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Hale’s Medications & Mothers’ Milk™

2019

A Manual of Lactational Pharmacology

Hale’s Medications & Mothers’ Milk™

2019

A Manual of Lactational Pharmacology

Eighteenth Edition

Professor

Department

Texas Tech University

School of Medicine

Amarillo, Texas

Copyright © 2019 Springer Publishing Company, LLC

All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, info@copyright.com or on the Web at www.copyright. com.

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The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. Because medical science is continually advancing, our knowledge base continues to expand. Therefore, as new information becomes available, changes in procedures become necessary. We recommend that the reader always consult current research and specific institutional policies before performing any clinical procedure. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

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CHANGES IN THIS EDITION

The 2019 edition has many significant updates including the addition of 39 new drugs, and updating of more than 331 current drugs. Each year there are so many new FDA-approved medications that it is difficult to choose which to add. As usual, I chose those that a breastfeeding mother would most likely use.

Key changes in 2019 include:

• My laboratories have been publishing many new breastfeeding drug studies, and I have tried to add as many of these as possible.

• I have added new infectious diseases and updated the old ones with current information.

• I’ve added dozens of new drugs, even though we don’t know if and how much they transfer into human milk.

• As before, with a few exceptions, I have removed the combination drugs (those with 2-4 drugs) and added them to a table in the Appendix. From this table you can look up the individual drugs.

Lastly, I would like to thank my InfantRisk Center staff for helping me decide which drugs are really popular, and make sure they were included in this edition. Each year 12,000 mothers call our service and I use these data to prepare this book.

Tom

PREFACE

We all agree that human milk is best for human infants. The benefits are simply enormous and supported by a world of good literature. However, the use of medications in breastfeeding mothers is often controversial, particularly with clinicians unexposed to this literature. This resource is dedicated to reducing some of these misconceptions. The truth is, most drugs simply don’t enter milk in levels that are hazardous to a breastfed infant. The problem, however, is devining which drugs are safe and which are hazardous.

Because so few clinicians understand lactational pharmacology, the number of women who are advised to discontinue breastfeeding in order to take a medication is still far too high. Fortunately, many mothers are now becoming aware of the enormous benefits of breastfeeding and simply refuse to follow some of the advice given by their healthcare professionals. They seek out the information on their own and invariably find this resource or my websites.

Because so many women ingest medications during the early neonatal period, it is not surprising that one of the most common questions encountered in pediatrics concerns the use of various drugs in a breastfeeding mother. Unfortunately, most healthcare professionals simply review the package insert or advise the mother not to breastfeed without having done a thorough study of the literature to find the true answer. Discontinuing breastfeeding is often the wrong decision, and most mothers could easily continue to breastfeed and take the medication without risk to the infant. Even the FDA has recognized this and now recommends drug manufacturers carry out studies to determine milk levels of their drug.

It is generally accepted that all medications transfer into human milk to some degree, although it is almost always quite low. Only rarely does the amount transferred into milk produce clinically relevant doses in the infant. Ultimately, it is the clinician’s responsibility to review the research I have on the drugs in this resource and make a clear decision as to whether the mother should continue to breastfeed.

Drugs may transfer into human milk if they:

Attain high concentrations in maternal plasma

Are low in molecular weight (<800)

Are low in protein binding

Pass into the brain easily

However, once medications transfer into human milk, other kinetic factors are involved. One of the most important is the oral bioavailability of the medication to the infant. Numerous medications are either destroyed in the infant’s gut, fail to be absorbed through the gut wall, or are rapidly picked up by the liver. Once in the liver, they are either metabolized or stored, but often never reach the mother’s plasma.

Drugs normally enter milk by passive diffusion, driven by equilibrium forces between the maternal plasma compartment and the maternal milk compartment. They pass from the maternal plasma through capillaries into the lactocytes lining the alveolus. Medications must generally pass through both bilayer lipid membranes of the alveolar cell to penetrate milk, although early on they may pass between the alveolar cells (first 72 hours postpartum). During the first 3 days postpartum, large gaps between the alveolar cells exist. These gaps permit enhanced access into the milk for most drugs, many immunoglobulins, maternal living cells (lymphocytes, leukocytes, macrophages), and other maternal proteins. By the end of the first week, the alveolar cells swell under the influence of prolactin, subsequently closing the intracellular gaps and reducing the transcellular entry of most maternal drugs, proteins, and other substances into the milk compartment. While it is generally agreed that medications penetrate into milk more during

the colostrum period than in mature milk, the absolute dose transferred during the colostrum period is still low as the total volume of milk is generally less than 30-100 mL/day for the first few days postpartum.

In most instances, the most important determinant of drug penetration into milk is the mother’s plasma level. Almost without exception, as the level of the medication in the mother’s plasma rises, the concentration in milk increases as well. Drugs enter and exit milk as a function of the mother’s plasma level. As soon as the maternal plasma level of a medication begins to fall, equilibrium forces drive the medication out of the milk compartment back into the maternal plasma for elimination. In some instances, drugs are trapped in milk (ion trapping) due to the lower pH of human milk (7.2). With drugs with a high pKa, the ionic state of the drug changes and stops its exit back into the maternal circulation. This is important in weakly basic drugs, such as the barbiturates (drugs with high pKa). There are a few known cellular pumping systems that actively pump drugs into milk. The most important is iodine. The iodine pump is the same

as found in everyone’s thyroid gland. Its purpose is to make sure the infant receives iodine to maintain thyroxine production.

