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The Transfer of Drugs and Other Chemicals Into Human Milk Committee on Drugs Pediatrics 2001;108;776
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2001 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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AMERICAN ACADEMY OF PEDIATRICS

Committee on Drugs
The Transfer of Drugs and Other Chemicals Into Human Milk

ABSTRACT. The American Academy of Pediatrics places emphasis on increasing breastfeeding in the United States. A common reason for the cessation of breastfeeding is the use of medication by the nursing mother and advice by her physician to stop nursing. Such advice may not be warranted. This statement is intended to supply the pediatrician, obstetrician, and family physician with data, if known, concerning the excretion of drugs into human milk. Most drugs likely to be prescribed to the nursing mother should have no effect on milk supply or on infant well-being. This information is important not only to protect nursing infants from untoward effects of maternal medication but also to allow effective pharmacologic treatment of breastfeeding mothers. Nicotine, psychotropic drugs, and silicone implants are 3 important topics reviewed in this statement. INTRODUCTION
statement on the transfer of drugs and chemicals into human milk was first published in 1983,1 with revisions in 19892 and 1994.3 Information continues to become available. The current statement is intended to revise the lists of agents transferred into human milk and describe their possible effects on the infant or on lactation, if known (Tables 17). If a pharmacologic or chemical agent does not appear in the tables, it does not mean that it is not transferred into human milk or that it does not have an effect on the infant; it only indicates that there were no reports found in the literature. These tables should assist the physician in counseling a nursing mother regarding breastfeeding when the mother has a condition for which a drug is medically indicated.
BREASTFEEDING AND SMOKING
In the previous edition of this statement, the Committee on Drugs placed nicotine (smoking) in Table 2, Drugs of Abuse-Contraindicated During Breastfeeding. The reasons for placing nicotine and, thus, smoking in Table 2 were documented decrease in milk production and weight gain in the infant of the smoking mother and exposure of the infant to environmental tobacco smoke as demonstrated by the presence of nicotine and its primary metabolite, cotinine, in human milk.4 12 There is controversy regarding the effects of nicotine on infant size at 1 year of age.13,14 There are hundreds of compounds in tobacco smoke; however, nicotine and its metabolite acotinine are most often used as markers of tobacco
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. PEDIATRICS (ISSN 0031 4005). Copyright 2001 by the American Academy of Pediatrics.
exposure. Nicotine is not necessarily the only component that might cause an increase in respiratory illnesses (including otitis media) in the nursing infant attributable to both transmammary secretion of compounds and environmental exposure. Nicotine is present in milk in concentrations between 1.5 and 3.0 times the simultaneous maternal plasma concentration,15 and elimination half-life is similar 60 to 90 minutes in milk and plasma.7 There is no evidence to document whether this amount of nicotine presents a health risk to the nursing infant. The Committee on Drugs wishes to support the emphasis of the American Academy of Pediatrics on increasing breastfeeding in the United States. Pregnancy and lactation are ideal occasions for physicians to urge cessation of smoking. It is recognized that there are women who are unable to stop smoking cigarettes. One study reported that, among women who continue to smoke throughout breastfeeding, the incidence of acute respiratory illness is decreased among their infants, compared with infants of smoking mothers who are bottle fed.16 It may be that breastfeeding and smoking is less detrimental to the child than bottle feeding and smoking. The Committee on Drugs awaits more data on this issue. The Committee on Drugs therefore has not placed nicotine (and thus smoking) in any of the Tables but hopes that the interest in breastfeeding by a smoking woman will serve as a point of discussion about smoking cessation between the pediatrician and the prospective lactating woman or nursing mother. Alternate (oral, transcutaneous) sources of nicotine to assist with smoking cessation, however, have not been studied sufficiently for the Committee on Drugs to make a recommendation for or against them in breastfeeding women.
PSYCHOTROPIC DRUGS
Anti-anxiety drugs, antidepressants, and neuroleptic drugs have been placed in Table 4, Drugs for Which the Effect on Nursing Infants is Unknown but May Be of Concern. These drugs appear in low concentrations (usually with a milk-to-plasma ratio of 0.51.0) in milk after maternal ingestion. Because of the long half-life of these compounds and some of their metabolites, nursing infants may have measurable amounts in their plasma and tissues, such as the brain. This is particularly important in infants during the first few months of life, with immature hepatic and renal function. Nursing mothers should be informed that if they take one of these drugs, the infant will be exposed to it. Because these drugs affect neurotransmitter function in the developing central
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nervous system, it may not be possible to predict long-term neurodevelopmental effects.

