In recent years, there has been a focus on encouraging exclusive breast-feeding for infants for approximately the first 6 months of life, and ideally for the first 1 year in combination with strained foods (American Academy of Pediatrics, 2012). These recommendations are supported by a number of professional groups concerned with promoting pediatric and adult health (Table 1). Endorsements are based on years of research on benefits of breast-feeding for mothers and infants and how human milk is uniquely suited to human infants, and therefore should be the first choice for infant feeding (Bar, Milanaik, & Adesman, 2016; Binns, Lee, & Low, 2016; Gertosio, Meazza, Pagani, & Bozzola, 2016; Sankar et al., 2015).
Professional Organizations Supporting Breastfeeding
Benefits for breastfeeding mothers include lower rates of breast and ovarian cancers and type 2 diabetes, as well as amenorrhea while breastfeeding for better pregnancy spacing (Victora et al., 2016). Breastfeeding is a possible protective factor against multiple sclerosis (MS), and women with MS experience fewer postpartum relapses when they exclusively breastfeed (Langer-Gould et al., 2017).
In infants, breastfeeding is linked to lower rates of infant mortality, including from sudden infant death syndrome (Debes, Kohli, Walker, Edmond, & Mullany, 2013; Sankar et al., 2015); protective effects against infection (Duijts, Jaddoe, Hofman, & Moll, 2010; Kramer & Kakuma, 2012); lower rates of dental malocclusion and obesity (Moss & Yeaton, 2014; Perrine, Galuska, Thompson, & Scanlon, 2014); and increases in cognitive function compared to formula-fed babies (Belfort et al., 2013; Huang, Peters, Vaughn, & Witko, 2014; Julvez et al., 2014; Kramer & Kakuma, 2012; Tozzi et al., 2012). Breastfeeding is also encouraged for mothers who use opioid drugs as an effective way to manage infant symptoms while the infant is going through withdrawal (Welle-Strand et al., 2013).
In recent years, emphasis has been less on documenting the benefits of breastfeeding and more on how to achieve the breastfeeding goals specified by Healthypeople.gov (2014). National and international goals that promote breastfeeding for all mothers who have the ability to breastfeed created a demand for more lactation support. To meet breastfeeding goals requires support of all care providers who interface with nursing mothers in any capacity.
Recommendations encouraging breastfeeding for all infants have been based on an accumulation of research regarding benefits of breastfeeding measured against evidence on levels of transmission of maternal medications via breast milk, and concern regarding medications' effects on infant health and development. Studies conducted have resulted in professional recommendations that no longer necessarily preclude the medicated mother from breastfeeding, but balance the benefits of breastfeeding and evidence on the risk to the infant of not medicating breastfeeding mothers with psychiatric conditions.
The purpose of the current article is to provide information on what psychiatric care providers should know when their patient is a breastfeeding mother: the possible psychological risks of discontinuing breastfeeding without careful consideration, resources available on breastfeeding support for women with psychiatric challenges, and how to determine which psychiatric drugs are or may be safe for breast-feeding.
Psychological Issues That May Affect Breastfeeding
There are common issues that can become apparent with breastfeeding mothers over time when their child is being seen for care by pediatric health care providers and lactation counselors. Breastfeeding can benefit women struggling with psychological issues, but may also deepen their distress. Below is a description of the types of issues pediatric providers see most often with breast-feeding mothers that may lead to a psychiatric referral and pose complications for breastfeeding.
Supportive documentation was drawn exclusively from peer-reviewed studies, meta-analyses, systematic reviews, and professionally supported websites designed to give professionals the most current information. Experiences reported from a focus group of 42 lactation counselors were also included to report common psychological issues encountered during lactation support by these counselors (Terres et al., 2013). Because of current emphasis on researching ways to support breast-feeding mothers, most research on the effects of breastfeeding on psychological state precedes the usual 5-year window on reporting health-related research. Some studies that preceded 5 years were included along with the more current literature because they offered insights into the relationship between a woman's psychological state and breastfeeding, or were the only studies addressing a particular psychological issue in relation to breastfeeding. No studies exist related specifically to breastfeeding issues raised by mothers treated for psychosis, suggesting an area for research.
