Ask Dr. Hale

Dear Dr. Hale,
I am a lactation Counselor working in the hospital setting. Our labor and delivery floor has recently decided to switch from Duramorph for pain medication for our c-section moms to using Depodur. Do you have any information on breastfeeding? The company can only tell me that it has not been studied and they have no information. This medication requires 48 hours of 02 Sat monitoring and will give patients 48 hours of pain control. I am very concerned for my breastfeeding mothers. I am told it is a morphine derivitive and am hoping the rules of morphine will apply. Any info you can give me is greatly appreciated.
 
Depodur is just another prolonged release formulation of morphine. Not much difference.

Dear Dr. Hale,

I am often asked by our surgicenter about time restrictions and/or the need for pumping and discarding breastmilk after general anesthesia for such surgeries as tubal ligation at 3-6 months postpartum. I am surprised at the combinations of medications and am looking for guidance to sort through. The most recent received Fentanyl, Versed, Decadron, Zofran, Propofol, Sevoflurane and Rocuronium. I did look up each individual med both in your book and on LactMed site for help. But like the anesthesiologist of a prior posting, I am concerned about the combinations and synergistic actions. Would using the general assumption that in 5 half-lives a med is nearly gone from the system be adequate? What of those meds that have stages of half-lives. Thank you so much for your help and advice.
 
The problem with using half-lives is that while it is true that after 5 "elimination" half-lives, 98% of the drug is gone, the other truth is that with some of these drugs (Versed, Propofol, etc), within 15 minutes, they are virtually gone from the plasma compartment and stuck in your adipose and muscle tissue. This is called the 'redistribution half-life,' which is 7 minutes for Versed and 2 minutes for propofol...hence, plasma levels and therefore milk levels are exceedingly low.

The gases are no problem. They are gone within minutes.

I still suggest that as soon as a mom is awake, alert, and not sedated, most of these drugs have been eliminated, or at least moved to a peripheral compartment where they are doing little harm.



Dear Dr. Hale,
I work at busy hospital with 400 deliveries per month. What is the time frame for feeding after taking a 10 mg dose of vicodin for newborn infant? Should a mother pump and dump?
 
There is no time restraint if the baby is stable.

Vicodin (hydrocodone) is the most commonly used opiate in breastfeeding mothers, certainly in the USA.



Dear Dr. Hale,
We are seeing more moms at our WIC clinic who are on Methadone and breastfeeding. Are there any differences or guidelines in weaning for these moms versus moms not on Methadone?
The closest thing to a 'protocol' is by the Academy of Breastfeeding Medicine.

However, so little methadone is present in milk that they basically wean themselves after delivery. However, I'd still suggest that:

1) Weaning is not necessary at all in a methadone-treated woman. They can continue to take their medication and safely breastfeed as long as they want.

2) Should the mom want to discontinue breastfeeding, then she should probably do so over 3-4 weeks, just in case the baby has a touch of withdrawal.

Dear Dr. Hale,
I am interested in the safety of breastfeeding and the use of Opana, a pain med a patient is using.

We do not have any specific data on oxymorphone (Opana). Its just another opiate drug.

Oxymorphone is a strong analgesic used to relieve moderate-to-severe pain. Oxymorphone has identical uses to morphine in the treatment of pain, but oxymorphone does not possess antitussive activity as observed with morphine.  It is 8-10 times more potent as morphine on a weight basis. It has been reported to produce more nausea and vomiting, however.

Oral use is only 1/6 as potent as IM use, so much of it is probably taken up first pass by the liver.

I can't really advise you as to its safety in breastfeeding mothers.