Dear Michelle, 
I am concerned that this baby is described very sleepy. I am also
concerned that this mother is on two different medications which are
known to be able to cause somnolence, so we may be seeing an additive
effect. 

Lamotrigine (Lamictal) can pass into the breast milk in significant
amounts, and a preemie baby may have extra trouble breaking this drug
down and getting it out of their system. Somnolence is a theoretical
concern in normally developing babies, and this is not a normally
developing baby. It is recommended that babies whose mothers are taking
lamotrigine have "close monitoring of the infant plasma levels."

Aripiprazole (Abilify) has been reported "unofficially" to cause
sedation in nurselings. 

As far as lorazepam (Ativan) and Cymbalta (duloxetine), my concern with
these drugs are that other potentially sedating drugs are on board, and
we could be seeing a drug interaction - we just don't know enough about
all four of these drugs together in the milk. 

Based on the medications we are looking at, I suspect that this mother
really needs these medications, and that the baby would benefit even
more from Mom keeping her underlying disease in check than from her
mother's milk, if she is unable to change her medications. 

Mom might ask her physician if she levetiracetam (Lamictal) could
provide similar efficacy as her lamotrigine for whatever indication she
is taking it for (this medley of drugs is making me think bipolar
disorder). Levetiracetam might be less likely to cause sedation than
lamotrigine (also only 5% of Mom's levetiracetam makes it into the milk,
versus 22% of the lamotrigine). I am not sure that there is any
alternative to the aripiprazole, but this would be an excellent
conversation for her to have with her physician if she prefers to keep
giving her own milk.

If she cannot change her mediations, I would consider donor milk until
this baby is taking solid foods, and then at that time, if Mom wishes to
continue pumping, consider reintroducing Mom's milk, with careful
monitoring for change in the baby's cognitive function. Of course, all
of this should be done in careful consultation with the pediatrician,
but with this list of medications, I am wondering if the pediatrician
was aware of what all Mom was taking. 

For those who are interested, the references I consulted are Hale's
Medications and Mothers' Milk and Lactnet.

I hope this helps!
Laura Block, PharmD

------------------------------

Date:    Sat, 18 Apr 2009 10:06:21 -0400
From:    Michelle Scott <[log in to unmask]>
Subject: Drugs and BF

Dear Colleagues, How would you advise a family where the baby born at 28
wk 
at 1170g, now 3690, with 19g/d gain, very slow feeds, very sleepy baby. 
Seen for comprehensive eval 1 mo ago, now dx with reflux and on
thickened 
feeds.  Mom has provided only breastmilk since birth, via bottles.  Mom 
takes lamictal 150mg @hs, cymbalta, 60mg and 90mg per day, and
aripiprazole 
10mg in pm, lorazapam 1mg PRN.   What concerns would you have?
Michelle Scott, MA, RD, IBCLC
Wellspring Nutrition and Lactation Services

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