New Mexico
Breastfeeding Task
Force 21st Annual
Conference:
Innovative
Approaches to
Lactation
Management
March 4-7, 2015
Emilie Sebesta, MD
Breastfeeding, Maternal
Medications, and Substance Use
Objectives
 (1) Understand the basics of drug transfer into
human milk
 (2) Know where to look or whom to contact with
questions about a particular drug and breastfeeding
 (3) Be familiar with one hospital’s breastfeeding and
substance abuse guidelines
AAP Clinical Report: The Transfer of Drugs and Therapeutics Into Human
Breast Milk: An Update on Selected Topics
 Few medications contraindicated or with adverse effects on infants
 Information for providers is needed but may not be available.
 Proposed new FDA rules will create a section called Lactation with
subsections:
1.
2.
3.
Risk Summary
Clinical Considerations
Data
AAP Committee on Drugs, “The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update
on Selected Topics,” http://pediatrics.aappublications.org/content/early/2013/08/20/peds.2013-1985
Transfer of Drugs into Human Milk
 When determining if a maternal drug is safe for
breastfeeding, the 3 most important factors are

the volume of distribution (Vd)

the percentage of maternal protein binding (PB)

the molecular weight (MW)
Nice, FJ, Luo, AC, “Medications and Breast-feeding: Current Concepts,” JAPhA, 52:1, 86-94 (2012).
Volume of Distribution (Vd)
distribution
milk levels
Vd of 1-20 L/kg generally
compatible
Nice, FJ, Luo, AC, “Medications and Breast-feeding: Current Concepts,” JAPhA,
52:1, 86-94 (2012).
Protein Binding
Protein
Binding
Milk
levels
PB >90% usually
compatible
Nice, FJ, Luo, AC, “Medications and Breast-feeding: Current Concepts,” JAPhA,
52:1, 86-94 (2012).
Molecular Weight
Molecular
Weight
Milk
levels
Drugs with MWs <200 pass
easily into the milk. Drugs with
MWs >800 are more compatible
with breast-feeding (e.g.,
insulin)
Nice, FJ, Luo, AC, “Medications and Breast-feeding: Current Concepts,” JAPhA,
52:1, 86-94 (2012).
Transfer of Drugs into Human Milk
 Other pharmacokinetic factors that influence if a maternal drug is safe for
breastfeeding include:
 pH: Because breast milk is more acidic than plasma, drugs with a high pH
may concentrate more in breast milk than plasma.

logP: Drug molecules that are water soluble are less likely to concentrate in
the breast milk.

t ½ : drugs with shorter half-life reach a low plasma concentration more
frequently and allow the mother to time her feedings to correspond to trough
levels. (Cocaine & PCP and their metabolites have very long half-lives and
are particularly dangerous to infants.)
Nice, FJ, Luo, AC, “Medications and Breast-feeding: Current Concepts,” JAPhA, 52:1, 86-94
(2012).
Transfer of Drugs into Human Milk

Tmax: time from administration when drug level is highest in mother’s
plasma.

Milk-to-plasma ratio (M/P) of less than 1 is usually safe to breastfeed.

Relative infant dose (RID) infant weight–adjusted dose supplied via
breast milk divided by maternal weight–adjusted dose. RID < 10% of
maternal dose generally safe for breast-feeding
Nice, FJ, Luo, AC, “Medications and Breast-feeding: Current Concepts,” JAPhA, 52:1, 86-94
(2012).
The special case of codeine and hydrocodone
 Codeine and hydrocodone should be avoided by nursing
mothers
 A fatality has been noted in an infant of a mother with
ultrarapid metabolism
 Unexplained apnea, bradycardia, cyanosis, and sedation
have been reported in nursing infants of mothers
receiving codeine.
 Given the reduced clearance of hydrocodone in neonates
and the adverse events observed in ultrarapid
metabolizers of codeine, caution is advised for use of
codeine and hydrocodone in both the mother and
nursing infant.
AAP Committee on Drugs, “The Transfer of Drugs and Therapeutics Into Human Breast
Milk: An Update on Selected Topics,”
http://pediatrics.aappublications.org/content/early/2013/08/20/peds.2013-1985
Tips for reducing a baby’s exposure


