Recently there was a case report of an infant death in Toronto. A
healthy, term nursing infant died at 10 days of life. The Mom had been
taking Tylenol #3 (acetaminophen/codeine), 2 tabs twice daily, and had
reduced the dose to 1 tab BID due to constipation. She was an ultrarapid
CYP2D6 metabolizer, and so the baby got a very high dose of morphine in
the milk. 

Initially I was thinking that since hydrocodone and oxycodone are so
safe, just to cover ourselves, it would be smart to remove
codeine-containing products from our standard post-partum orders (for
both vaginal and c-section). I went home post c-section on these meds. 

But further review of the literature (Thomas Hale PhD Medications and
Mothers Milk, Briggs et al Drugs in Pregnancy and Lactation, and Lactmed
online) tells me that we could have the same problem with Lortab
(hydrocodone/acetaminophen), as hydrocodone is metabolized to SIX active
metabolites, including hydromorphone. And Percocet
(oxycodone/acetaminophen), as oxycodone is metabolized to noroxycodone
and oxymorphone.

I took 8 Percocet (oxycodone/acetaminophen) a day for a week, and 8
Lortab (hydrocodone/acetaminophen) a day for a week. My baby was not
sedated or constipated. I've never seen a problem, but these moms and
babies usually go home within 72 hours on these meds, and if respiratory
depression develops, they could be referred to the local Children's
Hospital and we won't see it.

Clearly we need to treat pain in these moms, nursing or not. I am
thinking that we may need develop formal written discharge education to
moms to watch for sedation and constipation in these babies when taking
any medications for postpartum pain. What do y'all think? 

Laura Block, PharmD
Clinical Pharmacist

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