A 35-Year-Old Woman Experiencing Difficulty With Breastfeeding

DR DELBANCO: Mrs C, a 35-year-old communications professional, has a 3-week-old child and has been experiencing difficulty with breastfeeding. Married and living in Boston, she receives care from an obstetrician-gynecologist, Dr T, at the Beth Israel Deaconess Medical Center and has commercial health insurance in a managed care plan.

Mrs C experienced menarche at age 12 years, had a miscarriage 2 years ago, and gave birth after an uncomplicated pregnancy to her first child. She ruptured membranes on her due date and had a vaginal delivery aided by oxytocin and epidural anesthesia. During pregnancy, she noted mild breast enlargement without nipple discharge. She attended prenatal classes at the hospital, including 1 focusing on breastfeeding, something she felt important for both her and her child.

Weighing 7 lb 4 oz at birth, the infant took to the breast eagerly immediately following delivery. However, within 24 hours, the patient's nipples became cracked and painful and began to bleed. She applied a moist surgical wound dressing, as recommended in her class, and followed La Leche League's recommendation that she apply a lanolin-rich lotion to her nipples. Supported by telephone calls with a post-partum hospital nurse, she did well for the next 4 days, until she noted a bright red area on her lateral breast that quickly spread to cover three quarters of the breast. This soon was accompanied by a lump in the breast near the nipple that she felt was likely a "blocked duct," skin soreness that felt like a "sunburn," and temperature to about 39°C. She continued to breastfeed, despite increasing pain. Her mother told her she likely had mastitis, and Mrs C called her obstetrician, who concurred with the diagnosis and telephoned her pharmacy to order an antibiotic.

Mrs C did not like the idea of taking an antibiotic and instead called the Nursing Mothers Council, which referred her to a pediatrician specializing in "holistic" medicine. This doctor recommended 3 herbal preparations—Echinachea, belladonna, and Phytolacca—available at a local natural foods store. Mrs C took this advice, and 24 hours later her signs and symptoms had virtually cleared. Ten days after birth the infant weighed 8 lb 10 oz, and at present breastfeeding is proceeding uneventfully.

Mrs C's father died young with emphysema, but her mother is well. A great aunt had breast cancer. The patient was breastfed as an infant, as were her 2 siblings. She has been generally healthy, except for lactose intolerance that began during her childhood. Milk products still lead to diarrhea, and she avoids them. Mrs C has also had intermittent symptoms of heartburn and epigastric pain responsive to a variety of antacids. She is allergic to penicillin.

As an older mother and a career woman, I always thought that if I had a baby, I probably would need to use formula or at least be able to pump. I didn't really give it much thought until I was actually pregnant and started reading up on things and realizing that mother's milk is the way to go.

Even though you learn in a classroom with a doll how to hold the baby and practice different latch-on techniques, there's nothing like the real thing. What I found out was that although I had a textbook knowledge of how to breastfeed, I was hitting some unexpected roadblocks.

My baby came out like a little barracuda. She just wanted to eat. Sucking was not a problem for her. In fact, she wanted it so often I had to face the dilemma of whether to introduce a pacifier early on. But for me, physically, it was very traumatizing to have this little creature latching on and sucking part of my body. I didn't expect I would get so sore, so quickly, with blisters, cracks, and bleeding.

Meanwhile, the doorbell rings and the mailman arrives with free samples of formula. There's this outside force of commercialism with formulas at the back door, just waiting for you to say, "I can't do this anymore." And there's free formula with free bottles and free little nipples, and you look at that nipple and you say, "I could spare my own." It's very tempting. I think it would be extremely important at that fork in the road for my obstetrician, or even my pediatrician, to help me get past that point where I feel like I can't do this anymore. Having that support is key. Going home after having a baby, you're traumatized enough—you can't sit properly for 2 weeks, much less deal with sore nipples.

Mrs C is healthy, and she had a normal pregnancy and an uncomplicated delivery. She went home after 2 days in the hospital with no complications. About a week later, she had some breastfeeding problems. At the time, we also were concerned she might have mastitis. We recommended she start antibiotics, but she didn't want to take them.

Although insurance often doesn't cover breastfeeding problems and lactation consultants, more health plans are incorporating these services as a part of their package. But if you have a lactation consultant see a patient, it usually comes out of the patient's pocket.

