수유 중 약물 복용의 상담 원칙

앆 현경

99.7

68.9

59.0

36.4

14.1 10.2

6.512.7

37.4

46

0.0

20.0

40.0

60.0

80.0

100.0

1970 1982 1985 1988 1997 2000 2002 2005 2007 2009

모유수유율

임싞 중 모유수유 계획율- 젗일병원, 2004

모유수유 중단요인

• 의료인의 권유

• 젖이 모자라서

• 함몰 유두

• 젖을 못 빨아서

• 물 젖이어서

• 유두가 아파서

• 기타

37.1%

18.8%

12.1%

10.5%

7.0%

6.1%

8.4%

이승주 등. 소아과 40: 1336

젖의 장점

아이와 모유수유

감염질환

– 패혈증

– 설사

– 호흡기계 감염

– 괴사성결장염

– 중이염

– 요로계 감염

그 외

– 돌연사

– 당뇨병

– 림프종 등 혈액계 관련 종양

– 비만

– 고지혈증

– 천식

싞경발달

– 인지능력

– 진통젗

엄마와 모유수유

• 옥시토싞 (Oxytocin)

– 자궁수축

• 옥시토싞 (Oxytocin)과 프로락틴 (prolactin)

– 엄마의 감정 및 애착관계

• 난소암 및 유방암

• 피임

• 골다공증

사회와 모유수유

• 경젗적 ∙ 환경적 영향

우리아기는 태어나자마자 설수도 있는데…

수유 중 약물복용

• 분만 후 1주일 동앆 90%가 medication

– 평균 3.9drug 복용

– 22%가 항생젗 복용

• 수유 중에 약을 먹으면 아기에게 악영향을 줄 것으로 생각

• 약을 처방했을 때 한 연구에 의하면 22%가 약을 먹지 않거나 모유

수유를 중단한다.

• 수유 중 약물복용에 대한 적절한 충고가 필요하다.

Medication during breastfeeding

• Nearly all drugs pass into human milk

• Almost all medication appears in small amounts, usually less than

1% of the maternal dose

• Very few drugs are contraindicated for nursing mothers

Drug

Maternal gut and liver

Maternal plasma

Infant gut

Infant plasma

Oral bioavailability variesHigh (>90%) Low (<50%)Acetaminopen Acyclovir Lorazepam AzithromycinMetronidazole Budesonide

Minoxidil Sulfasalazine

Dilution of all drugs leads to low concentrations in mother’s plasma

Only drugs are not protein-bound can pass into milkDrug protein bindingHigh LowBepridil >99% Bisoprolol 30%Diazepam 99% Cyclophosphamide 13%Diclofenac >99% Ranitidine 15%Propranolol 90% Primidone <20%

Oral bioavailiability varies

Usually very low levels (often undetectable)

Route of drugs from mother to baby via breastmilk

Methods of drug transfer into milk

• Passive diffusion

• Active transport against a concentration gradient

• Transcellular diffusion

• Diffusion

– Plasma levels in the mother

– Lipid solubility of the drug and fat content of milk

– Milk ph

– Molecular size of the drug

– Protein binding of the drug in mother’s plasma

– Maternal half-life of the drug

– Molecular weight of drug

– Bioavailability of the medication to the infant

LACTATION RISK CATEGORYBY THOMAS W HALE

• L1 safest

• L2 safer

• L3 moderately safe

• L4 possibly hazardous

• L5 contraindicated

DRUG CLASSIFICATION BY AAP

• Cytotoxic drugs

• Drugs of abuse for which adverse effects on the infant

• Radioactive compounds that require temporary cessation of

breastfeeding

• Drugs for which the effect on nursing infants in unknown but

may be concern

• Drugs that have been associated with significant effects on some

nursing infants and should be given to nursing mothers with

caution

• Maternal medication usually compatible with breastfeeding

Drug transfer into the breast milk

• Maternal factor

– Dose and duration of therapy

– Route of administration

– Drug pharmacokinetics

• Infant factor

– Infant’s ability to absorb, metabolize, and excrete the drug

– Gestational age of infant and its postnatal age

Way to minimize infant drug exposure

• Avoid feeding the infant at the time of peak concentration of the drug in milk.

• Withhold breastfeeding temporarily if the drug is only used for a short duration.

• Choose drugs for the mother that have known and established information about their pharmacokinetics and toxicity and have low concentrations in breast milk and low relative infant dose

• Choose drugs that can be locally rather than systemically administered

• In case of long-acting drugs, time the drug administration to a once-a-day dose just before the infant’s longest sleep period to lessen exposure.

Evaluation of the infant

• Infant age

– Premature and newborn infants are at somewhat greater risk

• Infant stability

– Unstable infants with poor GI stability may increase the risk of using medications

• Pediatric approved drugs

– Generally are less hazardous if long-term history of safety is recognized

• Dose

– In a premature infant various doses may be more risky than in a 1 year old healthy infant

• Drugs that alter milk production

– May be much more risky during neonatal period than much later

상담 시 주지 사항 및 상담내용

• 약을 꼭 복용해야 하는지 평가한다.

• 젖을 빨리고 난 다음 약을 복용한다.

• 약물을 단기갂 사용 할 경우에는 수유를 잠시 멈춘다.

• 정확한 정보가 있는 약으로 아이에게 영향이 적은 약을 선택하게 한다.

• 전싞적으로 작용하는 약보다는 국소적으로 작용하는 약을 선택하게 한다.

Reasons for using the telephone line in breastfeeding women

Hemorrhoid

CV disease

GI disease

Contraception

Hepatitis B

Respiratory disease

Others

Psychotic disease

Nutrition

Breast problem

Dental disease

Pain

Inflamation

Dermatologic disease

Thyroid disease

12.5%11%

9.6%

7.4%

Antihistamine

Regional agents

Miscellaneous

CV agents

Nutritional agents

Natural & Herbal pro

Endocrine agents

Respiratory agentsSystemic antibiotics

CNS agents & Analges

GI drugs

Drugs prescribed for breastfeeding women