Depression and Anxiety
Maternal depression and anxiety are the most common issues that result in the referral of a postpartum woman for psychiatric therapy (Bergink, Rasgon, & Wisner, 2016; Fairbrother, Janssen, Antony, Tucker, & Young, 2016; Falah-Hassani, Shiri, & Dennis, 2016). Aside from the biologically adverse and persistent effects of maternal depression on child development (Apter-Levy, Feldman, Vakart, Ebstein, & Feldman, 2013; Conroy et al., 2012; Diego, Jones, & Field, 2010; Granat, Gadassi, Gilboa-Schechtman, & Feldman, 2017; Quevedo et al., 2012; Skotheim et al., 2013), there is some evidence that depression adversely affects breast-feeding, accounting for lower rates of breastfeeding duration in mothers with depression (Adedinsewo, Fleming, Steiner, Meaney, & Girard, 2014; Gagliardi, Petrozzi, & Rusconi, 2012). In some studies, depression was associated with lack of breastfeeding intention across cultures (Insaf et al., 2011; Nishioka et al., 2011). Depression undermines maternal confidence and disrupts the parent–infant bond, which leads to misreading infant feeding cues essential for successful breastfeeding (Field, 2011; Figueiredo, Canário, & Field, 2014). A link between depression and breastfeeding across studies was the lower level of self-efficacy in depressed women.
Some postpartum mothers experience posttraumatic stress disorder (PTSD), which can arise from physical or psychological difficulties in the prenatal period (Christodoulou-Smith et al., 2011; Kozhimannil, Jou, Attanasio, Joarnt, & McGovern, 2014), and traumatic birth experiences (Hahn-Holbrook, Haselton, Dunkel Schetter, & Glynn, 2013). Studies describe PTSD as negatively affecting the mother's choice to breastfeed and her sense of self-efficacy (Beck & Watson, 2008).
Some studies reported lower levels of depression in women who breast-fed compared to those who did not (Field, 2011; Field et al., 2010; Hahn-Holbrook et al., 2013; Zhu, Hao, Jiang, Huang, & Tao, 2013), suggesting that breastfeeding may offer advantages for depressed mothers. Although not examined in the studies, the advantage might be for mothers with successful breastfeeding rather than mothers who struggle and experience complications with breastfeeding.
As with depression, maternal anxiety affects women in multiple ways, including with breastfeeding. High levels of maternal anxiety can affect self-efficacy and undermine even the best breastfeeding intentions (Fallon, Groves, Halford, Bennett, & Harrold, 2016; Petzoldt, Wittchen, Einsle, & Martini, 2016). Anxiety regarding the belief that they have insufficient milk and returning to work are reasons mothers across cultures and socioeconomic groups most often discontinue breastfeeding, and these worries can be significant sources of breastfeeding anxiety even for mothers who continue to breastfeed (Attanasio, Kozhimannil, McGovern, Gjerdingen, & Johnson, 2013; Bartick & Reyes, 2012; Cottrell & Detman, 2013; Hedberg, 2013; Ishak et al., 2014). Anxiety interfering with breastfeeding may be rooted in layers of psychological factors such as self-concept, personality and economic factors, past experiences with breastfeeding, and influence of social support systems (Alexander, Dowling, & Furman, 2010; Christodoulou-Smith et al., 2011).