Any knowledge I have about breastfeeding is either self-taught or simply because I breastfed my children. I think our residents learn virtually nothing about breastfeeding. I went through an obstetrics and gynecology residency. I had my first child right when I graduated, and I knew zero about breastfeeding. So I read a book, and I learned from the nurses in the hospital—just like any patient would—and here I am the one who is supposed to be teaching.

I would like to ask Dr Lawrence about the medical advantages of breastfeeding, because of new data about the benefits to babies who are breastfed. One of the reasons women don't breastfeed or don't continue it long-term has to do with society's acceptance of women who breastfeed, particularly in public. Because if you have a baby who needs to be breastfed, you need to do it wherever you are, whenever the baby needs it.

What are typical experiences of women who are breastfeeding? What problems are encountered? In the developed world, what are the physiologic and emotional benefits and risks of breastfeeding to infant and mother? What are the risks of breastfeeding with regard to transmission of illicit drugs, pharmaceuticals, and infectious diseases? How should mothers be prepared for breastfeeding? What advice do you give, and who should give it in practice? How should we educate health professionals about breastfeeding and attendant problems? What systems work well? What would you recommend for Mrs C?

Dr Lawrence: Deciding how to feed her infant is one of the most important decisions Mrs C will make about her infant and herself. Although formula feeding may be adequate, she wished the best for her infant. Adapting to motherhood, establishing breastfeeding, and working with a newborn infant is a challenge. Mrs C is extremely well read and prepared herself intellectually for this event. For the average mother under these circumstances, breastfeeding goes smoothly. While it may be somewhat uncomfortable and certainly feels different from anything a woman has experienced before, breastfeeding should not be painful. If it is painful, that is a signal that something is not right.

Mrs C recognized the value of breastfeeding in modern society. The most compelling reason to consider breastfeeding for one's infant is species specificity,¹ that is, human milk is precisely engineered for the growth and development needs of the human infant. In the last decade, the popular press has focused on the impact of infant diet on brain development. Many long-term studies of infants exclusively breastfed for the first few months of life show significant advantages in long-term development when compared with formula-fed infants.^{2 - 6} Newton⁷ investigated 3-year-olds and showed that breastfed infants were more mature, more assertive, more outgoing, had higher self-esteem, and scored better on developmental tests. Horwood and Ferguson⁸ reported an 18-year study in which breastfed children were found to score better on intelligence tests, be more accomplished in school, and have better behavior assessments than a comparable matched cohort of bottle-fed children. While any analysis of the benefits of breastfeeding is hampered by the fact that infants cannot be randomly assigned to be breastfed or not, in the studies referenced here, the observers were blinded to the hypothesis and to the cohort placement of the individual child and the results were adjusted for socioeconomic status and education of the mother. Recent meta-analyses of developmental comparisons of breastfed and formula-fed infants support observations that breastfed infants score better on development and intelligence tests,^{9 - 10} a finding that attracted the attention of women like Mrs C.

These findings have a biochemical and physiological basis.¹¹ Three important constituents of human milk are also important constituents of brain and nerve tissue: cholesterol, taurine, and docosahexaenoic acid (DHA), which are found naturally in human milk and not in formula. Regardless of the mother's diet, the cholesterol in her milk remains consistent from the first days of lactation to the last day of weaning. Taurine, an amino acid identified in human brain tissue, is found in human but not cow milk. Synthetic taurine is now added to most formulas, but this supplementation of formula has not been studied. The most compelling argument, however, is regarding the omega-3 fatty acid DHA, which is not in formula but is present in human milk. Studies have shown that visual acuity,¹² auditory acuity,¹³ and the maturation of premature infants^{12 - 13} are more advanced in infants given human milk compared with infants given formula with DHA added and especially compared with formula with no added DHA. The US Food and Drug Administration is considering whether formula companies should be required to supplement their preparations with DHA.¹⁴

Studies in the United States and countries throughout the world¹¹ have shown that the immune protection qualities of human milk confer a statistically significant difference in the incidence of gastrointestinal infection,¹⁵ respiratory tract infection,¹⁶ otitis media,¹⁷ and even urinary tract¹⁸ infections in breastfed infants compared with infants who are formula-fed. Considering the costs associated with the increased number of ear infections, hospitalizations, and courses of antibiotics in infants who are not breastfed, it is estimated that breastfeeding an infant saves more than $1000 per year.^{19 - 21} These studies were done in managed care settings where costs of medical visits, hospitalization, and medications were carefully recorded for all infants in the first year of life. Breastfed infants required significantly less medical care and therefore less money.