SILICONE BREAST IMPLANTS AND BREASTFEEDING
Approximately 800 000 to 1 million women in the United States have received breast implants containing silicone (elemental silicon with chemical bonds to oxygen) in the implant envelope or in the envelope and the interior gel. Concern has been raised about the possible effects to the nursing infant if mothers with implants breastfeed. This concern was initially raised in reports that described esophageal dysfunction in 11 children whose mothers had implants.17,18 This finding has not been confirmed by other reports. Silicone chemistry is extremely complex; the polymer involved in the covering and the interior of the breast implant consists of a polymer of alternating silicon and oxygen atoms with methyl groups attached to the oxygen groups (methyl polydimethylsiloxane).19 The length of the polymer determines whether it is a solid, gel, or liquid. There are only a few instances of the polymer being assayed in the milk of women with implants; the concentrations are not elevated over control samples.20 There is no evidence at the present time that this polymer is directly toxic to human tissues; however, concern also exists that toxicity may be mediated through an immunologic mechanism. This has yet to be confirmed in humans. Except for the study cited above, there have been no other reports of clinical problems in infants of mothers with silicone breast implants.21 It is unlikely that elemental silicon causes difficulty, because silicon is present in higher concentrations in cow milk and formula than in milk of humans with implants.22 The anticolic compound simethicone is a silicone and has a structure very similar to the methyl polydimethylsiloxane in breast implants. Simethicone has been used for decades in this country and Europe without any evidence of toxicity to infants. The Committee on Drugs does not feel that the evidence currently justifies classifying silicone implants as a contraindication to breastfeeding.
DRUG THERAPY OF THE LACTATING WOMAN
quantitate drugs in milk continue to improve, this information will require frequent updating. Drugs cited in Tables 1 through 7 are listed in alphabetical order by generic name; brand names are available from the current Physicians Desk Reference,23 USP DI 2001: Drug Information for the Health Care Professional, Volume I,24 and USP Dictionary of USAN and International Drug Names.25 The reference list is not inclusive of all articles published on the topic. Physicians who encounter adverse effects in infants who have been receiving drug-contaminated human milk are urged to document these effects in a communication to the Food and Drug Administration (http://www.fda.gov/medwatch/index.html) and to the Committee on Drugs. This communication should include the generic and brand names of the drug, the maternal dose and mode of administration, the concentration of the drug in milk and maternal and infant blood in relation to the time of ingestion, the method used for laboratory identification, the age of the infant, and the adverse effects. Such reports may substantially increase the pediatric communitys fund of knowledge regarding drug transfer into human milk and the potential or actual risk to the infant.
Committee on Drugs, 2000 2001 Robert M. Ward, MD, Chairperson Brian A. Bates, MD William E. Benitz, MD David J. Burchfield, MD John C. Ring, MD Richard P. Walls, MD, PhD Philip D. Walson, MD Liaisons John Alexander, MD Food and Drug Administration Alternate Donald R. Bennett, MD, PhD American Medical Association/United States Pharmacopeia Therese Cvetkovich, MD Food and Drug Administration Owen R. Hagino, MD American Academy of Child and Adolescent Psychiatry Stuart M. MacLeod, MD, PhD Canadian Paediatric Society Siddika Mithani, MD Bureau of Pharmaceutical Assessment Health Protection Branch, Canada Joseph Mulinare, MD, MSPH Centers for Disease Control and Prevention Laura E. Riley, MD American College of Obstetricians and Gynecologists Sumner J. Yaffe, MD National Institutes of Health Section Liaisons Charles J. Cote , MD Section on Anesthesiology Eli O. Meltzer, MD Section on Allergy and Immunology Consultant Cheston M. Berlin, Jr, MD Staff Raymond J. Koteras, MHA 777
The following should be considered before prescribing drugs to lactating women: 1. Is drug therapy really necessary? If drugs are required, consultation between the pediatrician and the mothers physician can be most useful in determining what options to choose. 2. The safest drug should be chosen, for example, acetaminophen rather than aspirin for analgesia. 3. If there is a possibility that a drug may present a risk to the infant, consideration should be given to measurement of blood concentrations in the nursing infant. 4. Drug exposure to the nursing infant may be minimized by having the mother take the medication just after she has breastfed the infant or just before the infant is due to have a lengthy sleep period. Data have been obtained from a search of the medical literature. Because methodologies used to
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TABLE 1.
Cytotoxic Drugs That May Interfere With Cellular Metabolism of the Nursing Infant Drug Reason for Concern, Reported Sign or Symptom in Infant, or Effect on Lactation Possible immune suppression; unknown effect association with carcinogenesis; neutropenia Possible immune suppression; unknown effect association with carcinogenesis Possible immune suppression; unknown effect association with carcinogenesis Possible immune suppression; unknown effect association with carcinogenesis; neutropenia on growth or on growth or on growth or on growth or Reference No. 26, 27 28, 29 30 31
