Only a few drugs are absolutely contraindicated while breastfeeding (Berlin, 2013; Bertino, 2012). Cytotoxic drugs may interfere with cellular metabolism and potentially cause immune suppression or neutropenia, afect growth, and at least theoretically, increase the risk of childhood cancer. Examples include cyclophosphamide, cyclosporine, doxorubicin, metho trexate, and mycophenolate. If a medication presents a con cern, then the importance of therapy should be ascertained.
It should be determined whether there is a safer alternative or whether neonatal exposure can be minimized if the medication dose is taken immediately after each breastfeeding (American
Academy of Pediatrics, 2017). Finally, recreational drugs such of Obstetricians and Gynecologists, 2017 a). Data on individual drugs are available through the National Institutes of Health website, LactMed, which can be found at toxnet.nlm.nih.gov.
Radioactive isotopes of copper, gallium, indium, iodine, sodium, and technetium rapidly appear in breast milk. Con sultation with a nuclear medicine specialist is recommended before performing a diagnostic study with these isotopes (Chap. 46, p. 908). he goal is to use a radionuclide with the shortest excretion time in breast milk. The mother should pump her breasts before the study and store enough milk in a freezer to feed the infant. After the study, she should pump her breasts to maintain milk low but discard all milk produced during the time that radioactivity is present. his ranges from 15 hours to 2 weeks, depending on the isotope used. Importantly, radioactive iodine concentrates and persists in the thyroid. Its special considerations are discussed in Chapter 63 (p. 1201).
his is common in women who do not breastfeed. It is typified by milk leakage and breast pain, which peak 3 to 5 days after delivery (Spitz, 1998). Up to half of afected women require analgesia for breast pain relief, and as many as 10 percent report severe pain for up to 14 days.
Evidence is insuicient to irmly support any speciic treatment (Mangesi, 2016). hat said, breasts can be supported with a well-itting brassiere, breast binder, or sports bra. Cool packs and oral analgesics for 12 to 24 hours aid discomfort. Pharmacological or hormonal agents are in general not recommended to suppress lactation.
Fever caused by breast engorgement was common before the renaissance of breastfeeding. In one study, Almeida and Kitay (1986) reported that 13 percent of puerperas had fever from engorgement that ranged from 37.8 to 39°C. Fever seldom persists for longer than 4 to 16 hours. The incidence and severity of engorgement and of the fever associated with it are much lower if women breastfeed. Other causes of fever, especially those due to infection, must be excluded. Of these, mastitis is infection of the mammary parenchyma. I t is relatively common in lactating women and is discussed in Chapter 37 (p. 675).
• Other Issues with Lactation
With inverted nipples, lactiferous ducts open directly into a depression at the center of the areola. With these depressed nipples, nursing is diicult. If the depression is not deep, milk sometimes can be drawn out by a breast pump. If instead the
The Puerperium 659 nipple is greatly inverted, daily attempts are made during the last few months of pregnancy to draw or "tease" the nipple out with the fingers.
Extra breasts-poymastia, or extra nipples-poythelia, may develop along the former embryonic mammary ridge.