In databases of large multicenter cohorts such as the Colorado Central Cancer Registry (http://www.cdphe.state.co.us/pp/cccr/cccrhom.asp), breastfeeding was associated with a lower incidence of chronic disease when infants are exclusively breastfed for 4 months or longer. Studies have suggested a decreased incidence in childhood cancers²² (especially lymphoma and leukemia), type 1 diabetes mellitus,²³ Crohn disease,²⁴ and celiac disease.²⁵ Still other studies during several decades suggest that breastfeeding and the exclusion of cow milk for the first year of life are associated with a lower incidence of eczema,²⁶ asthma,²⁷ and other allergic symptoms.²⁸

Benefits for the mother include more rapid return to the prepartum state, as the uterus involutes rapidly when breastfeeding. Postpregnancy obesity is less common in women who breastfeed, as is the incidence of premenopausal breast cancer²⁹ and ovarian cancer.³⁰ Most notable, however, is the decreased incidence of osteoporosis in women who bear and breastfeed children, compared with women who do not bear children or bear children and do not breastfeed.^{31 - 32}

One potential disadvantage of breastfeeding is that only the mother can feed the infant, although mothers can pump their milk and provide it for the father or a caretaker to give to the infant by bottle on occasion. Women concerned about the father's role should recognize that the father has a very distinct and important role: that of the nonnutritive cuddler.¹¹ Breastfed infants need to be cuddled occasionally by someone who does not smell of milk. When a nursing mother picks up her breastfed infant, the infant naturally roots and acts as if it needs to be fed, although it may well be very adequately fed. A fussy, breastfed infant sometimes is difficult for a nursing mother to quiet, while the father, not smelling of milk, can quickly comfort and quiet the infant.¹¹ For a successful career woman, having a baby is a disruptive event regardless of the parents' eagerness to start a family. Convenience and breastfeeding have different implications for each individual. Bottle-feeding requires preparation; it is not instantly available. Mrs C had to weigh the issue of taking total responsibility for nourishing her infant by breastfeeding, or choosing to bottle feed so someone else could take over and she could ensure herself plenty of sleep. In fact, in many cultures, the family takes over all household chores and leaves only the breastfeeding to the mother.³³

The only identified contraindication to breastfeeding in the developed world is the presence of HIV (human immunodeficiency virus) in the mother.^{34 - 36} We do not know enough about the relationship of breastfeeding and HIV, but even the slightest risk of HIV being transmitted by the breast milk should be avoided in the industrial world where adequate substitutes are available.^{37 - 39} A recent study in Africa suggests that when infants are exclusively breastfed by their HIV-positive mother, the incidence of HIV is lowered, compared with the incidence in infants breastfed partially by an HIV-positive mother. There may be an association between herbal teas, ground bark, and other special foods in some cultures and the increased risk of irritating the gut and transmitting HIV.⁴⁰ This work is preliminary and needs to be repeated and closely examined. Hepatitis C is not a contraindication to breastfeeding.⁴¹

For an infant, the only contraindication to being breastfed is galactosemia, that is, lack of enzymes able to handle galactose and therefore lactose, the carbohydrate of all mammalian milks.^{18 ,42} Mrs C's infant was healthy at birth, with normal neonatal metabolic screening test results.

Women are not born knowing how to breastfeed. The experience of a woman who decides to breastfeed usually depends on her knowledge and the experience of her mother, mother-in-law, and other female relatives. Mrs C's own mother breastfed her 3 children; thus she has strong family support. However, this is not always the case, so physicians and other health care professionals play an important role in assisting a mother in establishing her breastfeeding.

