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Texas Tech Health Check
From Pregnancy to Postpartum: Medication Guidance That Matters, Support From the Infant Risk Center
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Moms and moms-to-be need all the support they can get. One of those sources of support is housed in the TTUHSC School of Medicine Department of Pediatrics in Amarillo. The Infant Risk Center is a call center used by physicians, nurse, lactation consultants and mothers worldwide. Our guest for this episode is director of the Infant Risk Center of Excellence, Kaytlin Krutsch, Ph.D., Pharm.D.
Dr. Krutsch tells us all about the IRC and the information they provide. Dr. Krutsch goes on to explain how substances transfer to breast milk, the most common concerns and questions the IRC addresses, how we can support the IRC and moms, and in a world full of artificial intelligence, assures us that when someone calls the center, they’re speaking to an actual health care provider.
Infant Risk Center: 1-806-352-2519
Resources: infantrisk.com/infantrisk-center-resources
Support: infantrisk.com/donate
Melissa Whitfield 00:10
Hello and welcome back to Texas Tech Health Check from Texas Tech University Health Sciences Center. I'm your host, Melissa Whitfield. We want you to get healthy and stay healthy with help from evidence based advice from our physicians, health care providers and researchers. Moms and moms-to-be need all the support that they can get. One of those sources of support is housed in the School of Medicine, Department of Pediatrics in Amarillo. That's the Infant Risk Center, a worldwide call center used by physicians, nurses, lactation consultants and mothers. Our guest for this episode is director of the Infant Risk Center of Excellence, Dr Kaytlin Krutsch. Dr. Krutsch also is an assistant professor of obstetrics and gynecology in the School of Medicine. She tells us about the Infant Risk Center and about the information available at our fingertips. Dr Krutsch explains how substances transferr to breast milk, the most common concerns and questions the IRC addresses, how we can support the IRC and moms, and in the world full of artificial intelligence, she assures us that when someone calls the center, they're speaking to an actual health care provider,
Melissa Whitfield 01:28
Dr. Krutsch, welcome to our podcast. Thanks, thanks. I'm happy to be here. How are you doing today?
Kaytlin Krutsch, Pharm.D., Ph.D. 01:33
I'm okay. I'm wrapping up a long week and starting off a what will hopefully be a fantastic summer.
Melissa Whitfield 01:40
Well, we're happy to have you on our podcast. Can you tell us a little bit about yourself, your expertise and what you do here at the Health Sciences Center?
Kaytlin Krutsch, Pharm.D., Ph.D. 01:48
All right. Well, I am a little bit of a, I don't want to call it Jack of all trades, but I have a very eclectic experience that happened to all fit together really nicely in this beautiful package at Texas Tech. So I have a background in nutrition, business, pharmacy and translational health research, and I ended up here at Tech, kind of coordinated with with a guy that founded the infant risk center at the School of Medicine. His name is Dr Thomas Hale, and he he was my mentor. And whenever we found each other, it was like, you know, I, I met him one afternoon, I told him what my expertise was, and I left that meeting with a new career. So he offered me a spot at at Tech, long story short. So I fell into this field of lactation pharmacology at the Infant Risk Center.
Melissa Whitfield 02:46
Well, since you mentioned it, what is the Infant Risk Center and what's its mission?
Kaytlin Krutsch, Pharm.D., Ph.D. 02:52
So the Infant Risk Center is this wonderful culmination of things where we are looking at mostly the transfer of medications into milk, mother's milk, and how that kind of clinical scenario ends up impacting the mom and the infant's health. So we know that breast milk is an unmatched form of infant nutrition. Thet W.H.O., the World Health Organization actually says that improving breastfeeding rates is like the number one health improvement opportunity in the world. And we kind of sit at this space where, okay, we want to increase breastfeeding rates, but what happens whenever you have moms that need medications to take care of their own health? And so we're here to answer the questions that they have about that. So we have a research lab upstairs at the School of Medicine. And downstairs, we have a group of nurses who help translate the information that that we produce in our research and that other people put out in publications, and actually help health care providers and mothers make sense of the information that comes out and kind of help them make it work for their specific situation. The reality is is, we can say how much drug there is in milk all day long, but people are still really worried about what's going to happen to their baby. And you know, we try and do all of these, like electronic means of reaching people or using chat bots or all of that kind of thing. But whenever you're talking about potentially hurting your baby, it's like they want to talk to a person, and that, that's what we've found. So we make the people available. We try and make the information available online as well. You know, we know that people go there first, but then they don't stop. So we're just trying to fit in to all of the cracks that exist in our system and bring them all together.
Melissa Whitfield 04:46
So what kind of information does the IRC provide? And who are the primary users?
