adverse pregnancy outcomes. Physicians treating pregnant women or women who become pregnant while they are stable taking buprenorphine-naloxone treatment are advised to continue this treatment but to consider transition to buprenorphine monotherapy.

Is it safe to use inhaled corticosteroids in pregnancy?

QUESTION: A healthy woman with mild to moderate asthma came to my clinic today after learning that she was pregnant. She inquired about continuing her inhaled corticosteroid (ICS) medication and whether there would be any risks to her unborn child if she were to do so. What would you advise? ANSWER: Given the published evidence, ICSs should be continued throughout pregnancy at low to moderate doses sufficient to control asthma symptoms and prevent exacerbations. However, caution must be taken with doses greater than 1000 µg/d (chlorofluorocarbon beclomethasone equivalent), although whether such doses cause adverse effects is currently still questionable. Patient education on proper ICS administration and adherence, including during the first trimester, must be ongoing. Well controlled asthma will reduce the need for higher ICS doses and possible exposure to systemic corticosteroids, and might decrease the risk of adverse pregnancy or perinatal outcomes.

Is caffeine consumption safe during pregnancy?

QUESTION: I have a pregnant patient who experienced a miscarriage in the past and who has asked me whether her consumption of 2 cups of coffee per day could have caused it. What should I tell her? ANSWER: There are conflicting data on the fetal safety of dietary caffeine consumption during pregnancy, particularly at levels of 300 mg/d or greater. Although it is difficult to assess the risk of spontaneous abortion with caffeine consumption, most of the data do not suggest an increased risk of adverse pregnancy, fertility, or neurodevelopmental outcomes with caffeine consumption of 300 mg/d or less from all sources. Therefore, consumption of 1 to 2 cups of coffee a day is not expected to be a concern.

Tdap vaccination during pregnancy to reduce pertussis infection in young infants.

QUESTION: What is the basis for the new recommendations to vaccinate pregnant women against pertussis after the first trimester? ANSWER: There have been outbreaks of epidemic proportions of pertussis, mostly among young infants who have not received sufficient passive immunity from their mothers. This strategy of vaccination during pregnancy aims at stopping these life-threatening epidemics.

Update on antidepressant use during breastfeeding.

QUESTION: Many of my patients who are diagnosed with postpartum depression want to continue breastfeeding. How safe are the newer antidepressant medications during breastfeeding? ANSWER: The newer antidepressants transfer into breast milk in low amounts and have not been associated with serious adverse events. Therefore, the antidepressant most effective for the woman should be considered.

Botulinum toxin type A in pregnancy.

QUESTION: My patient received 62 units of botulinum toxin type A (BTX-A) for facial lines. Two weeks later, she found out that she was pregnant. Will this cause any harm to her fetus? ANSWER: Botulinum toxin is not expected to be present in systemic circulation following proper intramuscular or intradermal injection. Moreover, BTX-A, which has a high molecular weight, does not appear to cross the placenta. From the 38 pregnancies reported in the literature, including women who had botulism poisoning during pregnancy, exposure to BTX-A does not appear to increase the risk of adverse outcome in the fetus.

Human papillomavirus vaccine and pregnancy.

UNLABELLED: QUESTION A: patient of mine who recently learned she was 6 weeks pregnant had received the recombinant human papillomavirus (HPV) quadrivalent vaccine at 4 weeks of gestation. She is quite worried about how this will affect her baby. What is known about the safety of the HPV vaccine during pregnancy? ANSWER: The HPV vaccine is generally not recommended for use in pregnant women. However, theoretically, because it is not a live vaccine, it is not expected to be associated with an increased risk. Also, information from the manufacturer's pregnancy registry and phase 3 clinical trials does not indicate an increased risk of fetal malformations or other adverse effects due to the vaccine.

Treating constipation during pregnancy.

QUESTION: Many of my patients experience constipation during pregnancy, even after increasing dietary fibre and fluids. Are there any safe treatments I can recommend to them? ANSWER: Although the recommended first-line therapy for constipation includes increasing fibre, fluids, and exercise, these are sometimes ineffective. Therefore, laxatives such as bulk-forming agents, lubricant laxatives, stool softeners, osmotic laxatives, and stimulant laxatives might be considered. Although few of the various types of laxatives have been assessed for safety in pregnancy, they have minimal systemic absorption. Therefore, they are not expected to be associated with an increased risk of congenital anomalies. However, it is recommended that osmotic and stimulant laxatives be used only in the short term or occasionally to avoid dehydration or electrolyte imbalances in pregnant women.

