Dear Kathleen,

        It is very disheartening to read your note about the neonatologist and
amitryptiline.  This is a perfect example of the neonatologist
"mindset", combined with "we really don't trust breastmilk", never mind
breastfeeding.

        One of the best ways, of course, to maintain breastmilk supply for a
premature baby is encourage the mother that pumping for the baby is
something worthwhile.  It helps a lot.  This mother isn't getting much
of that, is she?

        To the point that the mother was taking amitryptiline throughout the
pregnancy, the neonatologist will respond, but the mother was
metabolizing it for the fetus.  This is a valid point, but not
compelling enough to stop the baby getting breastmilk.

        However, how the neonatologist can then go on and say that even a trace
of amitryptiline renders breastmilk unsuitable for the baby is going to
far.  We have evidence that prematures getting even some breastmilk
increases their cognitive function at 8 years.  We have evidence that
breastmilk decreases the incidence of NEC.  We have evidence that there
are in milk, antibodies etc.

        Furthermore, for the archetypal bean counter (the neonatologist) to
then go on and say that the mother has to sacrifice breastfeeding on the
altar of ignorance for a month to make sure that all the amitryptiline
is out of her body is irrational, and fits poorly with his/her bean
counting approach.

        The half life of amitryptiline in adults is 10-22 hours.  Thus, the
amitryptiline would be eliminated from the mother's system completely in
5 times the half life, or about 5 days, at the most.  It is true that
amitryptiline has active metabolites, but these would not continue in
the mother's system much longer than the amitryptiline itself.  Thus, we
could reasonably expect that at the outside, the mother could start
giving her milk to the baby after a week, being extremely conservative.
Surprisingly, for a bean counter, the neonatologist did not suggest
measuring the mother's milk amitryptiline levels once she had gone off
the drug for say a few days.  Maybe the level would be unmeasurable
before a week (as I suspect).  The measurement includes amitryptiline
and nortryptiline (one of the active metabolites). By the way, to oral
bioavailability of amitryptiline is only about 30-60%, at least in
adults, suggesting that only a about half of the amitryptiline in the
milk gets into the baby.

        Finally, the approach of the neonatologist shows his/her special
treatment of breastmilk.  We have long given extremely premature babies
drugs of all sort with only very little evidence of their safety.
Remember indomethacin to close the ductus?  Indomethacin which can cause
acute renal failure?  How about gentamicin which can cause deafness and
renal failure?  Is there a premature baby who ever gets out of the unit
without having any gentamicin?  That's okay, of course, because it is
the neonatologist who is in charge.  But that's another story, and I've
already blathered on enough.

Jack Newman, MD, FRCPC