Kaytlin Krutsch, Pharm.D., Ph.D. 04:51
Well, the primary users are anyone who's interested in maternal infant health and these questions. So we get plenty of calls from health care providers, and we get plenty of calls from actually, usually moms, but sometimes, you know, the grandma will call, or the dad will call and say, "Hey, this is the situation. You know, what can we do to keep everybody the safest?"
Melissa Whitfield 05:16
So then, can you explain: How do medications transfer into breast milk?
Kaytlin Krutsch, Pharm.D., Ph.D. 05:21
There are a couple of ways. So the primary way that drugs get into milk is is called passive diffusion. So the way that the the body, you know, it's really beautiful. It just does the best that it can to keep the milk safe and and it really does a good job. So it's kind of like the blood brain barrier. So there's a blood milk barrier and a lot of things it will gate keep that so they can't get past. So anything that's a big molecule won't get passed, but sometimes they can be small enough to just slip through. And so that's where we get passive diffusion. So really small molecule drugs are what I'm worried about. But that's how some other things get into milk that you want to be there too. You know, some of the the nutrients get in that way. What we really worry about is whenever there is active transport. So maybe at that membrane there will be a little transporter. So, you know, you can think of it like a little pump working hard to do its job. And if it's pumping drugs into the milk, that's a problem. That's one, one thing that we want to know about, and so that's something that we are always watching out for, saying, Okay, if this drug got pumped into the milk, because we actually, right now, we don't know what transporters exist on that blood milk barrier. We're working on some research with a group at Dartmouth, actually, right now to do that. And once we know what the transporters are, we can predict better which which drugs are going to be present in milk, but those are the main ways that they get there.
Melissa Whitfield 06:48
I know breastfeeding varies from person to person, or from mom to mom, and that some moms, they breastfeed longer than others. Does the age of an infant impact medication safety during breastfeeding?
Kaytlin Krutsch, Pharm.D., Ph.D. 07:02
Oh, that's a great question. And yes, absolutely, absolutely it does. So the CDC increased its breastfeeding recommendation. Now, women are recommended to breastfeed for two years, and a lot of people don't know that. Sometimes, I think pediatricians might not have heard that yet, but whenever they made that recommendation, you know, it's hard for us because that doubles the amount of time. It used to be a year. That doubles the amount of time that we have to deal with this medication question. But during those later phases, I'm actually less worried about things about, I think two thirds of adverse effects. So whenever an infant has a problem due to maternal medication use and transfer via milk. About two thirds of those happen in the first month, and I think about 80% of them happen within the first two months. But it makes a lot of sense, because that's, you know, when the baby's the smallest, right? They have the least ability to metabolize the drugs, so their their little livers and their little kidneys just aren't functioning quite as well yet. And so not only do you have that, but they they are consuming the most milk on a weight basis that they ever will. So they get the most volume of milk, and that means the most volume of drug, and their little bodies can't clear it. So that's whenever we see the biggest issues, and then whenever you start, especially like once you get past around six months of age, that's whenever you start adding in complimentary foods, or if you're mixed feeding, that kind of thing, and then you're not as worried about it, because you just have less exposure.
Melissa Whitfield 08:33
Well, that makes sense. So who are people talking to when they call? I know you mentioned nurses at the call center,
Kaytlin Krutsch, Pharm.D., Ph.D. 08:40
Yes. So I have a team, gosh, right now, I think I have about six nurses that work for us in the call center. We have a really good range of nurses. So we have two nurses actually now, that are IBCLCs, and that's an Internationally Board Certified Lactation Consultant. One of our nurses has worked in the NICU; one of our nurses worked in like, women's health. We try and get a nice range of people who've worked in different things, because, you know, we're called the Infant Risk Center because everyone's asking about the risk to the baby, but really, most of what we're dealing with are maternal medications and what's going on in the mom's body. So we try and represent kind of both groups and have expertise on both sides.
Melissa Whitfield 09:25
Now, you mentioned research earlier. How does the IRC ensure that the information it provides is up to date and evidence based?
Kaytlin Krutsch, Pharm.D., Ph.D. 09:35
I think the IRC actually does a in some ways, a better job of this than anywhere else that I know because, because we're actively doing the research, and then we are literally telling the people who want to hear it, the moms. So generally speaking, it takes 17 years for research, you know, like discovery, something that we find and publish; it takes 17 years for that to actually get implemented into practice. And here at the Infant Risk Center, you know, if we're discovering something in the lab, you know we are going to immediately be able to tell the people what, what's going on. Sometimes, you know, if we get cases from from health care providers, we can tell them about things that aren't even published yet. You know, we have to be a little bit careful about that, because we don't go through peer review. But what it means is we literally get to answer their questions in real time, and then if we don't have answers for them, and we get a lot of the same questions, then that's when we say, hey, that's something that we need to look at. So we we have this really unique model where it's beautifully, like symbiotic, like, we just keep going around in this circle where we say, well, okay, we answered that question, and then the next question pops up, and then we just keep going,
Melissa Whitfield 10:49
What are some of the most common questions or concerns that the IRC addresses, and can someone call if they have a question about using illicit drugs while pregnant or nursing?