An estimated 68% of women in one study pumped milk, preferring to feed their infant the expressed milk rather than putting the baby to breast (Geraghty, Davidson, Tabangin, & Morrow, 2012). Exclusive pumping was a practice previously associated with women with premature or sick infants or mothers returning to work, with the milk supply often not sustainable over a prolonged period of time pumping. A study of 2,587 women documented that less than 6% of the sample mothers exclusively fed their infants pumped milk, and that breastfeeding duration was ≤1 month in these women (Shealy, Scanlon, Labiner-Wolfe, Fein, & Grummer-Strawn, 2008). Because a milk supply can be more difficult to sustain over time while exclusively pumping, pump-and-feed can ultimately work against the goal for exclusive breastfeeding for 6 months to 1 year. A more prudent approach would be to directly address anxieties that may be driving the mother's wish to pump rather than put the baby to breast.
In recent years, an increased number of women with eating disorder histories have been seen for prenatal care (Easter et al., 2015; Pettersson, Zandian, & Clinton, 2016; Sohail & Muazzam, 2012), and a higher rate of eating disorders has been found in pregnant women without previously identified histories of eating disorders (Broussard, 2012; Pettersson et al., 2016). Most research on eating disorders focuses on pregnancy rather than breastfeeding, indicating a high rate of remission of disordered eating behaviors during pregnancy (Bulik et al., 2007; Madsen, Hørder, & Støving, 2009), and high rates of depression and anxiety in pregnant women with such histories (Micali, Simonoff, Stahl, & Treasure, 2011). Although some women experience eating disorders during pregnancy and postpartum (Taborelli et al., 2016), difficulties with adjustment to motherhood have also been documented in women with eating disorders, with the most salient association being depression (Tierney, Fox, Butterfield, Stringer, & Furber, 2011).
How breastfeeding affects women with histories of eating disorders is not well researched. Existing studies report no difference in the initiation rates of breastfeeding between mothers with and without eating disorders (Tierney et al., 2011; Zanardo et al., 2016), but describe the persistence of the ideations associated with eating disorders throughout pregnancy and the postpartum (Goncalves, Freitas, Freitas-Rosa, & Machado, 2015), a desire expressed by the breastfeeding mother to bottle feed as soon as possible so as to return to her previous eating behavior (Stapleton, Fielder, & Kirkham, 2008), and an increased risk of postpartum depression in women with eating disorders compared to those with a history of eating disorders (Knoph et al., 2013). Women with anorexia nervosa were also found more likely to report a history of sexual trauma (Meltzer-Brody et al., 2011).
Most of the literature on sexual abuse and breastfeeding is based on case studies and clinical experiences of the authors with such clients. Most studies are not recent. In a case-based qualitative study, Beck (2009) described breast-feeding as triggering panic attacks, dissociation, and flashbacks to child sexual abuse. Bowman, Ryberg, and Becker (2009) found no relationship between sexual abuse and breastfeeding in Hispanic women. Due to evidence of its superiority over formula feeding, breastfeeding can be viewed by women as a moral choice, influencing them to breastfeed despite a history of sexual trauma (Burns, Schmied, Sheehan, & Fenwick, 2010), which may account for why women who reported childhood sexual abuse were more likely to breast-feed than women without that history (Prentice, Lu, Lange, & Halfon, 2002). Breastfeeding helped shift the association from the abuse to the positive feature of using an optimal infant feeding method (Wood & Van Esterik, 2010). A study conducted in Norway found a lower duration of breastfeeding in women with either a history of sexual abuse or any type of child abuse (Sørbo, Lukasse, Brantsæter, & Grimstad, 2015). In a study that included 944 women with a history of sexual assault, Kendall-Tackett, Cong, and Hale (2013) found that sexual assault survivors who breastfed were at lower risk on sleep and depression parameters than women with the same history of sexual assault who were formula feeding or mixing breast with bottle. Mothers in the study breastfed for ≤4 months (Kendall-Tackett et al., 2013), prompting the question of whether the mothers stopped nursing due to psychological or nonpsychological factors.
In summary, women with the types of psychological issues most often seen in pediatric practices may or may not benefit from continuing to breastfeed. Psychiatric providers are in the best position to evaluate the underlying motives of why the mother insists on continuing to breastfeed even in the face of any increase in distress with breast-feeding, and whether discontinuation of breastfeeding is in the best interests of the mother's psychological health.