When putting the infant to the breast, the mother should hold the infant facing her, abdomen to abdomen, looking straight at the breast.¹¹ She can offer her breast by gently supporting her breast with 3 fingers below the areola and 2 fingers above, gently compressing the areola so the infant can draw the nipple and areola into the mouth (Figure 1). By gently stroking the center of the infant's lower lip with the nipple, the mother stimulates the infant to latch on. The infant will reflexively extend the tongue, draw the nipple and areola into the mouth, and compress it against the hard palate. The nipple and areola, which are extremely elastic, will elongate into a teat. The sucking motion is a peristaltic motion of the tongue (Figure 2).⁴³ This peristaltic wave travels posteriorly in the tongue to the back of the mouth, to the posterior pharynx, then down the esophagus to the stomach, initiating peristaltic motion of the gastrointestinal tract. This suckling automatically initiates swallowing, and the infant does not have to coordinate suck and swallow because the peristaltic motion creates the necessary sequence.^{44 - 47} This is in striking contrast to bottle feeding, in which the infant controls the flow by a thrusting motion that closes the nipple holes on the bottle and releases them. When a bolus of milk has dripped out of the bottle, the infant closes the holes and then has to coordinate swallowing that bolus. This thrusting motion may cause "nipple confusion" for some infants as the infant then uses tongue thrusting when returning to breastfeeding.⁴⁷

Medical and nursing schools traditionally have not had adequate training about breastfeeding in their curricula.⁴⁸ In recent years, efforts have been made to change this situation. For example, based on reports of examinees, questions about the anatomy, physiology, and management of breastfeeding are now documented on the National Medical Boards, the Federal Licensing Examination (FLEX), and the board certification examinations for obstetrics and gynecology, pediatrics, and family medicine. The second Surgeon General's Workshop in 1985 worked with these examination boards to encourage the inclusion of breastfeeding on the examinations.⁴⁹ Curriculum models are available that include teaching about the breast at every stage of education beginning with anatomy and physiology, the study of nutrition, and finally, at the bedside in clinical management.^{11 ,49}

If a hospital or practitioner seeks the services of a lactation consultant, this person must have a license to practice, have adequate malpractice insurance, and be certified by the International Board of Lactation Consultant Examiners. Lactation consultants can participate in the management of a patient as any other consultant might, focusing on aspects of breastfeeding, while the primary care physician remains in charge of patient care. Very few lactation consultants, however, have a license to prescribe medications.

La Leche League, an international program of women with breastfeeding experience, has been in existence for more than 40 years. Members of the league are available to support nursing mothers, who can telephone them at 1-800-LALECHE to find a local contact person. Thus, today a network of professional lactation consultants and lay organizations can support the mother, infant, and family. The physician, however, continues to be responsible for medical care and the prescription of any medications and, ultimately, for the successful nourishment of the infant.

The important assessment milestones for the obstetrician begin with the initial examination prior to pregnancy, noting whether the breasts appear normal, symmetrical, and fully developed. Any prior surgery should be discussed.⁵⁰ It is possible to breastfeed following augmentation mammoplasty, and depending on the surgical technique involved it may be possible to breastfeed following reduction mammoplasty if the nipple and areola were not totally removed and their ducts severed.¹¹ The removal of cysts and lumps are not a contraindication to breastfeeding. The prenatal breast examination is an opportune time for the obstetrician to discuss with the mother her infant feeding plans and encourage her to ask questions and to share concerns about her ability to provide milk for her infant.

During pregnancy, it is important to document changes in the breast. Mrs C was observed to have a small increase in breast size. Failure of the breast to increase in size over the first and second trimesters is a signal that the breasts may not be able to respond by producing adequate milk.¹¹ If a woman's breasts do not become slightly engorged and full 48 to 72 hours after the placenta is delivered, this may also signal possible difficulty in providing adequate milk. The obstetrician should share this information with the pediatrician and offer additional help and support in establishing lactation.⁵⁰

Mrs C experienced sore nipples in the first few days. When nipples become sore, it is usually because the latch-on is incorrect.^{51 - 54} Therefore, the first step in treating this problem is to observe the mother and infant during suckling.

Putting the infant to the breast should begin shortly after birth, as soon as mother and infant are ready. This may be within 30 minutes, but should be within an hour in a healthy term infant with an uncomplicated delivery. The advantage of early initiation of breastfeeding is that it begins the stimulus of the breast to make milk and the process proceeds immediately. Since postpartum hospital stays are brief, usually about 48 hours, few opportunities arise to observe breastfeeding to ensure that mother and infant have mastered the simple technique. After the initial feeding, the infant should be put to breast every time the infant shows signs of hunger, including putting hand to mouth, making sucking motions, flexing the arms and the legs, and general wakefulness.^{53 - 54} Crying is a late sign of hunger.

