Asthma Management Handbook

Managing asthma in breastfeeding women

Recommendations

Manage asthma in breastfeeding women as for asthma in other adults, aiming to maintain the best possible asthma control and to avoid asthma flare-ups while using the lowest effective doses.

Use preventers as indicated, step up the regimen as necessary to regain or maintain control, and consider stepping down when asthma is well controlled.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Explain to patients that most asthma medicines can be used by breastfeeding women, because the risks of poor asthma control outweigh the risks associated with medicines.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If possible, use asthma medicines that are likely to have low concentrations in breast milk.

Table. Local pregnancy and breastfeeding safety information services Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/71

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If systemic corticosteroids are needed to manage an acute flare-up while a woman is breastfeeding, use oral prednisolone 37.5–50 mg as a single daily dose each morning for 5–10 days.

Reassure the woman that the amount of medicine in the breast milk will be low. Advise her that it can be reduced by feeding the baby just before each daily dose and avoiding feeding again until 4 hours after the dose.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

Advise women who smoke to quit, and offer support. Advise all breastfeeding women to avoid exposure to cigarette smoke.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Safety of asthma medicines while breastfeeding

Australian product information identifies some medicines that are known to pass into breast milk (e.g. adrenaline, aminophylline, prednisolone, sodium cromoglycate, terbutaline).3

The concentration of active ingredient in breast milk is likely to be low for several common asthma medicines (e.g. beclomethasone dipropionate, budesonide, fluticasone propionate, combination fluticasone propionate/salmeterol, nedocromil, ipratropium bromide).3

For some asthma medicines (e.g. formoterol, omalizumab, montelukast), or test substances (e.g. mannitol, used in bronchial provocation [challenge] testing), it is not known whether or not the active ingredient is excreted into breast milk, so caution is recommended.3

Australian product information identifies only a small number of asthma medicines that are not recommended for breastfeeding women (e.g. adrenaline, aminophylline, hydrocortisone for injection, prednisolone), and recommends that caution is needed when others (e.g. omalizumab, montelukast) are given to breastfeeding women.3

Information about the safety of medicines during lactation (included in product information for each medicine) emphasises the need to balance the potential benefits of asthma treatment with the possible risks to the infant.3

Note: Product information provided by pharmaceutical manufacturers and registered with the Therapeutic Goods Administration is written and approved when the medicine is first marketed, but is not routinely updated as new evidence becomes available. When product information includes a caution or contraindication for breastfeeding, health professionals should check current evidence before advising the woman about her choices, so that mothers do not stop breastfeeding unnecessarily, based on incomplete information.

Up to date information is available from the following sources:

  • The Drugs and Lactation Database (LactMed), compiled by the US National Library of Medicine, provides comprehensive current information on the safety of medicines during breastfeeding
  • The National Prescribing Service (NPS) Medicines Line provides information for the public about medicines and safety: 1300 MEDICINE (1300 633 424)
  • Telephone information services about the safety of medicines while breastfeeding are also available for health professionals and breastfeeding women in some areas of Australia.

Table. Local pregnancy and breastfeeding safety information services Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/71

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Systemic corticosteroids and breast milk

Peak plasma level of systemic corticosteroid occurs at approximately 2 hours post dose, so peak milk level will also occur around this time. Therefore, the infant’s exposure to corticosteroids in breast milk can be further reduced by breastfeeding the infant just before each daily dose and avoiding feeding again until at least 4 hours after the dose.1, 2

If high-dose corticosteroids need to be used for longer than 10 days, the infant should be monitored for growth and development.12

The US National Library of Medicine’s Drugs and Lactation Database (LactMed) states that: limited information indicates that maternal doses of prednisolone up to 50 mg produce low levels in milk and would not be expected to cause any adverse effects in breastfed infants. With high maternal doses, avoiding breastfeeding for 4 hours after a dose should markedly decrease the dose received by the infant. However, this [manoeuvre] is probably not necessary in most cases.

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Prenatal and childhood exposure to tobacco smoke

Tobacco smoking by pregnant women damages children’s respiratory health. It also increases the risk of stillbirth, spontaneous abortion, reduced foetal growth, preterm birth, low birth weight, placental abruption, sudden infant death, cleft palate, cleft lip and childhood cancers.4

Risk of developing asthma

Prenatal exposure to tobacco smoke and exposure during infancy increase the risk of wheezing during early childhood.5

Effects on children's asthma

Evidence from an Australian cohort study suggests that children with asthma whose mothers smoked during pregnancy benefit less from treatment with inhaled corticosteroids, and show less improvement in airway hyperresponsiveness over time, than those with asthma but no intrauterine exposure to smoke.6

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References

  1. Briggs G, Freeman R, Yaffe S. Drugs in Pregnancy and Lactation – A Reference Guide to Fetal and Neonatal Risk. Lippincott, Williams & Wilkins, Philadelphia, 2008.
  2. Hale T. Medications and Mothers’ Milk: Manual of Lactational Pharmacology. 14th edn. Hale Publishing, Amarillo, 2010.
  3. Therapeutic Goods Administration, TGA eBusiness Services. Information about prescription medicines in Australia, Australian Government Department of Health 2013. Available from: https://www.ebs.tga.gov.au
  4. Zwar N, Richmond R, Borland R, et al. Supporting smoking cessation: a guide for health professionals. Updated 2012. The Royal Australian College of General Practitioners (RACGP), Melbourne, 2011. Available from: http://www.racgp.org.au/your-practice/guidelines/
  5. Burke H, Leonardi-Bee J, Hashim A, et al. Prenatal and passive smoke exposure and incidence of asthma and wheeze: systematic review and meta-analysis. Pediatrics. 2012; 129: 735-744. Available from: http://pediatrics.aappublications.org/content/129/4/735.long
  6. Cohen RT, Raby BA, Van Steen K, et al. In utero smoke exposure and impaired response to inhaled corticosteroids in children with asthma. J Allergy Clin Immunol. 2010; 126: 491-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20673983