Re:  Diamorphine

        Diapmorphine,  more accuratly called diacetyl morphine or heroin,
is actually deacetylated in the brain to morphine,  which is the ACTIVE
component.  The diacetyl groups only enhance the entry of the drug into the
CNS(through the blood-brain-barrier).  Hence,  more rapid entry... the
greater the high experienced.  Nevertheless, as an analgesic,  heroin is
still metabolized to morphine.   Heroin,  due to its abuse potential,  is
classified as a Schedule I drug,  which is not cleared by the FDA for
therapeutic use in the USA.


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Re:  Diphenhydramine(Benadryl)

        I reviewed what Briggs had to say,  and in general they stated that
the "manufacturer" considers the drug contraindicated.   They(Briggs)
actually had very little to say about it.

        Benadryl has been used in pediatric patients,  particularly for
teething pains and colic,  for 30 years or more,  with few untoward effects.
Although some Benadryl administered to mom may find its way into breast
milk,  the levels are miniscule compared to the doses used clincally in
pediatric patients.   The most consistent side effect would be drowsiness in
the newborn.  We do know that the "TOPICAL" application of diphenhydramine
may lead to allergy in adults or children,  but this has not been
demonstrated following oral ingestion.  Topical forms such as benadryl
cream, and Caladryl have been reformulated to remove diphenhydramine,  at
least in this country.   Using Benadryl for days at higher levels,  may lead
to unusual hallucinations,  which are not really dangerous,  but indicate a
reduction in doseage is required.

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To : Dr. Montgomery
Re:  Lithium

        Unfortunately,  Lithium use both during pregnancy and during
lactation is a very controversial subject,  without any clear indications as
to how to approach this problem.  In general,  it is a weak teratogen but
has been repeatedly associated with certain birth defects,  particularly
cardiovascular.  Its use during the first trimester is quite dangerous.
Lithium is excreted into human milk.  Milk levels are approximately 40-50%
of the maternal plasma level.  The infants plasma levels are similar to the
milk levels.

        To begin with, I want to dispell a common misconception,  that using
a drug in-utero(during pregnancy) is SIMILAR to using a drug during
lactation.  This is simply not the case.  In utero, the mom takes care of
the metabolism and elimination of the drug and its metabolites,   so that
high levels in the fetus are not "usually"  a problem, since with most
drugs,  there is an equilibrium process between mom's plasma and the fetus's
plasma.  In most situtations this safeguards the fetus from attaining
extremely high levels of most drugs.  (This point is uniquely different from
the teratogenic effects of drugs)

        On the other hand in a breastfeeding newborn,  this equilibrium
process does not exist once the infant is delivered.  At that point,  the
infant's liver and kidneys must take over this elimination process,  a
process for which pediatric organs are not very efficient until some time
later(30-90 days).  Under these situations,  drugs can theoretically build
up to higher levels in newborns simply because they have longer half-lives
and lower volumes of distribution during this period.  So lets remember,
once delivered,  you must  "re-evaluate drug useage" in this immature
individual,  and its use during pregancy is largely  irrelevant.

        Lithium use in lactating patients must be approached very
cautiously,  but in general lithium clearance in pediatric kidneys is much
higher than in adults.   If the drug is strongly indicated,  then the
over-riding need of the mom is paramount.  The literature is conflicting
concerning lithium use in lactating women,  some articles state implicitely
that it is overtly dangerous and should not be used,   others state that
from their clinical trials it is safe,  as long as mom's plasma levels are
kept low,  and the infant is occasionally monitored.  If your judgement as a
clinician justifies exposure of the infant  to safeguard mom's health,  then
I would  watch the infant developmentally,  as well as for plasma levels of
lithium.  Others suggest occasional thyroid profiles,  particularly in
children.

         So,  it is a judgement call between you(MD) and the mom.   I might
add,  that in some instances of individuals who could not take lithium,
carbamazepine has been found useful.  Good Luck .



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T.W. Hale, Ph.D.
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