Cyclophosphamide Cyclosporine Doxorubicin* Methotrexate * Drug is concentrated in human milk.
TABLE 2.
Drugs of Abuse for Which Adverse Effects on the Infant During Breastfeeding Have Been Reported* Drug Reported Effect or Reasons for Concern Irritability, poor sleeping pattern Cocaine intoxication: irritability, vomiting, diarrhea, tremulousness, seizures Tremors, restlessness, vomiting, poor feeding Only 1 report in literature; no effect mentioned; very long half-life for some components Potent hallucinogen Reference No. 32 33 34 35 36
Amphetamine Cocaine Heroin Marijuana Phencyclidine
* The Committee on Drugs strongly believes that nursing mothers should not ingest drugs of abuse, because they are hazardous to the nursing infant and to the health of the mother. Drug is concentrated in human milk.
TABLE 3.
Radioactive Compounds That Require Temporary Cessation of Breastfeeding* Compound Recommended Time for Cessation of Breastfeeding Radioactivity in milk present at 50 h Radioactivity in milk present for 2 wk Very small amount present at 20 h Radioactivity in milk present up to 36 h Radioactivity in milk present for 12 d Radioactivity in milk present 214 d, depending on study If used for treatment of thyroid cancer, high radioactivity may prolong exposure to infant Radioactivity in milk present 96 h Radioactivity in milk present 15 h to 3 d Reference No. 37 38 39 40, 41 42 4346 47, 48 49 41, 5055
Copper 64 (64Cu) Gallium 67 (67Ga) Indium 111 (111In) Iodine 123 (123I) Iodine 125 (125I) Iodine 131 (131I) Iodine131 Radioactive sodium Technetium 99m (99mTc), 99mTc macroaggregates, 99mTc O4
* Consult nuclear medicine physician before performing diagnostic study so that radionuclide that has the shortest excretion time in breast milk can be used. Before study, the mother should pump her breast and store enough milk in the freezer for feeding the infant; after study, the mother should pump her breast to maintain milk production but discard all milk pumped for the required time that radioactivity is present in milk. Milk samples can be screened by radiology departments for radioactivity before resumption of nursing.
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TABLE 4.
Drugs for Which the Effect on Nursing Infants Is Unknown but May Be of Concern* Drug Reported or Possible Effect Reference No. 57 5862 63 64 65 66 67 68 69, 70 71 72 73 74, 75 76, 77 78 7987 88 74 89, 90 91 92, 93 94 9598 99 100 101104 105 104 106 107, 108 109 110 111, 112 113, 114 115
Anti-anxiety Alprazolam Diazepam Lorazepam Midazolam Perphenazine Prazepam Quazepam Temazepam Antidepressants Amitriptyline Amoxapine Bupropion Clomipramine Desipramine Dothiepin Doxepin Fluoxetine Fluvoxamine Imipramine Nortriptyline Paroxetine Sertraline Trazodone Antipsychotic Chlorpromazine Chlorprothixene Clozapine Haloperidol Mesoridazine Trifluoperazine OTHERS Amiodarone Chloramphenicol Clofazimine Lamotrigine Metoclopramide Metronidazole Tinidazole
None None None None None None None None None None None None None Colic, irritability, feeding and sleep disorders, slow weight gain None None None None None Galactorrhea in mother; drowsiness and lethargy in infant; decline in developmental scores None None Decline in developmental scores None None Possible hypothyroidism Possible idiosyncratic bone marrow suppression Potential for transfer of high percentage of maternal dose; possible increase in skin pigmentation Potential therapeutic serum concentrations in infant None described; dopaminergic blocking agent In vitro mutagen; may discontinue breastfeeding for 1224 h to allow excretion of dose when single-dose therapy given to mother See metronidazole
* Psychotropic drugs, the compounds listed under anti-anxiety, antidepressant, and antipsychotic categories, are of special concern when given to nursing mothers for long periods. Although there are very few case reports of adverse effects in breastfeeding infants, these drugs do appear in human milk and, thus, could conceivably alter short-term and long-term central nervous system function.56 See discussion in text of psychotropic drugs. Drug is concentrated in human milk relative to simultaneous maternal plasma concentrations.
TABLE 5. Drugs That Have Been Associated With Significant Effects on Some Nursing Infants and Should Be Given to Nursing Mothers With Caution* Drug Acebutolol 5-Aminosalicylic acid Atenolol Bromocriptine Aspirin (salicylates) Clemastine Ergotamine Lithium Phenindione Phenobarbital Primidone Sulfasalazine (salicylazosulfapyridine) Reported Effect Hypotension; bradycardia; tachypnea Diarrhea (1 case) Cyanosis; bradycardia Suppresses lactation; may be hazardous to the mother Metabolic acidosis (1 case) Drowsiness, irritability, refusal to feed, high-pitched cry, neck stiffness (1 case) Vomiting, diarrhea, convulsions (doses used in migraine medications) One-third to one-half therapeutic blood concentration in infants Anticoagulant: increased prothrombin and partial thromboplastin time in 1 infant; not used in United States Sedation; infantile spasms after weaning from milk containing phenobarbital, methemoglobinemia (1 case) Sedation, feeding problems Bloody diarrhea (1 case) Reference No. 116 117119 120124 125, 126 127129 130 131 132134 135 136140 136, 137 141
* Blood concentration in the infant may be of clinical importance.