Kaytlin Krutsch, Pharm.D., Ph.D. 11:00
Yeah, yeah, we actually hear about illicit drugs a lot there right now. Gosh, we get a lot of questions about cannabis, and we answer questions worldwide. So most of our users, I'd say, are from the US, but everyone is welcome to call us. You know, we get calls from New Zealand and from South Africa and from Ireland, and, you know, I guess they have to stay up in the middle of the night to call us, but, but we still answer them. And you know, it's, it's not up to me to say what's illicit and what's not wherever they're at. You know, whenever a mom has used a drug, they have a lot of shame involved. It's, it's a really hard time. And so there are some tools that we we can point them to and also give them some concrete recommendations on on how long it might take the drug to clear from their body, because it can be dangerous. You know, we we've got issues sometimes, like with with cocaine and heroin. I'm really worried about street fentanyl use, because it's so much stronger and so, you know, they said, Hey, I made a mistake. I don't want to hurt my baby. How long do I need to wait until I can return to breastfeeding? Because I don't want to do this again? Or a lot of times, they'll say, Hey, I went out with my girlfriends for the first time in a year, and I made some really bad choices. Please help. And you know, it's hard, but you know we could still come up with with better recommendations than than they could. The illicit drugs, the what makes them hard is we don't ever know, really, the dose that they had. You know, whenever you take a medication, it's, I know exactly how much drug there is, and it's a lot easier for me to work that out. But you know, if, if you don't know what your dose is, then that makes my job a lot harder.
Melissa Whitfield 12:38
I guess the good thing about that is that they're asking.
Kaytlin Krutsch, Pharm.D., Ph.D. 12:41
Yes, and we want them to ask. So we have a rule here. You know, it's no judgment. It's like we're here to help people.
Melissa Whitfield 12:50
What are some over the counter medications or supplements or herbal remedies that someone who's pregnant or nursing might not realize have risks?
Kaytlin Krutsch, Pharm.D., Ph.D. 13:00
I'd say most of the time, almost all of the time, people are overestimating the risk. The times that they don't realize that their risk, a lot of it is the herbal products. And, you know, I can't definitively say, Oh, this, this herbal product is bad. It's really hard for me to study. I can't study an herbal product because there's, like, so many different things in there. You know, whenever I look at a drug, it's it's one thing. Whenever I look at an herbal product, it can be 30 things really easily. And most of the time it's probably not an issue, but some of the time it is. So like, people will will get, like kratom, kratom, I'm not quite sure how you pronounce it, but if they get that, people, you use it as an opioid replacement, but it is actually an opioid. And so they'll be dosing themselves with something that that is really like we just we don't have enough understanding of that, and they don't know that they're giving themselves an opioid and potentially giving their baby an opioid, and I think that they're not as careful with that as what they might be otherwise, if they knew what it was. Another thing is iodine. So your your breast, the cells in your milk blood barrier, have the same cells that are in your your thyroid that pump iodine into milk and that can suppress a baby's thyroid function. I worry about that one. So if you get like like, people will use iodine drops and they put it on their skin, or something like that. I don't like that at all. And I think that, you know, whenever you have an opioid and you notice that your baby is getting sleepy, you might connect the dots, you know. You know, if you took a oxycodone and then your baby's, you know, not responding, you might know what happened, right? But with the iodine, I don't think that they would connect the iodine use with the infant adverse effects. And so that's that's really concerning to me, too.
Melissa Whitfield 14:53
How can listeners support the IRC?
Kaytlin Krutsch, Pharm.D., Ph.D. 14:58
Oh, you know. Yeah, they can download our apps. So our apps are paid. So there are paid subscriptions, and I think we have a couple of features on there that are free. So for the moms, there are features like we have a time to zero alcohol calculator. So if you go out, you have a few drinks, and you want to know when the alcohol has cleared through your your milk. So you don't have to pump and dump. You just wait for your body to clear the alcohol out of your milk. And we have a calculator that, you know, takes your weight, takes how many drinks you had, into consideration. We even have like the drink type, so you can say you had, you know, like a margarita or something like that. And it'll tell you a timeline. And then you can look up all of the drugs individually. For health care providers, you can compare drugs and find out really quickly what its safety is like for lactation and how much data there is. Whenever I came to the infant risk center, and I didn't know enough about all of all of these things, I just thought, Dr Hale, like you've got to make it easy for people who don't know lactation to be able to make a good choice when they're prescribing, because they don't have time to look up every drug to find out which one's the best one. So so I made that in the app so they can do that, and then also, through the Texas Tech Foundation, we can accept donations.
