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Is ths actually possible?

post #1 of 23
Thread Starter 

It's hard to look stuff up while nak. I came across this:

http://www.azcentral.com/news/articles/2011/06/24/20110624baby-dies-morphine-breast-milk.html

 

Is this actually possible? Isn't it more likely the baby was dosed directly?

post #2 of 23

Well there is a LOT the article leaves out - we dont know if the baby was nursing like 4 times a day ...being that she was taking the morphine since the baby was born - it stands to reason the baby was a little sleepy as well.  And it sounds like the mother was taking morphine orally as well as in a patch?  Was she taking them together?  Who prescribes a pregnant woman morphine?  And if she legally obtained the morphine in her 6 weeks postpartum  - how much morphine was that doctor on?  - Meaning - when the doc examined this woman couldnt he tell she had recently given birth?  Wouldnt this question come up "Are you breastfeeding?" 

i really dont know - its sad either way.

post #3 of 23

I read several articles about this case, one named 4 different pain medications she was on. Two were patches; two were pills:

Fentanyl - Pain med that comes in Patch form.  Often given to people who suffer from constant pain.

Duragesic - Pain med along the same type as Fentanyl.

Morphene - In pill form

Hydrocodon - also known as Vicoprofen

 

That list was copied/pasted from the article.

She fraudently obtained prescriptions for these medications.

 

Here's a quote from an article from a LLL spokeswoman: 

Breast-feeding mothers are allowed to take morphine because low levels of the painkiller pass into the mother's milk when taken properly, said Diana West, a spokeswoman for La Leche League International, which encourages breast-feeding in new mothers.

"Most drugs like morphine pass so poorly through human milk that it is nearly impossible for a child to have a therapeutic dose, much less a lethal dose," West said.

 

I would assume there were two ways this could happen. 1.The morphine was given to the baby directly or 2.This woman was on so much medication I don't see how she could function.

 

I hope this does not hurt women who need pain med prescriptions while breastfeeding! I have no idea what this woman was thinking. I don't normally hear of women abusing drugs/meds also breastfeeding. They tend to formula-feed or their family ends up taking care of the baby.

post #4 of 23

How tragic.

 

This is possible - some mothers metabolize opiates differently than others, and the metabolites are passed into breastmilk at levels that can sedate a newborn. This is why mothers prescribed opiates are now cautioned to look for excess sleepiness in baby.

 

Motherisk has some good info about codeine and breastfed babies. I gather there are similar cautions for other opiates.

post #5 of 23
Quote:
Originally Posted by PatioGardener View Post

How tragic.

 

This is possible - some mothers metabolize opiates differently than others, and the metabolites are passed into breastmilk at levels that can sedate a newborn. This is why mothers prescribed opiates are now cautioned to look for excess sleepiness in baby.

 

Motherisk has some good info about codeine and breastfed babies. I gather there are similar cautions for other opiates.

 

I have heard this as well, that some mom do metabolize opiates differently and more of the drug can get to the baby.  It is scary, but I don't think it's common.  I think that it's something that people should be aware of, though.



 

post #6 of 23
It's totally possibly - which is why I declined pain meds stronger than acetaminophen and ibuprofen after my C-section.
http://www.theglobeandmail.com/life/parenting/infant/breastfeeding/codeine-can-prove-toxic-for-breastfed-babies/article310860/singlepage/
post #7 of 23

The caution with codeine is actually different than other opiates. Codeine is converted to morphine in the body, and it's the morphine that is the active drug. Some people convert codeine faster ("fast metabolizers"), and thus end up effectively getting a monster dose of morphine, which can understandably have bad effects on mom and/or baby. If narcotics are necessary (i.e. ibuprofen and acetaminophen don't cut it), taking a lower dose of actual morphine would be safer, because then you know how much you and baby are getting and you don't run the risk of inadvertently getting that monster dose. In either case, baby should be watched for over-sedation, of course!

post #8 of 23
Quote:
Originally Posted by erigeron View Post

The caution with codeine is actually different than other opiates. Codeine is converted to morphine in the body, and it's the morphine that is the active drug. Some people convert codeine faster ("fast metabolizers"), and thus end up effectively getting a monster dose of morphine, which can understandably have bad effects on mom and/or baby. If narcotics are necessary (i.e. ibuprofen and acetaminophen don't cut it), taking a lower dose of actual morphine would be safer, because then you know how much you and baby are getting and you don't run the risk of inadvertently getting that monster dose. In either case, baby should be watched for over-sedation, of course!


nice explanation - thanks!