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TABLE 6.
Maternal Medication Usually Compatible With Breastfeeding* Drug Reported Sign or Symptom in Infant or Effect on Lactation None None None With large amounts, drowsiness, diaphoresis, deep sleep, weakness, decrease in linear growth, abnormal weight gain; maternal ingestion of 1 g/kg daily decreases milk ejection reflex None None None None None None None See Table 5 Suppresses lactation None Rash, weakness, absence of cry with maternal intake of 5.4 g/d None Irritability, poor sleeping pattern, excreted slowly; no effect with moderate intake of caffeinated beverages (23 cups per day) None None None Goiter None None None None None None None Sleepiness None None None Excreted slowly None None None Not found in milk None None None Rare breast enlargement; decrease in milk production and protein content (not confirmed in several studies) None None; follow up infants serum calcium level if mother receives pharmacologic doses Increased bowel activity None; sulfonamide detected in infants urine Crying, poor sleeping patterns, irritability None None None None None None None None Withdrawal, vaginal bleeding None Reference No. 142144 145 146 147, 148 4, 149152
Acetaminophen Acetazolamide Acitretin Acyclovir Alcohol (ethanol)
Allopurinol Amoxicillin Antimony Atropine Azapropazone (apazone) Aztreonam B1 (thiamin) B6 (pyridoxine) B12 Baclofen Barbiturate Bendroflumethiazide Bishydroxycoumarin (dicumarol) Bromide Butorphanol Caffeine Captopril Carbamazepine Carbetocin Carbimazole Cascara Cefadroxil Cefazolin Cefotaxime Cefoxitin Cefprozil Ceftazidime Ceftriaxone Chloral hydrate Chloroform Chloroquine Chlorothiazide Chlorthalidone Cimetidine Ciprofloxacin Cisapride Cisplatin Clindamycin Clogestone Codeine Colchicine Contraceptive pill with estrogen/progesterone Cycloserine D (vitamin) Danthron Dapsone Dexbrompheniramine maleate with d-isoephedrine Diatrizoate Digoxin Diltiazem Dipyrone Disopyramide Domperidone Dyphylline Enalapril Erythromycin Estradiol Ethambutol Ethanol (cf. alcohol)
153 154 155 156 157 158 159 160162 163 164 165 166 167 168 169174 175 176, 177 178 83, 179, 180 181 154 182 183 183 184 185 186 187 188 189191 192, 193 194 195, 196 197, 198 199 30 200 201 144, 156, 202 203205 206213 214 215217 218 191, 219 220 221 222, 223 224 225 226, 227 228 229 230 231 232 214
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TABLE 6.
Continued Drug Reported Sign or Symptom in Infant or Effect on Lactation None, drug appears in infant serum None One 400-mg dose given to nursing mothers; infants not given breast milk for 48 h None None None None None None None None None None Seizure (1 case) May affect thyroid activity; see iodine Goiter Elevated iodine levels in breast milk, odor of iodine on infants skin None None None; acetyl (hepatotoxic) metabolite secreted but no hepatotoxicity reported in infants None None None None None None None None None None None None None None None None Drowsiness None None None None None None; infant may have measurable blood concentration None None Hemolysis in infant with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency None Hemolysis in infant with G-6-PD deficiency None None None None None None Methemoglobinemia (1 case) None None None Reference No. 176, 233 234 235 236, 237 238 239 240 241 242 243 244 245249 250 251 192, 193 252, 253 254, 255 256258 259 259 259 97 260 214, 261 262 263, 264 265, 266 214 267 268 269, 270 271274 275 276 277 278 279 201, 280 281 61, 282 283287 288, 289 61 290 291 120 292 97 293, 294 295 282, 296298 299 300 301 302 303 304 305 306 307 308 198 309, 310 311 138, 176, 312 313 314, 315 316
Ethosuximide Fentanyl Fexofenadine Flecainide Fleroxacin Fluconazole Flufenamic acid Fluorescein Folic acid Gadopentetic (Gadolinium) Gentamicin Gold salts Halothane Hydralazine Hydrochlorothiazide Hydroxychloroquine Ibuprofen Indomethacin Iodides Iodine Iodine (povidone-iodine, eg, in a vaginal douche) Iohexol Iopanoic acid Isoniazid Interferon- Ivermectin K1 (vitamin) Kanamycin Ketoconazole Ketorolac Labetalol Levonorgestrel Levothyroxine Lidocaine Loperamide Loratadine Magnesium sulfate Medroxyprogesterone Mefenamic acid Meperidine Methadone Methimazole (active metabolite of carbimazole) Methohexital Methyldopa Methyprylon Metoprolol Metrizamide Metrizoate Mexiletine Minoxidil Morphine Moxalactam Nadolol Nalidixic acid Naproxen Nefopam Nifedipine Nitrofurantoin Norethynodrel Norsteroids Noscapine Ofloxacin Oxprenolol Phenylbutazone Phenytoin Piroxicam Prednisolone Prednisone
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TABLE 6.
Continued Drug Reported Sign or Symptom in Infant or Effect on Lactation None None None None None None None None None None None None None None None None None Caution in infant with jaundice or G-6-PD deficiency and ill, stressed, or premature infant; appears in infants milk Caution in infant with jaundice or G-6-PD deficiency and ill, stressed, or premature infant; appears in infants milk None None None None None; negligible absorption by infant Irritability None None mentioned; drug not used in United States None None Possible jaundice None None None None None None None Reference No. 317 318 319 320322 323 324 325 326 191, 327 296 159 214 156 328 329 237, 330 331 214 332 333, 334 335 336 337 338 235 339, 340 169, 341 139, 342 343 344 310 345 346 347, 348 324 176, 349, 350 351 352 353