Melissa Whitfield 16:13
Is there anything else that you would like to add?
Kaytlin Krutsch, Pharm.D., Ph.D. 16:14
I think people confuse the risks of medication use in pregnancy and in lactation. Whenever you're pregnant, your baby gets, you know, to some degree, and this is an oversimplification, but your baby is going to get a lot of exposure of the same things that you have. So they're usually going to get around the same dose that you do, but with milk, it's a lot less. The exposure is a lot less. But what happens is, after you have the baby, there's not anyone that's helping you so much. You know, you have an obstetrician when you're pregnant, and they know what to do. They've they've been around the block before, and they can help. But after you have the baby, you go back to your regular health care providers, and you go back to regular physicians who probably haven't been trained a lot on drugs and lactation, and they're really worried about hurting your baby. You're their patient, but they don't want to hurt your baby. And so they overestimate the risk of lactation exposures. And then I think that that they also undervalue the benefits of breast milk. So whenever I said that the CDC and the W.H.O., and virtually the whole world now is saying we should breastfeed for two years if the mom can. And the reason that they did that, the reason they extended it from 12 months to two years, is because of the health benefits to the mom. So we talk about benefits to the baby of breast milk a lot, and they exist. You know, they get less diarrheal, less ear infections, less childhood cancers. It's it's kind of crazy, all the things that breast milk will do for babies, but for mom, there's less heart attacks, there's less diabetes; and it's a dose intense response. So the more you breastfeed, the more protection you get, and that protection stays with you for decades. So you'll have lower risk of diabetes, hypertension. You know, it's just a nice long list of things. And so if you're not valuing those benefits, it's really easy to say, Well, maybe you should just stop breastfeeding so you can take this medicine that you need. And so to do a real risk benefit evaluation, you have to know what the benefits of breastfeeding are. And so I think that a lot of times with health care providers, that's, that's what I'm spending a lot of time doing, saying, Okay, we have a minuscule amount of drug in milk in most cases. I'll use this analogy a lot sometimes. I'm not sure if I've told it to you before, Melissa, but it's, it's about how much pee is in the pool, right? Like, if you are going to a pool, and you know that there's been some kid in there and and there's urine in the pool. And they can tell you how many nanograms per ml of urine there is in a pool-- there are studies on that -- but the reality is, is everyone has a different cut point of, like, how much is too much? You know, what am I willing to tolerate? Like, do I really want to get in the pool? Maybe I need the exercise. Maybe my knees hurt and I can't run, and so the pool is, like, my better option, but it's really hard whenever you have a mom and you have health care providers, because they might have different thresholds. And so, you know, the thing is, you've got to talk about it. And so a lot of times what we hear at the Infant Risk Center are moms that call in that say, Hey, I already went to the doctor's office, but you know, either I didn't tell them that I was breastfeeding because I was afraid they wouldn't help me, or I told them that I was breastfeeding and they told me that, you know this or that, or I needed to stop breastfeeding, or, you know that it was no problem, but we, I just want to double check; really, the prescriber and the mom should be talking about it together. That's the goal because they're going to know the most about the situation, about their situation, of the mom's health and the infant's ability to to handle exposure. So I hope the analogy helps.
Melissa Whitfield 18:57
It does.
Kaytlin Krutsch, Pharm.D., Ph.D. 18:58
It's a little bit crude, but, you know, it does the job.
Melissa Whitfield 19:51
Well that's great. Thank you so much for all this information and definitely opening our eyes to something that I mean, a lot of us have impressions that are just years old, or ideas or opinions that are outdated. I only breastfed my son for six months, but because I thought anything more than that was kind of, you know, weird, but I
Kaytlin Krutsch, Pharm.D., Ph.D. 20:29
it's hard. You know, we don't, we don't value how much time and effort it takes. It's hard. It's, it might be natural, but it's not easy,
Melissa Whitfield 20:37
Right. And my son only got two ear infections when he was little, and so I would tell everybody: breastfeed. I only did it for six months, but the benefits are great. So thank you so much for coming in our podcast and talking to us about this, and we will definitely put information in the show notes about how to contact the infant risk center.
Kaytlin Krutsch, Pharm.D., Ph.D. 20:56
All right. Thank you. Thank you.
Melissa Whitfield 21:00
Thank you for listening to Texas Tech Health Check. Make sure to subscribe or follow wherever you listen to podcasts. This information is not intended to be a substitute for professional medical advice. Always seek immediate medical advice from your physician or your health care provider for questions regarding your health or medical condition. Texas Tech Health Check is brought to you by Texas Tech University Health Sciences Center and produced by TR Castillo, Suzanna Cisneros, Mark Hendricks, Kay Williams, Krystal Meazell and me Melissa Whitfield.