Avoid nursing at times of peak drug concentrations in milk.
Nursing before a dose may avoid peak drug concentrations.
This works best for drugs with short half-lives.
Administer the drug before the infant’s longest sleep period.
This will minimize the infant’s dose and is useful for longacting drugs that can be given once daily.
Medications with Absolute Contraindication for
Breastfeeding
 Radioactive Iodine (131I)
 May increase baby’s risk of thyroid cancer later in life
 Mom should wean several weeks before receiving because
iodine will preferentially deposit in active breast tissue
increasing mother’s risk of breast cancer
 Most chemotherapy
 BUT radiation therapy is okay though if being
directed at a breast for breast cancer, milk
production may decrease in that breast.
Resources to Look up Drugs/Medications
 Best!
 Drugs and Lactation Database (LactMed) - A peer-reviewed and fully
referenced database of drugs to which breastfeeding mothers may be exposed.
Among the data included are maternal and infant levels of drugs, possible effects
on breastfed infants and on lactation, and alternate drugs to consider.
http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT

Hale’s Medication and Mothers’ Milk, 2014 – An excellent book and app
may be purchased. Has great tables/appendices looking at contrast materials,
vaccines, chemotherapeutic agents, and OTC medications.
 Also
 AAP Committee on Drugs, “The Transfer of Drugs and Other
Chemicals Into Human Milk” Pediatrics 2001; 108; 776.

AAP Committee on Drugs, “The Transfer of Drugs and Therapeutics
Into Human Breast Milk: An Update on Selected Topics,”
http://pediatrics.aappublications.org/content/early/2013/08/20/ped
s.2013-1985
Example: Bipolar Mother on Effexor
(Venlafaxine)
Pros:
-Volume of Distribution 3.8-11.2
L/kg(1-20 L/kg generally compatible)
-Relative Infant Dose 3-11% (<10%
generally safe)
Cons:
-Protein Binding 27%-30% (>90% safe)
-Relative Infant Dose 3-11% (<10%
generally safe
-Half life 3-7 hrs & 9-13 hrs for active
metabolite
-Milk to Plasma Ratio 2.75 (<1 generally
considered safe)
Example: Effexor (venlafaxine)

LactMed



Hale


“[N]o proven drug-related side effects have been reported. Breastfed infants, especially newborn or preterm
infants, should be monitored for excessive sedation and adequate weight gain if this drug is used during
lactation”
“[N]ewborn infants of mothers who took the drug during pregnancy may experience poor neonatal adaptation
syndrome as seen with other antidepressants such as SSRIs or SNRIs. Use of venlafaxine during breastfeeding
has been proposed as a method of mitigating infant venlafaxine withdrawal symptoms,[1] but only one
apparently successful case of this use has been reported.”
Rated “L3” = moderately safe
Reference Information from Insert

Newborns whose mothers took during pregnancy may experience
 Respiratory difficulty
 Poor feeding
 Temperature instability
 Vomiting
 Hypo or hypertonia
 Apnea
 Seizures
 Crying
Example: . . . And on Abilify (aripiprazole)
Pros:
-Volume of Distribution 4.9
L/kg(1-20 L/kg generally
compatible)
-Protein Binding >99% (>90%
safe)
-Relative Infant Dose 0.9%
(<10% generally safe)
Cons:
--Half life 75 hours
Example: Abilify (aripiprazole)

LactMed


Hale



“Limited information indicates that maternal doses of aripiprazole up to 15 mg daily produce low levels in milk”
Rated “L3” = moderately safe
“Several reports (personal communications) of somnolence have been reported to this author. The infant
should be monitored for somnolence.”
Reference Information from Insert

Newborns whose mothers took during pregnancy may experience
 Agitation
 Hper or hypotonia
 Somnolence
 Respiratory distress
 Feeding disorders
Example: Bipolar Mother on Effexor & Abilify
 Decision made to allow baby to breastfeed
 Baby seen in Newborn Clinic on DOL 5
 Mom feeding baby every 4-5 hours
 Weight down 15%
 Jaundiced, but not yet at light level
 Readmitted to hospital
 Lesson:
 More counseling
 Follow up sooner
Example: Mother with long history of depression
on Sertraline throughout pregnancy
Pros:
-Protein Binding 98% (>90% safe)
-Volume of Distribution >20 L/kg (120 L/kg generally compatible)
-Relative Infant Dose 0.2% (<10%
generally safe)
-Milk to Plasma Ratio 0.42-4.81
-Molecular Weight 342.7
Cons:
-Long Half life 13-45 hours
-Milk to Plasma Ratio 0.42-4.81 (<1
generally considered safe)
-Molecular Weight 342.7 (<200 likely to
pass easily into milk, >800 very safe)
Example: Sertraline
 Depression is common with a lifetime prevalence rate of
16.2%.
 Women are 1.7–2.7 times more likely to suffer from
depression than men.
 Estimates for rates of depression in pregnancy range
from 1% to 20%, depending on the classification used.
 Selective Serotonin Reuptake Inhibitors (SSRIs) are the
most common medications used for depression (and
anxiety) with an estimated use in 1.8-2.8% of
pregnancies.
Maternal use of SSRIs, SNRIs, and NaSSAs: practical recommendations during
pregnancy and lactation, Table 2, Arch Dis Child Fetal Neonatal Ed 2012;97:F472-F476
doi:10.1136/archdischild-2011-214239
Example: Sertraline
 According to a 2014 Cochrane Review looking at
treatment of postpartum depression:

There were very limited data on adverse effects experienced by
breastfed infants, with no long-term follow-up.
Antidepressant treatment for postnatal depression, Molyneaux, E, et al.,
Editorial Group: Cochrane Depression, Anxiety and Neurosis
Group,http://onlinelibrary.wiley.com.libproxy.unm.edu/doi/10.1002/14651858.CD002018.
pub2/full, 11 SEP 2014
Example: Sertraline

According to the AAP:

Most publications regarding psychoactive drugs describe the pharmacokinetics in
small numbers of lactating women with short-term observational studies of
their infants. In addition, interpretation of the effects on the infant from the small
number of longer-term studies is confounded by prenatal treatment or
exposure to multiple therapies. For these reasons, the long-term effect on the
developing infant is still largely unknown. (2013)

Among the agents considered to be least problematic were the tricyclic
antidepressants amitriptyline and clomipramine and the selective serotonin-reuptake
inhibitors paroxetine and sertraline. (2012)
The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics
Hari Cheryl Sachs & COMMITTEE ON DRUGS,
http://pediatrics.aappublications.org/content/early/2013/08/20/peds.2013-1985
AAP, Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3). Available at:
www.pediatrics.org/cgi/content/full/129/3/e827
Example: Sertraline
 According to LactMed, “most authoritative reviewers
consider sertraline one of the preferred antidepressants
during breastfeeding.”
http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/f?./temp/~lNb80V:1
Relative infant dose and available clinical data during
lactation for SSRIs, SNRIs, and NaSSAs
RID (%)
Selective serotonin reuptake inhibitor
Fluoxetin
6.5–11
Paroxetine
1.13–1.25
Sertraline
0.2
Fluvoxamine
1.34–1.38
Citalopram
4.4–5.1
Escitalopram
Serotonin-noradrenalin reuptake inhibitor
Venlafaxine
6.5
Noradrenergic and specific serotonergic antidepressants
Mirtazapine
±2
Available data (n)
Lactation
116
123
146
13
72
12
200
131
143
14
76
9
Discourage
Preference
Preference
Consider
Consider
Consider
10
15
Consider
10
9
Consider
Maternal use of SSRIs, SNRIs, and NaSSAs: practical recommendations during pregnancy and
lactation, Table 2, Arch Dis Child Fetal Neonatal Ed 2012;97:F472-F476 doi:10.1136/archdischild-2011214239
Serotonin Reuptake Inhibitor (SRI)-Related
Symptoms
 A variety of symptoms have been reported after prenatal
exposure to SSRIs and to a lesser extent to SNRIs and
NaSSAs:








Tremors
jitteriness
irritability
muscle tone regulation disorders
excessive crying
sleep disturbances
tachypnoea and
feeding problems
Maternal use of SSRIs, SNRIs, and NaSSAs: practical recommendations during pregnancy and
lactation, Table 2, Arch Dis Child Fetal Neonatal Ed 2012;97:F472-F476 doi:10.1136/archdischild-2011-214239
From: Neonatal Abstinence Syndrome After In Utero Exposure to Selective Serotonin Reuptake Inhibitors in
Term Infants
Arch Pediatr Adolesc Med. 2006;160(2):173-176. doi:10.1001/archpedi.160.2.173
Date of download: 11/5/2014
Copyright © 2014 American Medical
Association. All rights reserved.
Serotonin Reuptake Inhibitor (SRI)-Related
Symptoms
 Symptoms occur in approximately 30% of in utero exposed infants.
 Factors that may contribute to the likelihood of symptoms developing
include:





maternal dose and metabolism
specific SSRI use
individual drug clearance
genetic predisposition
prematurity
 Symptoms generally occur within 2 days after birth and are usually self-
limiting.
Levinson-Castiel R, Merlob P, Linder N, et al. Neonatal abstinence syndrome after in utero exposure to selective serotonin reuptake inhibitors in term infants. Arch
Pediatr Adolesc Med 2006;160:173–6.
Maternal use of SSRIs, SNRIs, and NaSSAs: practical recommendations during pregnancy and lactation, Table 2, Arch Dis Child Fetal Neonatal Ed 2012;97:F472F476 doi:10.1136/archdischild-2011-214239
Serotonin Reuptake Inhibitor (SRI)-Related
Symptoms
 Some now recommend monitoring all infants exposed to
SSRIs


For a minimum of 48 hours
Using Finnegan scoring (i.e., NAS scoring)
 “Breastfeeding is not contraindicated for SSRI
monotherapy, but follow-up for signs of NAS after
discharge is recommended.” (Levinson-Castiel)
Levinson-Castiel R, Merlob P, Linder N, et al. Neonatal abstinence syndrome after in utero exposure to selective serotonin
reuptake inhibitors in term infants. Arch Pediatr Adolesc Med 2006;160:173–6.
Maternal use of SSRIs, SNRIs, and NaSSAs: practical recommendations during pregnancy and lactation, Table 2, Arch Dis
Child Fetal Neonatal Ed 2012;97:F472-F476 doi:10.1136/archdischild-2011-214239
Example: Sertraline
 Mom continued to take 100 mg of sertraline daily throughout
pregnancy as discontinuing during prior pregnancy had resulted
in relapse into severe depression and need to restart medicine.
 Mother’s previous child experienced transient jitteriness
immediately after birth but otherwise had a normal newborn
course and normal development.
 This baby latched well immediately after birth and breastfed
exclusively without any SRI-related symptoms during 48 hour
hospital stay.
Example: Marijuana
Pros:
-Extensively bound to
plasma proteins with a PB
of 99.9% (>90% safe)
Vd 4-19 L/kg (1-20 L/kg
generally compatible)
-Predicted Relative Infant
Dose of 0.8% (<10% safe)
Cons:
-Highly lipophilic
-Milk to plasma ratio may
be up to 8:1 in heavy users
(<1 safe)
-Long half-life 25-57 hours
Example: Marijuana

AAP Committee on Drugs, “The Transfer of Drugs and Other Chemicals Into
Human Milk”
 “nursing mothers should not ingest drugs of abuse, because they are
hazardous to the nursing infant and to the health of the mother.”
 only 1 report in literature of an adverse effect of marijuana on nursing
infant but effect not mentioned.

2012 AAP Section on Breastfeeding Breastfeeding and the Use of Human
Milk
 “Maternal substance abuse is not a categorical contraindication to
breastfeeding,“ but
 “Street drugs such as PCP (phencyclidine), cocaine, and cannabis can be
detected in human milk, and their use by breastfeeding mothers is of
concern, particularly with regard to the infant’s long-term
neurobehavioral development and thus are contraindicated.”
Example: Marijuana

LactMed






Limited studies
One study found daily use might result in motor delay
Two studies found “occasional” use had no discernible effect
Studies” inadequate to rule out all long-term harm.”
“Marijuana use should be minimized or avoided by nursing mothers because it
may impair their judgment and child care abilities.
“Because breastfeeding can mitigate some of the effects of smoking and little
evidence of serious infant harm has been seen, it appears preferable to encourage
mothers who use marijuana to continue breastfeeding while minimizing infant
exposure to marijuana smoke and reducing marijuana use.”
http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/f?./temp/~GaIbPm:1
Example: Marijuana
 Medications & Mothers’ Milk 2014





L5 – Limited Data-Hazardous
“Cannabis should not be used during pregnancy or breastfeeding.”
“[T]here is increasing concern about the use of marijuana or other
cannabis products, in pregnant or breastfeeding mothers. Studies
continue to suggest that cannabis may produce long-term sequelae,
such as reduced cognition, and changes in mood and reward.”
“While the data on neurobehavioral effects of cannabis on infants
from breastfeeding mothers is limited, cannabis use in breastfeeding
mothers should be strongly discouraged.”
“For single or infrequent exposures, breastfeeding can continue after
24-48 hours. For daily continued use, mothers should be advised not
to breastfeed.”
Hale, T.W. and Rowe, H.E., Medications & Mothers’ Milk, 16th Ed. (2014).
Example: Marijuana

University of California San Diego Policy
“Mothers with known or suspected street drug or alcohol use will
be given the benefit of the doubt, educated about providing safe
milk for their infant, and followed closely.”
 There is “no need to discard milk, test the milk, or have the
mother refrain from breastfeeding.”