Procainamide Progesterone Propoxyphene Propranolol Propylthiouracil Pseudoephedrine Pyridostigmine Pyrimethamine Quinidine Quinine Riboflavin Rifampin Scopolamine Secobarbital Senna Sotalol Spironolactone Streptomycin Sulbactam Sulfapyridine Sulfisoxazole Sumatriptan Suprofen Terbutaline Terfenadine Tetracycline Theophylline Thiopental Thiouracil Ticarcillin Timolol Tolbutamide Tolmetin Trimethoprim/sulfamethoxazole Triprolidine Valproic acid Verapamil Warfarin Zolpidem
* Drugs listed have been reported in the literature as having the effects listed or no effect. The word none means that no observable change was seen in the nursing infant while the mother was ingesting the compound. Dashes indicate no mention of clinical effect on the infant. It is emphasized that many of the literature citations concern single case reports or small series of infants. Drug is concentrated in human milk.
TABLE 7.
Food and Environmental Agents: Effects on Breastfeeding Agent Reported Sign or Symptom in Infant or Effect on Lactation None Caution if mother or infant has phenylketonuria Potential absorption and bromide transfer into milk; see Table 6 None reported None reported Irritability or increased bowel activity if excess amounts (16 oz/d) consumed by mother None Hemolysis in patient with G-6-PD deficiency None Skin rash, diarrhea, vomiting, dark urine, neurotoxicity, death None; possible contamination of milk from nipple washing Possible neurotoxicity May affect neurodevelopment None None Lack of endurance, hypotonia, sullen, expressionless facies Esophageal dysmotility Obstructive jaundice, dark urine Signs of B12 deficiency Reference No. 354356 357 358 359 360 169, 361 362370 371 372, 373 374, 375 376 377380 381383 384 385 386390 1722 391 392
Aflatoxin Aspartame Bromide (photographic laboratory) Cadmium Chlordane Chocolate (theobromine) DDT, benzene hexachlorides, dieldrin, aldrin, hepatachlorepoxide Fava beans Fluorides Hexachlorobenzene Hexachlorophene Lead Mercury, methylmercury Methylmethacrylate Monosodium glutamate Polychlorinated biphenyls and polybrominated biphenyls Silicone Tetrachloroethylene cleaning fluid (perchloroethylene) Vegetarian diet
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ACKNOWLEDGMENT
The Committee on Drugs would like to thank Linda Watson for her work in reference identification, document retrieval, and manuscript preparation.
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372. Simpson WJ, Tuba J. An investigation of fluoride concentration in the milk of nursing mothers. J Oral Med. 1968;23:104 106 373. Esala S, Vuori E, Helle A. Effect of maternal fluorine intake on breast milk fluorine content. Br J Nutr. 1982;48:201204 374. Dreyfus-See G. Le passage dans le lait des aliments ou medicaments absorbes par denourrices. Rev Med Interne. 1934;51:198 375. Ando M, Hirano S, Itoh Y. Transfer of hexachlorobenzene (HCB) from mother to newborn baby through placenta and milk. Arch Toxicol. 1985;56:195200 376. West RW, Wilson DJ, Schaffner W. Hexachlorophene concentrations in human milk. Bull Environ Contam Toxicol. 1975;13:167169 377. Rabinowitz M, Leviton A, Needelman H. Lead in milk and infant blood: a dose-response model. Arch Environ Health. 1985;40:283286 378. Sternowsky JH, Wessolowski R. Lead and cadmium in breast milk. Higher levels in urban vs rural mothers during the first 3 months of lactation. Arch Toxicol. 1985;57:41 45 379. Namihira D, Saldivar L, Pustilnik N, Carreon GJ, Salinas ME. Lead in human blood and milk from nursing women living near a smelter in Mexico City. J Toxicol Environ Health. 1993;38:225232 380. Baum CR, Shannon MW. Lead in breast milk. Pediatrics. 1996;97:932 381. Koos BJ, Longo LD. Mercury toxicity in the pregnant woman, fetus, and newborn infant. A review. Am J Obstet Gynecol. 1976;126:390 409 382. Amin-Zaki L, Elhassani S, Majeed MA, Clarkson TW, Doherty RA, Greenwood MR. Studies of infants postnatally exposed to methylmercury. J Pediatr. 1974;85:81 84 383. Pitkin RM, Bahns JA, Filer LJ Jr, Reynolds WA. Mercury in human
384.
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maternal and cord blood, placenta, and milk. Proc Soc Exp Biol Med. 1976;151:565567 Hersh J, Bono JV, Padgett DE, Mancuso CA. Methyl methacrylate levels in the breast milk of a patient after total hip arthroplasty. J Arthroplasty. 1995;10:9192 Stegink LD, Filer LJ Jr, Baker GL. Monosodium glutamate: effect on plasma and breast milk amino acid levels in lactating women. Proc Soc Exp Biol Med. 1972;140:836 841 Miller RW. Pollutants in breast milk: PCBs and cola-colored babies [editorial]. J Pediatr. 1977;90:510 511 Rogan WJ, Bagniewska A, Damstra T. Pollutants in breast milk. N Engl J Med. 1980;302:1450 1453 Wickizer TM, Brilliant LB, Copeland R, Tilden R. Polychlorinated biphenyl contamination of nursing mothers milk in Michigan. Am J Public Health. 1981;71:132137 Brilliant LB, Van Amburg G, Isbister J, Bloomer AW, Humphrey H, Price H. Breast-milk monitoring to measure Michigans contamination with polybrominated biphenyls. Lancet. 1978;2:643 646 Wickizer TM, Brilliant LB. Testing for polychlorinated biphenyls in human milk. Pediatrics. 1981;68:411 415 Bagnell PC, Ellenberg HA. Obstructive jaundice due to a chlorinated hydrocarbon in breast milk. Can Med Assoc J. 1977;117:10471048 Higginbottom MC, Sweetman L, Nyhan WL. A syndrome of methylmalonic aciduria, homocystinuria, megaloblastic anemia neurologic abnormalities in a vitamin B12-deficient breast-fed infant of a strict vegetarian. N Engl J Med. 1978;299:317323
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AMERICAN ACADEMY OF PEDIATRICS