Health Canada advisory on domperidone should I avoid prescribing domperidone to women to increase milk production [corrected]?

QUESTION: I often prescribe domperidone to women as a galactagogue starting at a dose of 30 mg and increasing the dose as needed. In March of this year, Health Canada released an advisory warning of domperidone use and abnormal heart rhythms and sudden cardiac death. Should I cap doses at 30 mg or stop prescribing domperidone all together to these women? ANSWER: The Health Canada warning is based on 2 studies. The results of the studies are not directly applicable to breastfeeding and should not change the way you normally manage otherwise healthy breastfeeding women.

Smoking cessation therapy during pregnancy.

QUESTION: Despite being highly motivated to quit, many of my patients struggle with smoking cessation during pregnancy. Can you comment on the current treatment options and discuss their safety and efficacy during pregnancy? ANSWER: Given the considerable and well-documented adverse effects of antenatal smoking on mother and fetus, pharmacotherapy for smoking cessation should be considered. Available medications include nicotine replacement therapy, sustained-release bupropion, and varenicline. Nicotine replacement therapy and bupropion do not appear to increase the risk of major malformations; however, there is currently limited evidence on the use of varenicline during pregnancy. Given that these agents are only marginally successful in smoking cessation, their use should always be accompanied by behavioural counseling and education to maximize quit rates.

Maternal cocaine use during breastfeeding.

QUESTION: In my practice several patients have struggled with cocaine abuse during their pregnancies. One woman, now postpartum, wants to breastfeed her infant. Despite being abstinent for the final few months of her pregnancy, I am concerned about the potential adverse effects on her child if she happens to relapse. What is the current evidence about the risks of cocaine exposure during breastfeeding? ANSWER: Given the substantial benefits of breastfeeding for infant health and development, there is no reason for mothers who previously abused cocaine to avoid breastfeeding. It is important for the health care team to counsel patients both on the serious potential risks of cocaine exposure for babies and on the benefits of breastfeeding, to allow for an informed choice. Additionally, attempts should be made to estimate maternal commitment to breastfeeding and discontinuation of cocaine use, and to offer addiction counseling to mitigate the potential risks of infant cocaine exposure. It is paramount to minimize the risk to the infant, which would certainly include mothers ceasing use of cocaine while breastfeeding. For mothers who elect to breastfeed and use cocaine intermittently, breastfeeding should be delayed sufficiently after cocaine use to allow for drug elimination (approximately 24 hours).

Nausea and vomiting of pregnancy (NVP) and depression: cause or effect?

BACKGROUND: Both nausea and vomiting and depression are common conditions affecting women during pregnancy. Several studies have linked depression with nausea and vomiting of pregnancy (NVP); however, researchers were unable to determine whether depression was caused by NVP or by a pre-existing condition. OBJECTIVE: To determine whether NVP is associated with depression in women with no history of depression prior to pregnancy. STUDY DESIGN AND METHODS: This was a prospective, observational, longitudinal study. Women with no diagnosis of depression who contacted The Motherisk Program prior to becoming pregnant or were at < 6 weeks gestation were enrolled in the study. Each woman was interviewed at 8, 11, 18, 30 weeks gestation and at 6-18 weeks post-partum. At each interview, we administered the EDPS, Wellbeing and PUQE questionnaires and analyzed the data for correlation between depression and NVP. RESULTS: Data were analyzed obtained from 57 women. There were five EPDS scores ≥13 (one at baseline and two each at weeks 8 and 11) considered indicative of depression and 11 cases with PUQE scores ≥7, indicative of moderate-high severity of NVP. We did not find an association between high PUQE scores and high EPDS scores and conversely, there was no relationship between high EPDS scores and high PUQE scores. CONCLUSION: No association between depressive symptoms and NVP was observed; however, our sample size was very small and further studies could be done with a larger population of pregnant women.