Breastfeeding issues with any patient, especially a particularly vulnerable patient, often require consultation with an expert in breastfeeding. Just as obstetric and pediatric nurses at all levels of practice consult regularly with such experts, recognizing breastfeeding support as its own clinical specialty, psychiatric providers should know the limits of their ability to provide breast-feeding advice and seek an appropriate resource for themselves and the mother if the breastfeeding issues may be better addressed with such consultation.
Lactation Consultants as Critical Breastfeeding Resources
With short postpartum hospital stays, psychological issues may not become evident until days or weeks after hospital discharge, during which time community-based lactation consultants have forged a support relationship with mothers. Lactation consultants are in the best position to evaluate whether any physical problems the mother or infant might have breastfeeding have been fully addressed before the mother makes decisions about whether to continue breastfeeding.
Lactation counselor is a generic term. Lactation counselors have various levels of preparation: they may be volunteers who have breastfeeding experience but no certification, or counselors with considerable education and breastfeeding certification. Individuals with and without formal health care delivery backgrounds can be found at each level of lactation counseling and certification. Only International Board Certified Lactation Consultant® (IBCLC®) –certified counselors are prepared at a level of certification to handle the most complex breastfeeding situations, and only this level of certification qualifies a person to be called a lactation consultant. Lactation consultants are the breastfeeding support resource of choice for mothers with psychiatric histories and babies with complex feeding issues. The IBCLC–certified lactation consultant working in conjunction with psychiatric clinicians focuses on the mother's individual breastfeeding needs in the context of the mother's special issues. IBCLC certification is currently the credential required for insurance reimbursement for plans that will reimburse for lactation support services (International Board of Lactation Consultant Examiners, 2017).
Lactation counselors can be found on websites pertaining to the counselor's certification. Some websites will identify breastfeeding counselors by town or area, such as ZipMilk.org (access http://www.zipmilk.org). A caution to consider is that lists may not be up to date regarding which listed counselors are still engaged in breastfeeding support, and some counselors may work more collaboratively than others. The best resource is asking an obstetric or pediatric health care provider whom they would recommend based on their experiences with lactation consultants. IBCLC–certified pediatricians and pediatric nurse practitioners are also sometimes affiliated with primary care practices and provide breastfeeding support in addition to assessing the health and well-being of the infant over time. A pregnant woman in psychiatric care who has not yet chosen a pediatric practice for her infant could be directed to pediatric primary care providers who either are IBCLC–certified or have IBCLC–certified breastfeeding consultants in their practice.
The lactation counselor's main goal is to promote and support breastfeeding. How that goal might be affecting the mother could be missed or not suffi-ciently considered, creating more stress for the mother. As a result, the continued encouragement mothers receive from lactation counselors may be interpreted as purposeful pressure, if not coercion, to continue to breastfeed despite the mother's wishes to stop. The pressure the mother may feel from lactation counselors could be the result of knowing about the advantages of breast milk for an infant yet not being able to breastfeed, or feeling that the level of distress breastfeeding creates may not be good for her or the baby (Burns et al., 2010; Byrom, 2013). Guilt about discontinuing breastfeeding may be related to the mother's self-concept, as women who stop breastfeeding demonstrate a lower self-concept than mothers who exclusively breastfeed (Britton & Britton, 2008). Distress regarding the process of breastfeeding can affect the mother's sense of self-efficacy and work against breastfeeding goals (Coates, Ayers, & de Visser, 2014; Fallon et al., 2016). A psychiatric clinician, working in concert with the lactation consultant, can assess whether the mother is committed to breastfeeding or breastfeeding out of guilt, to her own detriment. Collaborating with the lactation consultant regarding approaches to the mother that are more supportive of the mother's goals and wishes, and including the best ways to discontinue breastfeeding for the mother's comfort and the baby's transition to bottle feeding, can minimize the physical and emotional discomfort of breast engorgement and hormonal shifts that come with rapid discontinuation of breastfeeding. Breastfed infants do not always readily accept bottle feeding, especially from the mother, who was the previous direct source of feeding for the infant. In such circumstances, psychiatric providers should interpret for the mother that the infant's behavior is not a personal rejection, but a sense of infant confusion or temporary discomfort over the change in nipples, taste, proximity to the mother's body, and other features typical of breastfeeding. If the mother has a partner or other supports at home, having the infant adjust to bottle feeding via other feeders can be a great support to the mother during the weaning process.