Committee on Child Health Financing and Committee on Substance Abuse
Improving Substance Abuse Prevention, Assessment, and Treatment Financing for Children and Adolescents
ABSTRACT. The numbers of children, adolescents, and families affected by substance abuse have sharply increased since the early 1990s. The American Academy of Pediatrics recognizes the scope and urgency of this problem and has developed this policy statement for consideration by Congress, federal and state agencies, employers, national organizations, health care professionals, health insurers, managed care organizations, advocacy groups, and families.
ABBREVIATIONS. SCHIP, State Childrens Health Insurance Program; LSD, lysergic acid diethylamide; PCP, phencyclidine hydrochloride; ADHD, attention-deficit/hyperactivity disorder.
comorbid psychiatric disorders among children with substance abuse problems.

PREVALENCE AND IMPACT OF SUBSTANCE ABUSE AMONG CHILDREN AND ADOLESCENTS
INTRODUCTION
eading the list of Americans concerns for children is drug abuse, according to a 1997 Harvard study.1 The numbers of children, adolescents, and families affected by substance abuse have sharply increased since the early 1990s.2 Unfortunately, the availability of and financing for substance abuse prevention, assessment, and treatment have not kept pace with the needs of young people. Access to substance abuse services has decreased during the past decade because of inadequate insurance coverage, managed care controls, and low reimbursement rates. Although there are no national estimates of unmet need for substance abuse services for children, the surgeon general estimated that as many as 75% to 80% of children who are in need of mental health treatment fail to receive it.3 The consequences of failing to intervene early and not providing ageappropriate substance abuse and mental health treatment are substantial and long-term. This policy statement includes a summary of the prevalence of substance abuse among children and adolescents along with a review of financing problems experienced by those who are insured through private health insurance, Medicaid, and the State Childrens Health Insurance Program (SCHIP), and those who are uninsured. The statement concludes with specific recommendations for financing substance abuse prevention, assessment, and treatment for children and adolescents. By necessity, these recommendations incorporate mental health problems and interventions because of the high prevalence of
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. PEDIATRICS (ISSN 0031 4005). Copyright 2001 by the American Academy of Pediatrics.
Substance abuse by young people has increased in the past decade, and it is occurring at younger ages. According to results from the Monitoring the Future Study conducted in 1999 at the University of Michigan Institute for Social Research, 33% of 12th graders and 9% of eighth graders reported being drunk 1 or more times during the last 30 days.2 As many as 23% of high school seniors and 10% of eighth graders reported using marijuana in the last 30 days, up from 14% and 3%, respectively, in 1991. The percentage of adolescents who reported using hallucinogens, lysergic acid diethylamide (LSD), phencyclidine hydrochloride (PCP), cocaine and crack cocaine, heroin, amphetamines, methamphetamines, barbiturates, and tranquilizers also increased between 1991 and 1999. In addition, cigarette use among adolescents, which is a risk factor for use of marijuana and other illicit drugs, also markedly increased during this decade. In 1999, 35% of 12th graders reported smoking cigarettes during the last 30 days, up from 28% in 1991. Among eighth graders, the reported 30-day cigarette use rate increased from 14% to 18%. Epidemiologic data revealed that 9% of adolescent females and 20% of adolescent males meet adult diagnostic criteria for an alcohol use disorder.4 Among adolescents and young adults with a substance abuse disorder, 41% to 65% also have a mental health disorder.3 The most common of these are depression, conduct disorder, and attention-deficit/hyperactivity disorder (ADHD) in combination with conduct disorder. ADHD and learning disorders in combination with depression and anxiety disorders also carry a high risk of substance abuse. If the significant number of drug-exposed infants and the 1 in 6 children exposed to substance abuse within their families are added to these estimates, the size of the population affected by substance abuse and, therefore, potentially needing assistance dramatically increases.5 Obtaining accurate estimates of the prevalence of substance abuse among children and adolescents is very difficult. Most national studies survey only students, but many high-risk youth do not regularly attend school and, thus, are not included in these estimates. Other difficulties in obtaining reliable estimates are the results of coverage and reimbursement problems. Rather than using a substance abuse
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diagnosis, health care professionals may be using procedure codes for treating associated symptoms of substance abuse, such as fatigue, irritability, weight loss, headache, abdominal pain, or depression. The lack of use of substance abuse codes may also reflect health care professionals attempt to avoid stigmatizing a child. Consequently, existing prevalence data likely underestimate the scope of the problem. Data specific to adolescents are limited, but there is growing evidence that successful early intervention and treatment carries significant benefit for the individual and society.6 The most appropriate assessment of costs and benefits of treatment are based on broader outcome measures rather than abstinence alone. Despite the fact that there is no single treatment approach that works for all patients, standard treatments have been shown to produce significant decreases in drug use and in drug-related problems of crime, family violence, unemployment, welfare dependence, underachievement, and other antisocial behaviors.7
EXTENT OF FINANCING PROBLEMS FOR SUBSTANCE ABUSE SERVICES
Although most families whose children require substance abuse services experience financial difficulties related to high out-of-pocket expenses, those who are uninsured are at the greatest disadvantage. An estimated 14 million or 15.9% of children younger than 22 years had no health insurance coverage in 1999.8 These families must rely exclusively on publicly funded services through their states substance abuse and mental health agencies or must pay for care themselves. Often, uninsured youth receive uncompensated hospital and emergency care for acute symptoms only, which is seldom coordinated with primary care and behavioral health services. Unfortunately, publicly supported substance abuse and mental health services are underfunded and are typically available only for youth with serious emotional disturbances whose families meet a certain income threshold. Many young people, particularly those who are just beginning to abuse alcohol and other drugs, do not have serious emotional disturbances and, therefore, do not qualify for state-funded services. Moreover, children who are privately insured but without adequate substance abuse and mental health benefits are seldom eligible for statefunded services. Most children under age 22 (65.4% or 57.7 million) are privately insured by plans purchased by their families individually or through their employers.8 Often, these families rapidly exhaust their annual and even lifetime allotment of substance abuse benefits and must pay for needed services themselves or rely exclusively on self-help organizations, such as Alcoholics Anonymous and Narcotics Anonymous. Most private health insurance plans impose benefit limitations and cost-sharing requirements on substance abuse and mental health services that are greater than those imposed on general medical services.9,10 For example, coverage of outpatient substance abuse services, when available, is typically short in duration and is often capped at an inade1026
