May 25, 2020

Rebellion in EM 2019: Got Milk? via Jenny Beck-Esmay, MD

“You’re working a shift in whatever the lower acuity version is of your department. So maybe it’s fast track, maybe you call it an urgent care. Whatever it is, it’s a unit where they take doctors, who trained for 7 or 8 years to become expert resuscitationists, and make us spend all day seeing sniffles, sore throats and chronic back pain in a manner that I can only assume was designed specifically to make us all exceptionally crazy. But, either way: that’s where you’re working. You’ve taken care of a young woman, you’ve treated her ailments, you’ve decided what’s wrong with her. And you’re deciding you are going to prescribe a few medications for her and send her on her way. You’ve answered all of her questions and you are walking out the door, your hand is on the door handle and she says “Oh, but doc, did I tell you I’m currently breastfeeding my 6-month old baby? Can I even take these medications?” And your heart stops. And you freeze. And your hand is still on the door handle. And the first thought that goes through your head is “Oh my God, I have no idea.” Because you, like most of us, had one lecture on medications in pregnancy and lactation back in your second year of medical school and you have no idea what you learned. That’s your first thought. “Oh my god, I have no idea.” Your second thought is “Oh my god, I have 8 more patients that just got triaged, while I had that thought. What am I gonna do?” Your third thought then is that you breathe a sigh of relief and you go “It’s ok, I’ve got an ED pharmacist. I’ll just ask her.” But then you’re horrified again because you realized it’s Saturday! And while you work in a 24/7/365 emergency department, your department has decided to staff this one crucial member for just business hours from Monday through Friday. And you think “That’s terrible.” And now you’re back to horror. Because, again, you don’t know what to do. And another 8 patients have been triaged and they all have chronic back pain and they’re asking why they haven’t been seen yet. And you’re still in that room and your hand is still on the door. Now you think “I don’t know. I don’t know.” “Honestly lady, I don’t know, you probably should just pump and dump.” Out of an abundance of caution we always just revert back to “You should pump and dump.” But I’m going to argue that that’s probably not the best strategy.”

Rebellion in EM 2019: Got Milk via Jenny Beck-Esmay, MD

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Clinical Question:

The blind application of a “pump and dump” strategy is hurting our patients and their families. What is the approach to patients who are lactating? What are some tools to help us make decisions as we care for these patients?

Background:

We know that medications will diffuse into breastmilk based on many factors, for example:

  • Lipid soluble and nonionic medications will diffuse more rapidly into breastmilk
  • Medications that bind to proteins will diffuse less rapidly into breast milk

“But either way, it doesn’t really matter because most medications are going to be detoxified by the neonate without any problem. So the “pump and dump” strategy should only be recommended when it is crucial to do so. Why? Because breastfeeding is good.”

Benefits of breastfeeding include:

  • Breastfed infants have decreased risks of type 2 DM, obesity, asthma, ear and respiratory infections and SIDS.
  • Moms who breastfeed have decreased risk of type 2 DM, hypertension, ovarian and breast cancers.

And we know that moms want to do this. But based on CDC data on babies born in 2015:

  • After birth: 83.2% started off breastfeeding
  • By 6 months: 57.6% are still breastfeeding
  • By 12 months: 35.9% are still breastfeeding

So we’re failing in our ability to keep these mothers breastfeeding. And that’s bad because according to the WHO and UNICEF, infants need to be breastfed for as long as possible. They recommend:

  • 0-6 months: exclusive breast feeding
  • 6 months – 2 years: breastfeeding alongside age-appropriate solid foods

Recommendations:

Resources to have on-hand during shifts:

  1. LactMed: “searchable, internet based, database brought to you by the NIH. It’s online and it’s also available in a free app. You can type in almost literally any medication and get specific, really easy to interpret medical information about whether this medication is safe to use in a lactating patient.”
  2. InfantRisk: “this is a 1-800 hotline number available during business hours in central time. And what I like about this is it’s probably not what you’re going to use, but you can give this phone number to your patients and they can get advice on something over the counter without your advice.”

Relevant medication recommendations:

  • Intubation:
    • Etomidate, Propofol, Succinylcholine and Rocuronium: all safe in patients who are lactating.
    • Ketamine: insufficient evidence in humans. Current guidelines are to avoid use in patients known to be lactating.
      • Note: “These guidelines are designed for anesthesiologists who have time to plan an intubation. If you are intubating in the ED or out in the field, you need to do whatever you have to do to save that patient’s life. Which is probably using whatever you are comfortable with.”
    • Imaging:

Patient care recommendations:

  1. “I want you to ask your patients if they could be lactating. We are very good at asking our patients if they are pregnant. And we don’t believe them anyway, and we order a test to see. But we never ask if they could be lactating. If we just ask any young woman of reproductive age if they are breastfeeding at home. Then we would know far earlier in the care of our patients and that’s going to affect every decision we make and we’re not going to be making a panicked decision with our hand on the doorknob.”
  2. “These women who are nursing need to be feeding their infants or pumping every 3-4 hours for a couple of reasons. 1) to maintain their milk supply and 2) for their own comfort. I don’t know about you, but in my ER, any patient who is getting any amount of work-up is probably going to be there for at least 3-4 hours. And certainly if you’re going to be admitting them, they are going to be in my department for more than 3-4 hours. Your hospital has breast pumps, do what you can to facilitate the pumping needs of your nursing mothers.”

Treating mastitis:

  • Definition: painful, red, swollen breast tissue that’s usually caused by nipple trauma and/or clogged milk ducts.
  • Treatment
    • Within first 24 hours: warm compresses, anti-inflammatories like Ibuprofen and frequent nursing or pumping
    • No improvement after 24 hours: give antibiotics, choices include: Dicloxicillin, Cephalexin and Clindamycin.
    • No improvement despite antibiotics: get an ultrasound to rule out breast abscess
  • Important note: advise patients to keep breastfeeding or pumping. A major cause is clogging of the ducts, so this becomes vital in treatment.

Transcript/Summary By: Yasien Eltigani, MS4 at St. George’s University (@yasieneltigani)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Salim Rezaie, "Rebellion in EM 2019: Got Milk? via Jenny Beck-Esmay, MD", REBEL EM blog, May 25, 2020. Available at: https://rebelem.com/rebellion-in-em-2019-got-milk-via-jenny-beck-esmay-md/.
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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of REBEL EM
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