 

post #9 of 23

wow if this is real its sooo sad

post #10 of 23
Quote:
Originally Posted by Megan73 View Post

It's totally possibly - which is why I declined pain meds stronger than acetaminophen and ibuprofen after my C-section.
http://www.theglobeandmail.com/life/parenting/infant/breastfeeding/codeine-can-prove-toxic-for-breastfed-babies/article310860/singlepage/

 

...and this is why I wish I had been told a bit more after my c-section.  My baby almost did this. on oxycodone that my OB prescribed, which I didn't know was a painkiller (I read up on natural birth but not on medications, *smacksface*).  We were blessed, our lactation specialist was quick on the uptake and I quit that stuff cold turkey. Breastmilk is best because it can effectively deliver nutrients, you need to eat really nutritiously and eschew drugs when possible.  You're eating for two 

post #11 of 23

This baby had to be given the opiates directly. No matter how you "process" opiates, there simply would not be enough metabolites of most of them in your milk (especially things like morphine, hydrocodone etc) to actually "poison" the baby. Meperidine is not advised, either are some of the older opiates that are now taken off of the US Pharmacopia like Darvocet (the ONLY opiate I have ever seen have side effects in a breastfed baby, and those were mild!) (Although I was given codeine after my first two C Sections and for migraines while I nursed my first two kids as were most breastfeeding women who had C Sections and/or migraines and.... our babies all lived.)

 

I have seen women not be able to have an ejection reflex from pain! The opiates are only excreted in minute forms in human milk, especially with newer opiates that transfer even less well into milk.

 

If this mother was on a fenanyl patch it is quite possible that the patch could have got stuck to the baby's skin and harmed her that way. Through the milk? I can't see it happen. I've worked with many women post C Section and in the long run it's actually MORE dangerous to try to deal with the pain without opiates. Pain can hinder milk ejection. I've worked with women in chronic pain (and I have a chronic pain condition myself)  and the doctor has done his research her pain can be controlled, even with high quality opiates, without effecting the baby.

 

Most self medicating is up for grabs, but in many case studies even heroin doesn't kill babies through breastmilk alone, However, in some cases of drug abuse (there have been half a dozen cases of this) it was found that the mother was giving the actual drug straight to the baby to "make the baby sleep." While pain meds can be given to babies if necessary in medically controlled situation, too much directly given to the baby could be lethal. Especially if the mother is "guessing" at the dose and using a formulation made for adults.  I suspect strongly that is what happened here.

 

I did want to clear something up. you are NOT "eating for two" when you are breastfeeding. At most, you are using less than 500 calories a day to make milk, and there is NO reason to eat more when you are breastfeeding. It ISN'T pregnancy and has nothing in common with pregnancy. And most medications, when needed for treatment reasons, are compatible with breastfeeding. A few are not, opiates, by and large are part of the group of drugs that do not transfer well into human milk.

 

There is no reason to start panic. MOST women need opiates post C Section. It's major abdominal surgery and pain itself is damaging to the body!!!! If you do have a C Section, talk to your doctor and have him or her look in Dr. Hales Medications and Mother's Milk to look up the drug. You should not be enduring post surgical pain with a newborn just to "be too careful" of something that isn't going to hurt YOU or your baby!

 

This article says it better than I: http://www.nbci.ca/index.php?option=com_content&view=article&id=26:breastfeeding-and-medications&catid=5:information&Itemid=17

 

One thing to keep in mind, although most drugs that are safe during pregnancy are usually safe in lactation, MANY drugs that are contraindicated in pregnancy are completely safe during lactation because the breast and the placenta are two completely different organs with two different functions.


Edited by MaggieLC - 10/22/13 at 10:55am
post #12 of 23

I suggest reviewing this article, particularly the concerns pertaining to ultra-rapid metabolizers. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm118113.htm

 

I don't think it has to be a question of whether to treat the mother's pain or not. It's certainly possible to do so without putting the baby at risk. It's important to have all the facts, though, and not to adhere too closely to a principle that may not be true universally, be it "avoid medications at all costs" or "practically anything is fine, go nuts". 

post #13 of 23
I'm certainly not saying 'go nuts' but the risks of using meds in lactation have been far over stated. Witness the poster above who refused ALL pain meds after her C section. That type of untreated pain could cause serious problems cortisol rises, risk of Chronic pain syndrome and healing and milk ejection problems.