quate number of visits. Family therapy is often excluded. Inpatient substance abuse services are sometimes excluded altogether or covered only for acute detoxification purposes. Coverage of prevention, assessment, early intervention, relapse prevention, crisis intervention, partial hospitalization or day treatment, and residential care is seldom covered by private plans. Mental health benefits, however, are often provided somewhat more generously than are substance abuse benefits.2,11 In addition to benefit limitations, many private insurance plans require higher copayments or coinsurance in addition to separate deductibles for substance abuse benefits.11 The Mental Health Parity Act of 1996 prohibits plans from imposing higher annual and lifetime out-of-pocket maximums for mental health services than for general medical services.12 Although many states have passed mental health parity legislation, substance abuse parity is often not included. Thus, many of the gains that have been made in achieving parity only apply to mental health. This may perpetuate the pattern of physicians using procedure codes for treating associated symptoms of substance abuse rather than codes for a substance abuse diagnosis, which further distorts prevalence statistics. Also, the lack of specific data furthers the misconception that substance abuse is a consequence of mental illness rather than a primary disease, a comorbidity, or a significant precipitant of mental health problems. Medicaid, the source of insurance for 16.4 million or 18.7% of all children younger than 22 years, has historically covered fewer adolescents than younger children.8 Not until the enactment of SCHIP have many states taken the option to expand Medicaid to cover all adolescents from families with incomes at 100% of the federal poverty level. Unlike private coverage, Medicaids benefits for children and adolescents are comprehensive and cover a continuum of inpatient and outpatient substance abuse and mental health services. Although Medicaid benefits are expansive, reimbursement rates have been very low and, as a result, serve as a disincentive to provide qualified pediatric and substance abuse services. Regardless of the source of health insurance coverage, most substance abuse and mental health services are delivered by managed behavioral plans, distinct from general managed care plans and primary pediatric medical care. Although the literature shows that managed behavioral health plans have provided greater overall access to mental health services and a greater continuum of care, it also shows that as a result of tight utilization management, rates of ambulatory visits and hospitalizations have decreased.3 Pediatricians and other referring health care providers report persistent problems in obtaining authorization for substance abuse treatment for children and adolescents. Often, utilization review criteria address the needs of adults, and childrens conditions must be severe or associated with comorbidities to warrant extended counseling or hospital stays. For example, criteria such as chronicity, loss of work, and adult comorbiditieswhich are inappro-
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priate for young peopleare often used to determine whether substance abuse treatment is medically necessary. Moreover, many behavioral health plans have closed panels of mental health professionals with limited pediatric substance abuse training or experience. Seldom does coordination between primary care and behavioral health care take place effectively. Problems have also been reported in sharing medical information between behavioral health plans and primary care providers. Compounding these difficulties is the overall shortage of ambulatory and inpatient substance abuse and mental health services for children and adolescents. Many inpatient facilities have closed during recent years. These shortages have resulted from many factors, including historically low rates of reimbursement provided to substance abuse and mental health professionals. To serve this population effectively is very labor intensive, and insurance dollars and public funds consistently fail to provide adequate reimbursement. Also contributing to payment and service gaps is the fact few insurers recognize the new Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: Primary Care Version, which was developed jointly by the pediatric and mental health communities to encourage earlier identification and primary behavioral interventions.13 In addition, pediatricians are seldom able to receive reimbursement for providing counseling and education services to children at high risk of developing substance abuse problems. Serious problems exist in the availability and organization of behavioral health services for the treatment of substance abuse problems among youth. Although there are substantial problems with low payment and persistent obstacles in gaining access to needed interventions, pediatricians are in a unique role to identify and intervene with children and adolescents who have or are at risk of substance abuse problems.14 In addition, a cadre of physicians needs to be trained in the field of pediatric addiction medicine. However, the recruitment and retention of pediatricians and other health care providers in the field of addiction medicine has been very difficult, which seriously compromises the provision of highquality substance abuse care.14
FINANCING RECOMMENDATIONS
That article and this policy statement on financing should serve as blueprints for Congress, federal and state policy-makers, and employers. The American Academy of Pediatrics recommends that Congress authorize the Substance Abuse and Mental Health Services Administration to conduct a comprehensive national study of the supply, distribution, financing, and quality of substance abuse prevention, assessment, and treatment services for children and adolescents. Additional recommendations address the needs of all children, regardless of insurance status. In addition, there are specific recommendations that apply to those with private insurance, those with Medicaid or SCHIP coverage, and those who are uninsured.
For All Children and Adolescents, Regardless of Insurance Status
Many changes need to be made to the financing and delivery of substance abuse care to improve the availability of services for all children and adolescents. Change in this area, however, is not likely to occur without the participation of a coalition of national and state legislators, public purchasers, employers, health professionals, families, and health services researchers. The American Academy of Pediatrics, together with other participating behavioral health organizations and consumer groups, released a consensus statement on insurance coverage for mental health and substance abuse services for children and adolescents, which highlights the deterioration of mental health and substance abuse services and recommends access, coordination, and monitoring strategies for achieving service improvements.15
1. Ensure that substance abuse and mental health benefits are sufficient in amount, duration, and scope to reasonably achieve their purpose. 2. Allow pediatricians and safety net providers trained or experienced in substance abuse prevention, assessment, evaluation, and management services to be included in panels of professionals that provide these services. 3. Create an integrated system of referral and treatment for substance abuse that is consistent with the referral and treatment process of other chronic diseases. 4. Simplify and coordinate processes for families attempting to access substance abuse and mental health services for their children across public and private insurers plans, and public programs. 5. Improve preauthorization and utilization review criteria to be consistent with national standards on the treatment of substance abuse among youth developed by the American Academy of Pediatrics,16 the Substance Abuse and Mental Health Services Administration,17 the National Institute on Alcohol Abuse and Alcoholism,18 and the American Society of Addiction Medicine.19 6. Provide reasonable compensation and allow reimbursement of counseling, coordination, and consultation procedure codes to enable pediatricians and other primary care providers to provide primary substance abuse and mental health services. 7. Adjust capitation rates to take into account substance abuse service needs and recommended clinical guidelines for length of care for children and adolescents rather than relying on historic utilization rates to establish capitation amounts.19 8. Encourage payers to reimburse for individual and group counseling and risk factor reduction interventions for children at risk of substance abuse problems. 9. Establish financing mechanism for smoking cessation programs for children. 10. Create financial incentives for comanagement of substance abuse treatment between primary care and behavioral health care (eg, transferring some behavioral health dollars into primary care).
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11. Create mechanisms for sharing risk among public and private payors to allow for coverage of a comprehensive set of interventions to better manage children with complex cases. 12. Establish clear delineation of responsibilities with regard to children involved with multiple state agencies and required court-ordered treatment. 13. Ensure that health plans and health care providers adopt medical record and billing procedures to protect the confidentiality of children and adolescents.
For Privately Insured Children and Adolescents