Psychiatric Medications and Breastfeeding
The use of any medication during pregnancy and breastfeeding is usually met with caution. Discontinuing psychiatric medication during this period leaves mothers at a particularly vulnerable time of their lives, without medications that controlled their symptoms before pregnancy, or that address the mothers' postpartum need for medication along with their infants' need for an optimal feeding method (Maina, Rosso, Aguglia, & Bogetto, 2014; Viguera et al., 2011).
Research on the safety of specific medications for pregnant and nursing mothers has produced mixed results in terms of effects of specific drugs on breastfeeding infants. Most studies are focused on the effects of prenatal medications, and on short-rather than long-term effects on the infant (Adam, Polifka, & Friedman, 2011; Howard et al., 2014; Sachs, 2013). Evidence that exists on adverse effects on the infant is often contradictory, and different outcomes have been found among studies for the same drug, suggesting that there are other variables that may be affecting the outcome, or perhaps are synergistic with the medication (Anderson, Manoguerra, & Valdés, 2016; Austin et al., 2013; Galbally, Lewis, & Buist, 2011; Hanley, Brain, & Oberlander, 2013; Payne, 2017; Quevedo et al., 2012).
Because of limitations on types of studies that can be ethically conducted on pregnant women and infants, research on drug safety for these populations is retrospective, observational, based mostly on case reports, or conducted primarily on rodents, as opposed to the gold standard of randomized double-blind placebo controlled large sample human studies that are preferred when testing drugs for recommendations in adult, non-pregnant populations. Conclusions about safety involve small samples, correlations rather than causations, focus on the psychiatric drug alone rather than other variables that could affect the same infant outcome, or rely on self-report rather than toxicology screening for substances such as tobacco, alcohol, and others associated with adverse effects on infants. Some studies include mothers taking a variety of medications, making it difficult if not impossible to isolate the effect of any one drug (Klinger, Stahl, Fusar-Poli, & Merlob, 2013; Liu et al., 2017; Var, Ince, Topuzoglu, & Yildiz, 2013). Increasingly, guidelines for medication use are based on examining studies together as a conglomerate rather than examining any one small set of case studies (Whitworth, 2017). When examined as a whole, studies that exist on effects of maternal psychiatric medication on breastfeeding infants provide little evidence of infant harm for most medications in mothers treated for psychiatric illness, particularly those treated for depression (Kronenfeld, Berlin, Shaniv, & Berkovitch, 2017; Larsen et al., 2015; Pacchiarotti et al., 2016; Rowe, Baker, & Hale, 2015). Even the previous restrictions on lithium have come under question due to findings from increased research on effects of lithium on infants (Anderson et al., 2016; Bogen, Sit, Genovese, & Wisner, 2012; Moretti, Koren, Verjee, & Ito, 2003; Uguz & Sharma, 2016; Viguera et al., 2007).
Research on the effects of maternal antipsychotic medications on the breastfeeding infant reveals little evidence documenting significant levels of most drugs in breast milk (Uguz, 2016). Recommendations on the safety of these drugs is based on evidence gleaned from case studies, the incidence of maternal galactorrhea, alterations in prolactin levels that affect milk supply, or safety of a drug within specific doses. Recommendations against specific drugs are based mostly on lack of studies or the fact that another drug has been studied and should be chosen on that basis (Frew, 2015; Klinger et al., 2013; Kronenfeld et al., 2017; Weggelaar, Keijer, & Janssen, 2011).