I'm well aware of "rapid metabolizers" however even this study said side effects are rarely a problem. The solution is to use something like hydrocodone for post surgical pain whicj does not cause the rare "rapid metabolizer" side effect at all.

Also I did want to mention that several high profile cases of "morphine poisoning thru breast milk" have been found later thru investigation to be due to DIRECT administration of t he drug to the infants.

It is similar to the "over lying" theory
It's possible but the less savory truth is usually what really happened.
post #14 of 23

I think if a bf mum is in so much pain that she requires morphine, she and baby should be inpatient. C-Section Mamas used to be in hospital for two weeks when I was a baby! Too high a risk. 

post #15 of 23
Quote:
Originally Posted by EineMutti View Post
 

I think if a bf mum is in so much pain that she requires morphine, she and baby should be inpatient. C-Section Mamas used to be in hospital for two weeks when I was a baby! Too high a risk. 


At least in our area, women who have just had C Sections are rarely if ever sent home while still on morphine. The story originated as codeine metabolizes into morphine in the human body, and some women (at least in the literature) don't metabolize codiene well and it can build up in the body and ostensibly in her milk as well. (I still think more study is needed. Until then, MD could use Hydrocodone (Vicodin, Hydone, Vicoprofen and other brand names), as it doesn't metabolize the same way as codeine.)

 

In most cases for acute pain, morphine itself only ordered for inpatients.  Sometimes you don't even get it. I had Demerol injections after my first C Birth, for 2 days, then on to oral meds. I had morphine via PCH (patient controlled analgesia, and it was wonderful) but again, only for two days. With my third C Birth, I had been given a gigantic Spinal for the C Birth because I had so much scar tissue and layers bound together the second time that we thought I would need more time after the C Birth to "clean" me up. I ended up being pristine (I had had some surgery to clean out scar tissue and endometriosis about 4 years before my last C Birth and I stayed scar tissue free.)  The Spinal was expected to last a long time, (it didn't, but I was "maxed out" on morphine and fentanyl for the next 8-10 hours)  so the next morning I wanted the IV and the Foley Catheter out more than I wanted the morphine, so I only got oral meds, a combo of Vicodin and 800 mg ibuprofen, and that was fine. 

 

Two weeks in the hospital after a C Section is a bit excessive, I think, and for most uncomplicated abdominal surgeries. (I've had 6 abdominal surgeries, and the longest I ever stayed in hospital was 5 days and that was with some serious complications.) No insurance company or hospital is going to let a woman lie around in a hospital for two weeks, raising her risk of blood clots and pneumonia and racking up hundreds of thousands of dollars in expenses after an uncomplicated C Section. I was up an walking around the morning after ALL my C Births, no more than 6-8 hours after the surgery. You recover more quickly if you move around. Unless there are complications, there is really no medical reason to be in the hospital that long after a C Birth.

 

I would have lost my mind if I had had to stay in the hospital for two weeks, in most cases that is too long. I did go home ASAP after my first C Birth and regretted it (I really needed an other day in the hospital, but only one or so) so with my next two surgical births, I stayed an extra day. I ended up staying 3-4 days in the hospital and by then I was more than happy to go home. That was enough to get over the worst of the pain and get onto oral pain meds. (And I went home to a new baby and a toddler the second time, and two older children and a new born the third time.) 

 

I think that woman whose baby supposedly died from "morphine in breast milk" was taking lots of pain meds for a condition unrelated to the birth. To be honest, I'm pretty skeptical about the whole "morphine in the breastmilk" stories. I remember back in the early 2000s there were repeated "amphetamine in the breast milk stories" until it was found out that in order to actually have enough amph in your milk, one would have to take about 3-4 times the lethal level for the mother.  She would have DIED before the amount got into the milk in the first place. The TV show ER did a story about this, and was later found out to be propaganda (untrue!) paid for by the DEA and "Partnership for a drug free America" and I haven't trusted these stories since.  I'm very skeptical of "anti-drug" propaganda, and I'm a really hard sell as too many of these stories in the past have been shown to be B.S.

 

Remember the stories of kids who stared at the sun while on Acid and went blind? Propaganda by the DEA! Remember the stories about the chick on acid (or PCP depending on the decade) who put the baby in the oven and put a diaper on the turkey and put it in the crib? BS propaganda by the DEA. Remember the story of the "Mickey Mouse Blotter Acid' supposedly to "get kids addicted?" Again, total BS propaganda propagated by the DEA and local police departments. NONE of this stuff happened.  I simply don't trust the source these stories at all.

post #16 of 23
I'm a bit skeptical. It seems like if her milk had that much of the drug in it, she would have so much of the drug in her that she would have OD'd. If she was that drugged up, she might not have noticed if the baby had gotten hold of a patch, or if a used patch hadn't been thrown out and had been on the baby's skin, or something like that. It seems more likely to me.

