labetalol, metoprolol, and propranolol are the beta-blockers of choice during breastfeeding (1)
very small amounts get into breast milk, and they have shorter half-lives leading to a lower risk of accumulation in a breastfed infant. Labetalol and metoprolol also do not rely on excretion in the urine, again leading to less risk of accumulation
amount of beta-blockers found in breastmilk varies depending on the exact medication (2)
atenolol, acebutolol, and nadolol are present in high amounts in breast milk and may not be recommended while breastfeeding
propranolol, labetalol, and metoprolol have been found in small amounts in breastmilk and are considered compatible with breastfeeding.
labetalol and propranolol are used therapeutically in neonates, and metoprolol in infants from one month of age
however, any beta-blocker may be used during breastfeeding if clinically appropriate, although more careful monitoring may be required
labetalol
infant monitoring whilst using labetalol whilst breastfeeding (1)
as a precaution, monitor infants for signs of bradycardia or hypoglycaemia including drowsiness, lethargy, and poor feeding and inadequate weight gain
hypoglycaemia may also manifest as jitteriness/ tremors, sweating, irritability, fast breathing, looking pale, and unusual cry
notes on labetalol
limited evidence indicates that levels in breast milk are generally very small
most breastfed infants are likely to get less than 1% of maternal weight-adjusted dose via breast milk
labetalol is mostly metabolised in the liver, and its half-life in adults is 6-8 hours
risk of accumulation in a breastfed infant is therefore low
most studies have not reported any adverse effects in breastfed infants
one premature infant developed sinus bradycardia when exposed to labetalol via breast milk, suggesting additional caution is needed in very young or premature infants
metoprolol
infant monitoring whilst using metoprolol whilst breastfeeding (1)
as a precaution, monitor infants for signs of bradycardia or hypoglycaemia including drowsiness, lethargy, and poor feeding and inadequate weight gain
hypoglycaemia may also manifest as jitteriness/tremors, sweating, irritability, fast breathing, looking pale, and unusual cry
notes on metoprolol
limited evidence indicates that amounts in breast milk are generally very small
most breastfed infants are likely to get less than 2% of the weight-adjusted maternal dose of metoprolol via breast milk
metoprolol is mostly metabolised in the liver, and its half-life in most adults is 3-7 hours, and 5-10 hours in neonates
note though that, metoprolol is metabolised by the hepatic cytochrome P450 2D6 enzyme
some individuals do not have effective levels of this enzyme ("poor metabolisers"), resulting in slower metabolism and a half-life of 7-9 hours in adults, and presumably longer in neonates
s may increase the risk of infant side effects
risk of significant accumulation in a breastfed infant is therefore relatively low, but not impossible, especially in very young infants
propranolol
infant monitoring whilst using propranolol whilst breastfeeding (1)
as a precaution, monitor infants for signs of bradycardia or hypoglycaemia including drowsiness, lethargy, and poor feeding and inadequate weight gain
hypoglycaemia may also manifest as jitteriness/tremors, sweating, irritability, fast breathing, looking pale, and unusual cry
notes on propranolol
limited evidence indicates the amounts in breast milk are very small
most breastfed infants are likely to get less than 1% of the weight-adjusted maternal daily dose of propranolol via breast milk
despite propranolol almost being completely excreted in the urine, it is highly lipid soluble and highly protein bound, and has a half-life of 3-6 hours
accumulation in a breastfed infant is therefore unlikely
have been no reported side effects in infants clearly attributed to exposure to propranolol via breast milk
is used therapeutically in infants from birth
Effect on breastfeeding
beta-blockers are not known to have an effect on breastfeeding (1)
however, non-selective beta-blockers (especially labetalol) have been reported to cause nipple pain or Raynaud’s phenomenon of the nipple
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