Stanford

No official policy. Their “practice tends to run along the lines of
[UNM’s], but each practitioner is left to decide for him/herself
how to manage these patients.” (personal correspondence with
medical director)
Example: Marijuana

Seton Hospital in Austin, TX



Discourages breastfeeding when the mother has used marijuana in the 12
weeks prior to birth. Quotes 2014 NEJM article on Adverse Effects of
Marijuana:
“Marijuana use has been associated with substantial adverse effects,
some of which have been determined with a high level of confidence;
these include addiction to marijuana and other substances, abnormal
brain development, progression to use of other drugs, schizophrenia,
depression or anxiety, diminished lifetime achievement, and others.”
Denver Health

Handout on “Marijuana and Your Baby” discusses potential effects on
mothers and their babies and “strongly advise[s] that marijuana not be
mixed with pregnancy, breastfeeding, or parenting.”
Why do Hospitals Need a Breastfeeding &
Substance Abuse Guideline?
 Inconsistency between practitioners
 Nurses ask for guidance
 Babies of mothers with substance use may be at
increased risk for child abuse



NAS babies more irritable
Mothers often lack resources, support
Breastfeeding shown to reduce risk of abuse
 Babies of mothers with substance use may have
increased risk of poorer neurodevelopmental
outcomes

Breastfeeding may improve neurodevelopmental outcomes
Breastfeeding Generally Supported
 Mothers with a history of occasional use of alcohol or marijuana and
who:



quit when they discovered they were pregnant in the first or second trimester or
continued to use occasionally, i.e.., small amounts and not every day, and
plan not to drink alcohol or smoke marijuana while they are breastfeeding or plan
only to use small amounts and not every day (i.e., occasional use vs. abuse).
 Mothers with a known history of substance abuse during the current
pregnancy and:




urine toxicology screen is negative at delivery & in 90 days prior to delivery,
she indicates she does not intend to use while breastfeeding her baby, and
she has received consistent prenatal care starting in the first half of her pregnancy.
Mothers using methadone or buprenorphine and


Not using other drugs of abuse
Enrolled in a substance abuse program
Marijuana

A maternal or infant urine toxicology screen positive for THC
at delivery should not alone preclude breastfeeding if
The provider has reason to believe the mother’s use is occasional,
 Documents reasons for believing the mother’s use is occasional and
therefore the benefits of breastfeeding outweigh the potential risks of
the infant’s exposure to marijuana in the breast milk, and
 Counsels mother regarding the potential effects of marijuana on her
infant and her ability to care for her infant and encourages her to quit.


There is little evidence regarding the effect of maternal marijuana
use and breastfeeding. What evidence there is suggests that the
risk would only be significant when the mother is a “heavy user”
of marijuana.

See Djulus, et al., Nice & Luo, LactMed, ABM, and AAP Committee on
Drugs.
Marijuana
 Approximately 2.5% of women admit to using marijuana during
pregnancy.
 Prenatal exposure to THC may effect endocannabinoid-mediated
neuronal maturation, disrupt developing neurotransmitter systems,
and interfere with maturation of the dopaminergic system and
serotonin receptors, which could lead to an increased risk of
neuropsychiatric disorders, such as drug addiction, schizophrenia and
depression.
 “Whether these changes are implicated in the future risk of addictive
behaviours and depression in the human is as yet uncertain.”
Jaques, SC, “Cannabis, the pregnant woman and her child: Weeding out the myths,” J. Perinat. (2014), 1-8.
Marijuana
 “[S]pecific recommendations with respect to breast feeding while
using cannabis are hampered by the lack of substantial and
definitive studies.”
 “Depending on family circumstances, the benefits of breast feeding,
even with continued cannabis use, may outweigh the negative sideeffects, especially in infrequent cannabis users. Each institution
should work towards a policy of ensuring best practices for their
particular population of cannabis users.”
Jaques, SC, “Cannabis, the pregnant woman and her child: Weeding out the myths,” J.
Perinat. (2014), 1-8.
Volkow ND et al. N Engl J Med 2014;370:2219-2227.
Marijuana
 “There is inadequate evidence to make a statement about the isolated use of
marijuana in breast-feeding mothers. The studies that address this issue are
confounded by the fact that few women have isolated use during breast-feeding
in the absence of additional prenatal use of marijuana.”
 Based on 2 large cohorts, “there may be some effects on visuoperceptual ability,
reasoning and attention in older children, [but] the association was statistically
significant only with prolonged, heavy maternal use (>5 joints per week
throughout pregnancy and breast-feeding).”
 “Based on these findings, mandatory reporting of marijuana use during [] or
breast-feeding do not seem medically warranted. A consistent message of
“breast is best” seems appropriate for mothers who continue to use marijuana
while breast-feeding.”
Hill, M & Reed, K, “Pregnancy, Breast-feeding, and Marijuana: A Review Article,” Obstetrical & Gynecological
Survey. 68(10):710-718, October 2013.
Breastfeeding Generally Discouraged