Poor baby. greensad.gif
post #17 of 23
Quote:
Originally Posted by MaggieLC View Post
 


At least in our area, women who have just had C Sections are rarely if ever sent home while still on morphine. The story originated as codeine metabolizes into morphine in the human body, and some women (at least in the literature) don't metabolize codiene well and it can build up in the body and ostensibly in her milk as well. (I still think more study is needed. Until then, MD could use Hydrocodone (Vicodin, Hydone, Vicoprofen and other brand names), as it doesn't metabolize the same way as codeine.)

Well, actually hydrocodone is metabolized to hydromorphone by the same enzyme as converts codeine to morphine. So an ultra-rapid metabolizer could theoretically have the same problem with hydrocodone as with codeine. Don't get me wrong, I don't think the medications should never be used in breastfeeding, but I do think people should be aware that there is this fraction of the population that might have a problem, and know how to tell if their baby is affected and what to do. A lot of people don't make it to child-bearing age without having narcotics a couple of times, so somebody who took Vicodin when she had her wisdom teeth out or whatever and didn't have issues can probably figure she'll be fine. But those who have never had them should just be aware of the fractional chance of a problem. IMO. 

 

I have a friend who can't take codeine because it affects her really badly, and neither can anybody else in her family; I suspect this is their problem and that it's genetic. She also had a problem with hydrocodone. 

post #18 of 23
I know someone who can't take codeine too, because it affects her way too strongly. I do find that interesting.
post #19 of 23
Quote:
Originally Posted by erigeron View Post
 

Well, actually hydrocodone is metabolized to hydromorphone by the same enzyme as converts codeine to morphine. So an ultra-rapid metabolizer could theoretically have the same problem with hydrocodone as with codeine. Don't get me wrong, I don't think the medications should never be used in breastfeeding, but I do think people should be aware that there is this fraction of the population that might have a problem, and know how to tell if their baby is affected and what to do. A lot of people don't make it to child-bearing age without having narcotics a couple of times, so somebody who took Vicodin when she had her wisdom teeth out or whatever and didn't have issues can probably figure she'll be fine. But those who have never had them should just be aware of the fractional chance of a problem. IMO. 

 

I have a friend who can't take codeine because it affects her really badly, and neither can anybody else in her family; I suspect this is their problem and that it's genetic. She also had a problem with hydrocodone. 


I've seen little in the literature about hydrocodone and ultra rapid metabolizers. One or two scattered studies, none of which are easily accessed. Something being possible doesn't mean it's probable. I've worked with literally thousands of post partum women over the past 25 years, by my estimate 60-75% of them are given some form of opiate after birth, even if it was a vaginal birth. (In our area many doctors understand that after pains as well as pain from stretching and tearing can effect milk ejection, cause cortisol rises and be damaging to new mothers, so many are very understanding and provide pain relief for a few days, even for vaginal births.) In all that time, with thousands of women I can say I have seen only a few (less than maybe 5) who told me they thought (self reporting) their baby was sleepy from their codeine. (I have also seen hundreds of excessively sleepy babies whose mothers are on no medication whatsoever, so the links I have seen are tenuous.)  I have NEVER had a client report excessive sleepiness from mom taking hydrocodone. (Most of the docs in our area do not prescribe oxycodone for post partum pain, but they do in other states and I counseled those mothers when I worked that famous breastfeeding organization's Hot Line as well as working as a Professional Liaison.)

 

I suppose this could be considered "anecdotal data." But, I have thousands of logs going back to 1989!  From my data (maybe I should publish....) a few cases of reported sleepiness while mom was taking codeine, none bad enough to prevent feeding or cause weigh gain problems, all seemed to resolve when the mother, on my advice, changed over to hydrocodone. I have also seen about 20  cases of "twitching"  and restlessness (two cases in my own children with Darvocet being prescribed for migraine) while mom was taking Darvon or Darvocet, but as those drugs are now off the market (IMO, they were pretty ineffectual pain relievers not to mention at one point in time were causing the majority of ODs in the senior community, probably because of the drug's weakness and older people increasing dosage to a dangerous level just to get some relief.)  I reported those cases to the FDA, and I never heard back from them.

