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. -------------------------------------------------- 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. ----------------------------------------------------- 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 . *********************************** T.W. Hale, Ph.D. ***********************************