Although research on the effects of maternal psychiatric medication on infants is ongoing, a number of psychiatric drugs have been approved for use in pregnancy and breastfeeding (Anderson et al., 2016; Payne, 2017; Rowe et al., 2015). The American Academy of Pediatrics has guidelines of what to consider when prescribing for mothers (especially those whose infants are ≤2 months old), which include whether the infant was pre- or full-term, which drugs may accumulate in the breast milk in regard to infants' immature metabolic and renal systems for eliminating the drug once ingested from the breast milk, and other health conditions of the infant; or maternal health conditions such as HIV or cancer–related chemotherapy (Sachs, 2013).
Because of the evolving nature of research on the effects of psychiatric medications on breastfeeding infants, health care providers, including psychiatric clinicians, should not base their prescriptive decisions without consulting an evidence-based resource listing which medications are considered safe for the breastfeeding infant. Such research is regularly published in medical journals and appears on various websites. One of the most comprehensive references for breastfeeding medication research is the work of Texas pharmacist, researcher, and professor, Thomas Hale, and colleague, Hilary Rowe. Their book on medications and mother's milk is updated often, available online, and the reference of choice for lactation counselors at all levels of certification (Hale & Rowe, 2017; Terres et al., 2013).
Other resources for identifying medications safe for the breastfeeding infant can be found on various websites, but must be viewed with caution, as some of the sites are not as up-to-date as others, have come under criticism for not having been adequately vetted for research rigor, or do not provide enough evidence to be able to prescribe without concern about effects on the infant. Table 2 lists some of the most reliable professional websites that address breastfeeding medication safety and are involved in efforts to keep information current according to peer-reviewed studies. For example, LactMed® is a website that is updated monthly, favored by pediatricians, and most often cited in pharmacologically focused articles on prescribing for the breastfeeding mother (United States National Library of Medicine: Toxicology Data Network, 2018). Information from these sites must be supplemented with clinical judgement regarding the specifics of individual cases, and checked frequently for updates for the most current information. Published studies that include charts for safe versus non-safe maternal drugs for breast-fed infants are not substitutes for a web-site such as LactMed. LactMed is most current in its updates and recommends alternative medications that are safer for the infant or that can be tried if the mother's milk supply is affected by a specific drug.
Resources for Psychiatric Clinicians Working with Breastfeeding Mothers: Website References for Medications Safe for the Breastfeeding Infant
Collaboration with the infant's health care provider will give perspective on how the infant may be responding to the breastfeeding mother's medication, assuming the mother in therapy gives consent for such communication. If consent is not given for this communication, asking the mother about the health and development of the infant, just as the clinician would assess the effects of any prescribed medication on the mother, is an important part of medication assessment. Any observed or reported areas of concern, such as infant health concerns, questions about developmental progress, or concerns about the mother–infant affective relationship, should be noted. Mothers should be encouraged by their psychiatric clinician to be forthcoming with their child's pediatric health care provider about any medications she is taking.
Pediatric providers tend to support the use of psychiatric medications for nursing mothers, even in the face of methodological concerns about the literature on effects of the drugs on infants, because of the stronger evidence on the adverse effects on the neurological development and behavior of infants and children of mothers struggling with psychiatric conditions, in particular depression (Apter-Levy et al., 2013; Conroy et al., 2012; Douglas & Harmer, 2011; Field, 2011; Granat et al., 2017; Quevedo et al., 2012; Skotheim et al., 2013). Any negative effects on infants from medicating breastfeeding mothers described in the research are considered more manageable than the longer-term effects on the infant of maternal depression (Sachs, 2013). Consequently, pediatric care providers, considering the risk–benefit ratio of a mother with a psychiatric condition either not taking her medication or not breastfeeding because she is medicated, increasingly choose to encourage breastfeeding in the medicated mother (Payne, 2017; Sachs, 2013).