 

Women who have C Births as well as some who have vaginal births often do need pain relief. (I know you are agreeing with me here.)  The percentage of cases of PAIN causing serious side effects in new mothers is an order of magnitude higher than the academic risk of someone perhaps being an ultra rapid metabolizer and having hydrocodone causing a problem, if it is even a real world problem at all. And, having had C Births myself, I can be quite honest in saying I probably would have taken much longer to recover without opiate relief and maybe would have had problems that uber high cortisol levels cause. As an LC and a Post Partum Doula I have seen many cases of women whose ejection (let down) reflex was muted or postponed by severe and moderate pain. We shouldn't be denying MOST mothers pain relief because of a very small percentage of the population. Too much fear in medicine leads to bad choices, I think we have all seen that. Few things scare the populace more than a "dead baby story."  And often those unfounded fears can lead to poor choices in both HCPs and their patients (again see the PP who refused all pain medication after a C Section. The chance of her being an ultra metabolizer is low, yet the chance of unmitigated pain effecting her seriously in the post partim period is very high.

 

Perhaps testing for being an ultra rapid metabolizer should be done on not only pregnant women, but perhaps everyone. I think most MDs (and insurance companies who would end up paying for the test) would say "The condition is SO rare, that the cost doesn't justify the risk."

 

If a woman has symptoms of ultra rapid metabolization or knows has CYP2D6 issues, her doctor may decide to test her (if she hasn't been tested for CYP2D6 problems) or perhaps use Toradol (again, this drug comes with its own pile of KNOW and common risks, mostly to the kidneys and) or perhaps Tramadol (then you risk causing a possible serotonin syndrome in susceptible people and some CYP3D6 patients may have problems metabolizing this drug....) IMO, in most cases, commonly used synthetic opioids like hydrocodone and oxycodone seem the least amount of problems in short term use for acute pain relief.

 

If you have actual cases of hydrocodone causing build up of hydromorphone in ultra rapid metabolizers, I would like to read them. I've seen one that I can't access and also haven't been able to access even a abstract so I don't know the outcome of even the sample size.  My guess is it's just an other academic fear that has no actual post market drug use proof. Also, you have the problem that as hydrocodone is usually dispensed as generic, the drug companies have no more interest in studying its effects, which is sad, but that's the way it goes when their main concern in profit. Drug companies seem to have little interest in pursuing drugs that have been on the market for decades. Their interest seems to lie with drugs that are used long term and drugs that are new enough so the companies can keep the drug from becoming generic for as long as possible.

 

We also have to keep in mind that there are at least 4 different types of ultra rapid metabolizers (one type of which the drug is not metabolized at all, and the patient receives NO therapeutic effect at all. In this thread we are talking about the type where the drug is held in the body for a long period of time.) 

 

Also, as you and I were talking about metabolites, codeine and hydrocodone actually have very different metabolite breakdowns. Codeine has: Morphine,small amounts of Hydrocodone (described as MINOR in the literature) and codeine itself. While hydrocodone's metabolites are mainly: hydromorphone, hydrocodone itself and hydrocodal. I see codeine and hydrocodone as being fairly significantly different drugs, both in function, efficacy and concerning their metabolite break downs.

 

In lactation we consider hydrocodone usually the drug of choice in lactating women, unless there are unusual factors. CYP2D6 patients have issues with at least 30% of the drugs in the US pharmacopeia, some of which are used fairly commonly. As this condition often runs in families, perhaps those who have relatives with multiple drug related issues or have had  medication issues themselves do have to do attempt to do due diligence to make sure their doctors know they have an enzyme deficiency or at least talk to their doctors about testing for the deficiency.  In most states, CYP2D6 is not a common test done after birth, perhaps it should be as it may effect a wide variety of medications that that patient will most likely run into in their lifetimes.


Edited by MaggieLC - 11/4/13 at 8:14am
post #20 of 23

Thanks for the information, Maggie. That's very good to know. One real frustrating thing about my practice is I don't get to really follow up with patients all that often and see how they do on their medications. I get a lot of theoretical stuff but little in the way of a personal impression based on experience. I'm still a pretty new practitioner, but it's going to take me forever to accumulate any of these experiences because of the way my practice is structured. Blah! I do get breastfeeding patients asking me about hydrocodone sometimes. I'm glad to hear you haven't noticed any problems with it. 

 

On a personal note, my daughter was sleepy and I didn't take anything stronger than ibuprofen. I think for her it was a touch of jaundice causing that, though. 

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