Review Article: The Management of Heartburn in Pregnancy

J.E. Richter

Disclosures

Aliment Pharmacol Ther. 2005;22(9):749-757. 

In This Article

Safety of Medical Treatments for GERD During Lactation

The heartburn of pregnancy typically resolves shortly after delivery, although some women still experience symptoms postpartum requiring treatment. All systemic antireflux medications are excreted in breast milk and could harm the infant. Therapeutic options must be explained and discussed with women who require treatment but who want to breastfeed.

Drug safety during lactation has been assessed in animal studies and human case reports ( Table 3 ). Aluminium and magnesium hydroxide antacids are not concentrated in breast milk and, thus, are safe during lactation. Neither Gaviscon nor sucralfate have been studied during lactation, but are presumed safe because of limited maternal absorption.

All H2RAs are excreted in human breast milk. Cimetidine and ranitidine reach concentrations in breast milk four to seven times the doses present in maternal serum.[41] In contrast, famotidine only reaches a mean milk:plasma concentration of 1.78, 6 h after ingestions.[42] Small amounts of nizatidine are excreted into human breast milk.[43] In the only animal studies assessing H2RA safety during lactation, pups reared by lactating rats ingesting nizatidine experienced growth retardation.[44] The effects of H2RAs in breast milk on the nursing human infant are unknown. In 1994, the American Academy of Pediatrics classified cimetidine as compatible with breast feeding.[45] The present review also suggests that ranitidine and famotidine are safe and the latter H2RA may be preferred because of the lower concentration in human breast milk. Nizatidine should be avoided in the breast feeding mother because of the single animal study.[44]

Little is known about PPI excretion in breast milk or infant safety in lactating women. PPIs probably are excreted in human milk, because of their relatively low-molecular weight. This was confirmed in the only report of PPI use during breast feeding.[46] During the day, the patient fed her infant son just before taking omeprazole at 8:00 AM, refraining from nursing for 4 h, and then expressed and discarded her breast milk at noon. At 3 weeks postpartum, blood and milk samples were obtained at 8:00 AM, and then every 30 min for 4 h. Breast milk levels of omeprazole began to rise at 9:30 AM and peaked at 11:00 AM at 58 mM, considerably lower value than simultaneous maternal level of 950 mM. The infant was doing well at 1 year. However, rats administered omeprazole at 35-345 times and rabenprazole at a dose of 195 times the recommended human dose during late pregnancy and lactation had decreased body weight gain of their pups.[33,47] Therefore, PPIs are not recommended for use by lactating mothers. Women with severe GERD symptoms can either take PPIs and discontinue nursing or use a GERD medication (i.e. H2RA) from another class.

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