To : Lyla
Re : Clotrimazole

Of the azole antifungal family, some are known to be more hepatotoxic than
others.  In pediatrics numerous studies have shown that the risk of elevated
liver enzymes is lowest with fluconazole, and slightly higher with
clotrimazole.  While the risk is relatively low,  it is nevertheless worth
mentioning.

I have for some time advocated the use of oral fluconazole as the better
choice for treating systemic and breast fungal infections, due to its low
milk levels and its rather limited hepatotoxicity,  and its FDA clearance in
infants 6 months and older.

Topically I generally prefer miconazole, simply because it is relatively
nontoxic to the liver,  cleared for pediatric use, and it is poorly
bioavailable orally.  For this reason, any left on the nipple and ingested
by the infant would be only minimally absorbed.  However, if the mom has
clotrimazole available or the physician prefers it, then I would not be
overly concerned about using it, if the mom uses it sparingly on the nipple.
Basically, if you can see it on the nipple, you've used too much.  I would
not necessarily advocate the chronic use of any of these azole members(month
after month).


To : Elaine
Re : Prozac

As for the use of Prozac in this patient,  the fact that this infant is
already 2 months old and has had no discernable side effects, it is more
likely that the risk of Prozac toxicity will diminish as the infant ages.
I am most concerned with Prozac's use in the first month or two,
particularly in those women who have used it during pregnancy.   As for
converting her to Zoloft, that may or may not work.  Please remember, that
the SSRI family is not always interchangeable.  While one patient may do
fine on Prozac, they may do poorly on Zoloft.  No one knows why some work
and some don't...its just a fact of life in depression that you may have to
change from one drug to another until you find one that is perfect for you.
In this case,  I would relax and just have the mom observe the infant for
tremor, colic, insomnia, and excitement.  I doubt they will occur at this
date postpartum.

Regards
Tom Hale, Ph.D.

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