For the health care provider, the first step is to observe the process of getting the infant onto the breast and making appropriate adjustments. If some irritation and soreness has already occurred, it may help to suggest alternative positions for the mother so that the suckling infant puts pressure on a different point on the breast. The mother should wear a well-fitting, nursing brassiere, especially early in lactation. She should avoid nursing pads that contain plastic, which retain moisture and may cause irritation. It is usually best to keep the nipple and areola dry between feedings. In the case of extremely sore nipples, an appropriate initial intervention may be moisture. Too much nursing does not cause sore nipples, and feeding should not be rigidly timed.

Mrs C received oxytocin and an epidural during labor, either of which could have interfered with the infant's initial efforts to latch on to the breast. Oxytocin augmentation can make labor more difficult; many women describe their contractions as more forceful and uncomfortable.⁵⁵ Mrs C received epidural anesthesia. It is not known whether an epidural influences the initiation of breastfeeding,^{56 - 57} but it probably depends on the duration of the anesthesia and whether any of the drug has been absorbed into the mother's plasma and therefore reached the infant transplacentally. In theory, this could affect the infant's suck, making it more discordant and forceful.^{58 - 59}

A special effort to assess breastfeeding before discharge is important. The pediatrician's discharge examination should include observation of a feeding and confirm that the infant latches on well and that the mother is able to position the infant optimally for breastfeeding. A birthing place that supports breastfeeding is one where every nurse in the perinatal program, labor, delivery, postpartum, newborn nursery, and birthing center knows how to assist a mother in putting the infant to the breast.⁶⁰

The key to successful lactation is a system of careful follow-up immediately postpartum. The mother should be instructed what to watch for, especially the infant's voiding, stooling, and feeding patterns. In the first month of life, it is abnormal for an infant not to stool daily while breastfeeding. The infant's weight should also be followed carefully. A breastfed infant loses up to 7% of its body weight in the first 72 hours of life. The weight should then plateau for 1 or 2 days, and the infant should finally begin to gain weight on the fourth or fifth day, reaching the original birth weight in 7 to 10 days. Failure to regain birth weight in the first 10 days requires careful assessment of the infant. The American Academy of Pediatrics⁶¹ recommends some assessment 48 hours after discharge, at least by telephone, and a visit to the office by 7 days.

Care of the breastfeeding dyad also includes supportive care for the mother. Instilling confidence in the mother in her ability to nourish her infant is primary. The mother should also be encouraged to eat no less than 7531KJ (1800 kcal) per day to replace her own nutrient stores. She will experience a natural thirst and consume extra water and other fluids.

After 4 days, Mrs C noted a bright red spot on her breast that spread to cover three quarters of the breast, and then she developed a temperature of 39°C. While this might be mastitis, only an examination can confirm that diagnosis. Mrs C's history suggests, in contrast, extended engorgement and a plugged duct, particularly since the problem responded to supportive care and herbs. When true mastitis is untreated or is inadequately treated, it can lead to an abscess that may require drainage but does not necessitate stopping breastfeeding. In fact, the most common cause of abscess formation is discontinuing breastfeeding on the involved side when mastitis first develops.^{11 ,62}

Redness and heat in a pie-shaped wedge, with or without swelling below the surface, suggests mastitis.⁶³ Fever, generalized aches and pains, and a flu-like condition confirms a mastitis diagnosis, which should be treated with antibiotics.^{11 ,64 - 65} Engorgement, early mastitis, and severe mastitis are usually associated with fatigue and lack of sleep. The important primary steps to treatment are to recommend a regimen of rest and added sleep while the woman continues to nurse on the involved breast or breasts. Cold packs following a feeding may give some relief from pain. Acetaminophen and ibuprofen can be used for fever and discomfort. Pending the physical examination, antibiotics may or may not be indicated. In a full-blown mastitis, antibiotics are imperative and must be given for at least 10 days. The most common bacteria in mastitis are staphylococci, followed by Escherichia coli. If both breasts are involved with swelling and heat, streptococcal infection is likely.¹¹

The use of herbal preparations during breastfeeding is not well documented in the medical literature. There are no controlled studies of the use of herbs and much of the information is anecdotal, with only single case reports. The most important questions are: will natural-occurring chemicals be passed into the breast milk and are these chemicals safe for the infant? A few herbs are known to be particularly dangerous. For example, comfrey is associated with veno-occlusive disease.⁶⁶ Because of infant deaths from veno-occlusive disease, comfrey has been banned in Canada and other parts of the world.⁶⁷

