Kvinna född -54 med LED som skall sectioförlösa barn IDAG. Postpartum planeras Prednisolon 15 mg x

Fråga: Kvinna född -54 med LED som skall sectioförlösa barn IDAG. Postpartum planeras Prednisolon 15 mg x 2 x VII, 10 mg x 2 x VII, 7.5 mg x 2 x VII. Ev också furosemid 40 mg x 2. Kan hon amma barnet?

Sammanfattning: From 0.04 to 0.12 per cent of the prednisolone dose taken by the breast-feeding mother would be delivered via milk to the infant. Deleterious effects have not been observed. Therefore, corticosteroid can be administered with strict indications to a breast feeding mother on condition that the baby is carefully monitored for side effects.

Svar: There have been controversial ideas on the problem of continuing corticosteroid therapy in breast feeding mothers. Some authors have advised that breast feeding should stop if the mother is taking large doses of the corticosteroids (1). Evidence in the literature show that a very small amount of the prednisone dose taken by the breast-feeding mother would be delivered via milk to the infant (2-5). Although it was suspected theoretically that metabolite of steroid hormones such as pregnane-3-alpha,20beta-diol secreted in breast milk might contribute to prolonged neonatal jaundice either by inhibiting glucuronyl transferase or by inhibiting the secretion of bilirubin glucuronide from the liver, only rat studies provide basis for this opinion. Clinically, side effects in infants who have been breast-fed by mother recieving prednisone have not been recorded (5-7).

Sagraves et al (1981) reported that prednisone was detected within 45 min postdose in milk in a breast-feeding mother after 3 weeks therapy with Deltasone 20 mg daily for LE. The peak milk concentrations of prednisone and prednisolone were noted 2 hrs after dose and as measured by HPLC method were 69.3 and 32.7 ng/ml respectively (2). Berlin et al (1979) demonstrated in a nursing mother receiving prednisone 120 mg for idiopathic thrombocytopenic purpura that both prednisone and prednisolone were detected in milk within 6 hr post-dose, the highest concentration of the two steroids in milk amounted to 627 ng/ml (3). Katz and Duncan (1977) reported concentrations of 2.67 and 0.16 ug/dl of prednisone and prednisolone respectively in breast milk 2 hr after a dose of 10 mg prednisone to a nursing woman for the treatment of iridocyclitis (4). McKenzie et al (1975) by measuring the radioactivity in milk after giving a 5 mg dose of 3H-prednisolone to 7 healthy lactating volunteers, found that the mean total recovery of the radioactive dose in breast milk over the period about 48 hr normalized to a milk volume of 1 litre was 0.14 per cent (5). The little amount of corticoisteroid that a baby would receive via breast milk is estimated to range from 0.04 to 0.12 per cent of the maternal dose (6,7).

Assuming that the nursed infant consumes 100 ml of breast milk every 4 hr, ie a total milk-consumption of 600 ml per day, he would ingest about 45 ug of prednisone and prednisolone daily according to a calculation following the highest concentrations of these substances noted in the milk reported by Sagraves et al, or a similar value of 42 ug of the two drugs daily according to the calculation by Katz and Duncan, both values have been corrected to 15 mg daily doses. No hazards of such small amounts of the steroids have been noted in nursed infants. Adverse effects by low corticoisteroid concentrations on the differentiation of neurons have been observed in vitro with neurons from animals (8) and, in addition, when 20 mg/day os cortisone was given to lactating rats, poor body-weight gain and delayed sexual development resulted in the sucklings (9). The possible implications of these investigations for man are not clear but they warrant a strict indication for the corticosteroid therapy. In our opinion, no deleterious effects are likely to occur in the baby nursed by a mother on corticosteroid, but if she is on large doses, the baby should be monitored for side effects and the milk concentration of the steroids should be measured if possible.

As to the high-ceiling diuretic furosemide to be used concurrently with corticosteroid in this patient, due to its high protein binding property it may be expected to be bound to milk protein and occur in the breast milk theoretically (10). However, neither maternal milk concentration nor adverse effects in the nursed baby of corticosteroid have been documented. 1 Drugs in breast milk. Pharmacy Int 1982; 3: 12-14 2 Sagraves R, Kaiser D, Sharpe GL: Prednisone and prednisolone concentrations in the milk of a lactating mother. Drug Intell Clin Pharm 1981; 15: 484 3 Berlin CM Jr, Kaiser DG, Demers L: Excretion of prednisone and prednisolone in human milk. Pharmacologist 1979; 21: 264 4 Katz FH, Duncan BR: Entry of prednisone into milk. N Engl J Med 1975; 293: 1154 5 McKenzie SA, Selly JA, Agnew JE: Secretion of prednisolone into breast milk. Arch Dis Child 1975; 50: 894- 6 Berlin CM Jr: Pharmacologic considerations of drug use in the lactating mother. Obstet Gynecol 1981; 58: 17S-23S 7 Wilson JT, Brown RD, Cherek DR, Dailey JW, Hilman B, Jobe PC, Manno BR, Manno JE, Redetzki HM, Stewart JJ: Drug excretion in human breast milk. Principles, pharmacokinetics and projected consequences. Clin Pharmacokinet 1980; 5: 1-66 8 Boreus LO: Prednisolon och amning. Läkartidningen 1981; 78: 323 9 Mercier-Parot L: Troubles du development postnatal du rat apres administration de cortisone a la mere gestante ou alaitante. Comptes Rendus Des Seances De L´Academic Des Sciences 1955; 240: 2259 10 Shirkey HC, In: Avery GS, Drug treatment, 1980, 2nd ed, p. 115