5. Identify new revenue sources to increase availability of substance abuse services, including tobacco settlement funds and new taxes on alcohol.
Committee on Child Health Financing, 2000 2001 Richard P. Nelson, MD, Chairperson Jeffrey M. Brown, MD, MPH Wallace D. Brown, MD Beverly L. Koops, MD Thomas K. McInerny, MD John R. Meurer, MD, MM Maria E. Minon, MD Mark J. Werner, MD, CPE Jean A. Wright, MD, MBA Consultant Margaret McManus, MHS Staff Jean Davis Committee on Substance Abuse, 2000 2001 Edward A. Jacobs, MD, Chairperson Alain Joffe, MD, MPH John R. Knight, MD John Kulig, MD, MPH Peter D. Rogers, MD, MPH Liaisons Gayle M. Boyd, PhD National Institute of Alcohol Abuse and Alcoholism Dorynne Czechowicz, MD National Institute on Drug Abuse Deborah Simkin, MD American Academy of Child and Adolescent Psychiatry Staff Karen Smith REFERENCES
1. Harvard University, The Robert Wood Johnson Foundation, and University of Maryland. American Attitudes Toward Childrens Health Care Issues. Princeton, NJ: Harvard University School of Public Health; 1997 2. Johnston LD, OMalley PM, Bachman JG. The Monitoring the Future National Survey Results on Adolescent Drug Use. Overview of Key Findings, 1999. Bethesda, MD: National Institute on Drug Abuse; 2000. Available at: http://www.monitoringthefuture.org/pubs.html. Accessed December 18, 2000 3. US Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services; 1999 4. Cohen P, Cohen J, Kasen S, et al. An epidemiological study of disorders in late childhood and adolescenceI. Age- and gender-specific prevalence. J Child Psychol Psychiatry. 1993;34:851 867 5. Grant B. Estimates of US children exposed to alcohol abuse and dependence in the family. Am J Public Health. 2000;90:112115 6. Bukowski WJ, Evans RI, eds. Cost-Benefit/Cost-Effectiveness Research of Drug Abuse Prevention: Implications for Programming and Policy. Rockville, MD: National Institute on Drug Abuse; 1998 7. National Institute on Drug Abuse. Principles of Drug Addiction Treatment. Rockville, MD: National Institute on Drug Abuse, National Institutes of Health; 1999. NIH Publ. No. 00-4180. Available at: http://www.nida. nih.gov/PODAT/PODATindex.html. Accessed February 8, 2001 8. American Academy of Pediatrics, Division of Health Policy Research. US Childrens Health Insurance Status and Public Program Participation: State Reports, 1999 and 2001 Estimates. Elk Grove Village, IL: American Academy of Pediatrics; 2000 9. Buck JA, Teich JL, Umland B, Stein M. Behavioral health benefits in
1. Extend benefits to include a broader array of substance abuse prevention, assessment, and treatment services. 2. Establish parity between medical services and substance abuse and mental health services so that coverage of the management of substance abuse and mental health disorders is the same as coverage of other chronic conditions. 3. Reduce limitations on substance abuse and mental health services and allow for substitution of mental health and substance abuse benefits and use of alternative sites of care, including schools and homes. 4. Eliminate exclusions for specific diagnostic categories, chronic disorders, and preexisting conditions. 5. Reduce cost-sharing requirements for substance abuse services to encourage their use.
For Medicaid and SCHIP Insured Children and Adolescents
1. Target outreach efforts to ensure that Medicaidand SCHIP-eligible adolescents are covered. 2. Ensure that a continuum of substance abuse and mental health services for children and adolescents are specified in state Medicaid plans and contracts, using a variety of benefit categories, including Early and Periodic Screening, Diagnosis, and Treatment expanded services. 3. In non-Medicaid SCHIP programs, offer supplemental or wraparound benefits to allow expanded behavioral health coverage for those who meet certain risk criteria.
For Uninsured Children and Adolescents
1. Expand SCHIP income eligibility levels to the maximum possible. 2. Expand the eligibility criteria of states substance abuse and mental health service programs to include children with all levels of substance abuse and mental health risk. 3. Increase funding of state substance abuse and mental health programs for children and adolescents on the basis of comprehensive needs assessments and behavioral risk profiles of local communities. 4. Earmark a reasonable share of state block grants for prevention, assessment, and treatment services for children and adolescents.
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11. 12. 13.
14.
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employer-sponsored health plans, 1997. Health Aff (Millwood). 1999;18: 6778 Dilonardo J, Chalk M. Employer-Sponsored Health Plans Still Limit Alcohol and Other Drug Coverage. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism; 1999 Buck JA, Umland B. Covering mental health and substance abuse services. Health Aff (Millwood). 1997;16:120 126 Mental Health Parity Act of 1996. Pub L No. 104 204 (1997) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: Primary Care Version. 4th ed. Washington, DC: American Psychiatric Association; 1996 American Academy of Pediatrics, Committee on Substance Abuse. Tobacco, alcohol, and other drugs: the role of the pediatrician in prevention and management of substance abuse. Pediatrics. 1998;101:125128 Academy for Eating Disorders, American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Psychiatric Association, American Psychological Association, Family Voices,
16.
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International Society of Psychiatric-Mental Health Nurses, and Society for Developmental and Behavioral Pediatrics. Consensus statement on insurance coverage of mental health and substance abuse services for children and adolescents. Pediatrics. 2000;106:860 862 American Academy of Pediatrics. Current AAP policy statements. Available at: http://www.aap.org/policy/pprgtoc.cfm. Accessed June 11, 2001 Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Treatment improvement protocol series. Available at: http://www.samhsa.gov/centers/csat/csat.html. Accessed June 1, 2001 National Institute on Alcohol Abuse and Alcoholism. Reports, manuals, and guides. Available at: http://www.niaaa.nih.gov/publications/ guides.htm. Accessed June 11, 2001 American Society of Addiction Medicine. Patient Placement Criteria, Second Edition. Chevy Chase, MD: American Society of Addiction Medicine; 2000
ERRATUM
An error occurred in the policy statement Transfer of Drugs and Other Chemicals Into Human Milk (Pediatrics 2001;108:776 789). In the first paragraph under Breastfeeding and Smoking, line 14, the word acotinine should be cotinine.
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The Transfer of Drugs and Other Chemicals Into Human Milk Committee on Drugs Pediatrics 2001;108;776
Updated Information & Services including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/108/3/776.full.ht ml This article cites 384 articles, 86 of which can be accessed free at: http://pediatrics.aappublications.org/content/108/3/776.full.ht ml#ref-list-1 This article has been cited by 76 HighWire-hosted articles: http://pediatrics.aappublications.org/content/108/3/776.full.ht ml#related-urls This article, along with others on similar topics, appears in the following collection(s): Therapeutics & Toxicology http://pediatrics.aappublications.org/cgi/collection/therapeutic s_and_toxicology An erratum has been published regarding this article. Please see: http://pediatrics.aappublications.org/content/108/4/1029.full.h tml Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2001 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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The Transfer of Drugs and Other Chemicals Into Human Milk Committee on Drugs Pediatrics 2001;108;776

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AMERICAN ACADEMY OF PEDIATRICS

The Transfer of Drugs and Other Chemicals Into Human Milk

nervous system, it may not be possible to predict long-term neurodevelopmental effects.

Cyclophosphamide Cyclosporine Doxorubicin* Methotrexate * Drug is concentrated in human milk.

Amphetamine Cocaine Heroin Marijuana Phencyclidine

* Blood concentration in the infant may be of clinical importance.

Acetaminophen Acetazolamide Acitretin Acyclovir Alcohol (ethanol)

58. 59. 60.

67. 68. 69. 70. 71. 72. 73.

81. 82. 83. 84. 85. 86.

129. 130. 131. 132.

133. 134. 135. 136.

139. 140. 141.

145. 146. 147.

148. 149. 150. 151.

155. 156. 157.

161. 162. 163.

164. 165. 166. 167. 168.

169. 170. 171.

173. 174. 175. 176.

178. 179. 180.

181. 182. 183.

187. 188. 189.

192. 193. 194.

195. 196. 197.

199. 200. 201.

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AMERICAN ACADEMY OF PEDIATRICS

comorbid psychiatric disorders among children with substance abuse problems.

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