The first herb Mrs C took was Echinachea, promoted as a treatment for impending infections.^{66 - 67} It is widely used in this country by lay people to ward off colds. There are no reports of toxicity; however, one needs to be very careful of the preparation that is purchased, as many herbals now contain more than 1 plant. The second herbal medication prescribed for Mrs C was belladonna. Belladonna is a constituent of several plants, including nightshade. Therapeutic doses of belladonna should not be used during lactation because it may decrease the mother's milk supply and also cause tachycardia, fever, and other symptoms in the neonate.⁶⁸ However, Mrs C took a homeopathic dose of belladonna, which suggests it was about one hundredth of the therapeutic dose. The third compound that Mrs C took was Phytolacca. Phytolacca americana (family Phytolacca) is pokeroot (inkberry), a well-known poisonous plant. To quote Tyler's Honest Herbal, "Pokeroot is not therapeutically useful for anything."⁶⁶ It may cause severe nausea, vomiting, diarrhea, hypotension, and even cardiotoxicity. The dose was apparently small, as Mrs C did not develop these symptoms. Although treatment for swollen breasts is listed as a benefit of phytolacca, most herbalists considered it neither efficacious nor safe.^{66 - 67}

How long a woman breastfeeds often depends on other life constraints, especially returning to work or school. The American Academy of Pediatrics recommends exclusive breastfeeding for 6 months, continued breastfeeding with the addition of appropriate weaning foods until 12 months of age, and then for as long as mother and infant wish, purposely avoiding any mandatory termination date.⁶¹ Mrs C plans to continue breastfeeding for the first year of her infant's life, and to extend her maternity leave beyond the standard time of 6 weeks to 3 months. It is possible to maintain a milk supply if mother returns to work. The woman should begin to introduce a bottle several weeks prior to beginning or returning to work. She also should begin to pump and save her milk ahead of time to have some extra as backup for feeding the infant in her absence. Ideally, a woman can arrange to pump milk at work with a portable pump and refrigerate it to use the next day. Accommodations for pumping such as space, storage, and time need to be negotiated with one's employer. As the infant begins to feed less frequently, the process becomes simpler. How a mother schedules separation from her infant is an individual affair, but the physician can be helpful and supportive. The more flexible the job and the greater mother's autonomy, the easier it is. Any time spent breastfeeding is a good investment in infant health.

MRS C: I'm glad that I had support at the medical center in terms of my obstetrician having knowledge and encouraging me to breastfeed. Also, having the preparation ahead of time and lactation support at the women's center was great.

A PHYSICIAN: One challenge is when patients are not interested in breastfeeding at all. I think the medical profession takes a step back and says, "This is a question of maternal choice. There are 2 feeding methods, and the mother should decide what to do." I don't feel that way about it. I believe that all mothers, with the exception of those who have specific medical problems, ought to breastfeed their babies. Do you have any advice about how to counsel women?

DR LAWRENCE: One of the things we can do in an obstetrical practice is create an environment supportive of breastfeeding. Sometimes, through pregnancy, the patient changes her mind. Part of that is becoming more comfortable with one's body. One of the hardest parts about pregnancy is the shape women take, but once they are used to that, they often feel differently about their breasts. These mothers often will decide to try breastfeeding. Women may change their mind in the delivery room. The staff should be supportive of breastfeeding, and every woman should be offered the opportunity to put her baby to breast. Also, be careful of subtleties in your office. Physicians are so used to dispensing prenatal vitamins that they don't realize the problem in giving out free formula. Formula companies come to your office because pediatricians, as a group, have refused to promote formula and don't have formula promotional material in their offices.

A PHYSICIAN: One of the common difficulties I encounter is that patients on any medication are generally discouraged from considering breastfeeding, even though the medications themselves may be quite safe. I see it sometimes when I have told the patient during pregnancy that the medication she is taking, whether it's an antihypertensive or antidepressant, should be safe but then she is discouraged by some other medical professional.

DR LAWRENCE: I think most drugs are okay. There's a very short list of contraindicated drugs—antimetabolites, anticancer drugs, and radioactive drugs taken therapeutically.^{11 ,69} If they are taken diagnostically as 1 dose, the patient can pump and discard the milk until the drug has cleared the system. The trouble is that physicians look drugs up in the Physicians' Desk Reference, 54th edition (PDR), and it always says "no information, do not recommend breast feeding." I have yet to find a drug the PDR said was safe for breastfeeding.