In a mother with a known history of substance abuse
during the current pregnancy and
Mother’s urine toxicology screen is positive at time of delivery or in 30
days prior to delivery, or
 Mother admits to use of illicit substance or non-prescribed opiate at
the time of delivery or in 30 days prior to delivery, or
 Mother did not receive prenatal care during this pregnancy.


Exceptions permitted with
chart documentation of the rationale for the exception and
 written order
 may be appropriate to “pump and dump” until the drugs are cleared
and to check weekly maternal UDMs over the first month or longer

Breastfeeding Discretionary
 In the 30-90 day period prior to delivery mother admits to use or has a positive
urine toxicology screen and provider believes this is
 Limited relapse
 Mom not likely to use upon discharge
 Mother only obtained sobriety in an inpatient setting, including incarceration
 When deciding whether to encourage/support a mother’s decision to breastfeed
in the hospital, providers should consider:




Mother’s history of drug use/abuse
Mother’s participation in substance abuse treatment program
Mother’s behavior in hospital
Providers should try to talk with mother’s prenatal providers
regarding risk of continued abuse.
Provider Counseling
 Whether a provider is encouraging or discouraging breastfeeding
in a woman with a history of substance use or abuse, he or she
must counsel the mother on the possible harm to her baby if she
breastfeeds and continues to use illicit substances or nonprescribed opiates or is a heavy user of alcohol or marijuana,
including but not necessarily limited to:

mother being impaired in her ability to care for her infant.

baby becoming sleepy or agitated or having difficulty sleeping depending on the
drug.

the possibility of long-term effects on her baby’s neurobehavioral development.

the possibility of legal repercussions if baby is found to be positive for an illicit
substance or non-prescription opiate.
What to do if you’re not sure what to do
Err on the side of letting
the mother breastfeed,
let her know the plan
might change, and
document this, as well
as the final decision by
mother’s and/or baby’s
providers, in the baby’s
chart.
References

Jaques, SC, “Cannabis, the pregnant woman and her child: Weeding out the myths,” J.
Perinat. (2014), 1-8.

Volkow, ND, et al., “Adverse Health Effects of Marijuana Use,” N Engl J Med 2014;
370:2219-2227.

Hale, TW, Medications and Mothers’ Milk, 16th Edition, 2014.

Hill, M & Reed, K, “Pregnancy, Breast-feeding, and Marijuana: A Review Article,”
Obstetrical & Gynecological Survey. 68(10):710-718, October 2013.

AAP Committee on Drugs, “The Transfer of Drugs and Therapeutics Into
Human Breast Milk: An Update on Selected Topics,”
http://pediatrics.aappublications.org/content/early/2013/08/20/peds.20131985

AAP Section on Breastfeeding, “Breastfeeding and the Use of Human Milk”, Pediatrics,
129:3 (2012).

The Academy of Breastfeeding Medicine Protocol Committee, “ABM Clinical Protocol
#21: Guidelines for Breastfeeding and the Drug-Dependent Woman,” Breastfeeding
Medicine, 4:4 (2009).
References
 Nice, FJ, Luo, AC, “Medications and Breast-feeding: Current Concepts,”
JAPhA, 52:1, 86-94 (2012).
 Garry, A, et al., “Cannabis and Breastfeeding,” J. Toxicol. 2009; 2009:596149.
 Djulus, J, Moretti, M, Koren, G, “Marijuana Use and Breastfeeding,” Canadian
Family Physician, 51:349-350 (2005).
 AAP Committee on Drugs, “The Transfer of Drugs and Other Chemicals Into
Human Milk” Pediatrics 2001; 108; 776.
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