Psychiatric clinicians may decide after reviewing the evidence that the risks to the infant of medicating the breastfeeding mother are greater than not medicating the mother unless she discontinues breastfeeding, or that the resources to make that decision are not sufficient to make the individual clinician feel comfortable to prescribe. The current article provides the psychiatric clinician with information and resources available regarding medicating breastfeeding mothers that are in use by other health care providers in their decision making, and not as a substitute for clinical judgement in individual cases.
Supporting women to successfully breastfeed while working with the mother to cope with psychological issues that require medication need not be mutually exclusive goals. There is little research to support the concern of harm to the breastfeeding infant if the mother is taking specific psychiatric medications. In contrast, there is stronger evidence on the negative effects of untreated maternal psychiatric illness on infants. Therefore, no solid argument exists against breastfeeding for mothers who are pharmacologically treated with many of the psychiatric medications tested.
The best interests of a breastfeeding mother can be served by psychiatric clinicians who are familiar with the research on breastfeeding and the psychological effects of maternal decisions around breastfeeding, as well as the resources available regarding latest research on medication safety for nursing infants. Forming relationships with lactation consultants with whom the psychiatric clinician and mother can work collaboratively can assist the psychiatric clinician in supporting maternal goals for breastfeeding while providing the optimal psychological care the mother requires.
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Professional Organizations Supporting Breastfeeding
|American Academy of Pediatrics||https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/aap-reaffirms-breastfeeding-guidelines.aspx|
|Academy of Breastfeeding Medicine||http://www.bfmed.org/about|
|American College of Nurse Midwives||http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000248/Breastfeeding-statement-Feb-2016.pdf|
|American College of Obstetricians and Gynecologists||https://www.acog.org/About-ACOG/ACOG-Departments/Breastfeeding|
|American Public Health Association||https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/13/23/a-call-to-action-on-breastfeeding-a-fundamental-public-health-issue|
|Association of Women's Health, Obstetric and Neonatal Nurses||https://www.awhonn.org/?Breastfeeding|
|Baby-Friendly Hospital Initiative||https://www.babyfriendlyusa.org/get-started/the-guidelines-evaluation-criteria|
|Healthy People 2020 Initiatives for Maternal–Child Health||http://www.usbreastfeeding.org/p/cm/ld/fid=221|
|Health and Human Services||http://www.pnmc-hsr.org/wp-content/uploads/2011/01/BreastfeedingBlueprint.pdf|
|World Health Organization||http://www.who.int/topics/breastfeeding/en|
Resources for Psychiatric Clinicians Working with Breastfeeding Mothers: Website References for Medications Safe for the Breastfeeding Infant
|Resource||URL||Site C haracteristics|
|American Academy of Pediatrics (AAP)|
|Medical professional body for setting the standards for pediatric health care. Standards based on a subcommittee's examination of the research on drugs and the benefits of breastfeeding, considering risk–benefit ratios.|
|Centers for Disease Control and Prevention (CDC)|
|General guidelines on disease conditions requiring cessation of breastfeeding; referring primarily to the AAP list for specific safe medications for breastfeeding infants and World Health Organization guidelines.|
|Information from pharmacists, Cerner MultumTM, Micromedex®, Wolters Kluwer Health publishers, and the FDA are detailed on the website (access https://www.drugs.com/support/editorial_policy.html).|
|U.S. Food and Drug Administration (FDA)|
|Provides general information on FDA-approved medications and labeling requirements, taken from studies that were deemed to provide sufficient evidence to warrant a specific cautionary label.|
|United States National Library of Medicine. Toxicology Data Network: Drugs and Lactation Database (LactMed®)|
|National Institutes of Health–sponsored site. Drugs can be entered into a search function; results describe details of the drug and its use during lactation. AAP preferred reference.|