The iodides, such as 131I or any “ionic” form of iodine, concentrate in milk due to this pump. Thus iodides, particularly radioactive ones, should be avoided as their milk concentrations are exceedingly high. Two other physicochemical factors are important in evaluating drugs in breastfeeding mothers—the degree of protein binding and lipid solubility. Drugs that are very lipid soluble penetrate into milk in higher concentrations almost without exception. Of particular interest are the drugs that are active in the central nervous system (CNS). CNSactive drugs invariably have the unique characteristics required to enter milk. Therefore, if a drug is active in the CNS, higher levels in milk can be expected, although the amounts still are often subclinical. Many of the neuroactive drugs produce Relative Infant Doses (RIDs) of >5%. Protein binding also plays an important role. Drugs circulate in the maternal plasma, either bound to albumin or freely soluble in the plasma. It is the free component (unbound fraction) that transfers into milk, while the bound fraction stays in the maternal circulation. Therefore, drugs that have high maternal protein binding (warfarin, many NSAIDs) have reduced milk levels simply because they are excluded from the milk compartment.

Once a drug has entered the mother’s milk and has been ingested by the infant, it must traverse through the infant’s gastrointestinal (GI) tract prior to absorption. Some drugs are poorly stable in this environment due to the proteolytic enzymes and acids present in the infant’s

stomach. This includes the aminoglycoside family, omeprazole, and large peptide drugs, such as heparin. Other drugs are poorly absorbed by the infant’s GI tract and do not enter the infant’s bloodstream. Thus, oral bioavailability is a useful tool to estimate just how much of the drug will be absorbed by the infant. Many drugs are sequestered in the liver (first pass) and may never actually reach the plasma compartment where they are active. Absorption characteristics such as these ultimately tend to reduce the overall effect of many drugs in breastfed infants. There are certainly exceptions to this rule, and one must always be aware that the action of a drug in the GI tract can be profound, producing diarrhea, constipation, and occasionally syndromes such as pseudomembranous colitis. One of the more popular methods for estimating risk is to determine the Relative Infant Dose (RID). The RID is calculated by dividing the infant’s dose via milk (mg/ kg/day) by the mother’s dose in mg/kg/day. The RID gives the clinician a feeling for just how much medication the infant is exposed to on a weight-normalized basis. However, many authors calculate the infant dose without normalizing for maternal and infant weight, so be cautious.

Key Points About Breastfeeding and Medications

• Avoid using medications that are not necessary. Herbal drugs, high-dose vitamins, unusual supplements, iodine supplements, etc. that are simply not necessary should be avoided.

• If the RID is less than 10%, most medications are considered relatively safe to use, but again this is dependent on the type of drug taken.

• Choose drugs for which we have published data, rather than those recently introduced.

• Evaluate the infant for risks. Be more cautious with premature infants or neonates.

• Medications used in the first 3 to 4 days generally produce subclinical levels in the infant due to the limited volume of milk.

• Recommend that mothers with symptoms of depression or other mental disorders seek treatment. Most of the medications used to treat these syndromes are safe. Remember, healthy moms make healthy babies.

• Most drugs are quite safe in breastfeeding mothers. The hazards of using formula are well known and documented.

• With some medications, discontinuing breastfeeding for some hours/days may be required, particularly with radioactive compounds and anticancer drugs. If the drug is hazardous to you, it is probably hazardous to your infant.

• Choose drugs with short half-lives, high protein binding, low oral bioavailability, or high molecular weight.

Lastly, it is terribly important to always evaluate the infant’s ability to handle small amounts of medications. Some infants, such as premature or unstable infants, may not be suitable candidates

RID =
Dose in infant
Dose in mother

for certain medications. But remember that early postpartum (and in late-stage lactation), the amount of milk produced (30-100 mL/day) is so low that the clinical dose of drug transferred is often low, so even premature neonates would receive only a limited amount from the milk.

Evaluation of the Infant

• Inquire about the infant—always inquire as to the infant’s age, size, and stability. These are perhaps the most important criteria to be evaluated prior to using the medication.

• Infant age—premature and newborn infants are at somewhat greater risk. Older infants are at somewhat lower risk due to high metabolic capacity.

• Infant stability—unstable infants with poor GI stability may be at increased risk from certain medications.

• Pediatric approved drugs—generally they are less hazardous if long-term history of safety is recognized.

• Dose vs. age—the age of an infant is critical. Use medications cautiously in premature infants. Older, mature infants can metabolize and clear medications much more easily. Remember the dose of the drug is dependent on milk supply. In mothers in late-stage lactation ( >1 year), milk production is often low, so the dose of drug delivered is lower.

• Drugs that alter milk production—avoid medications that may alter the mother’s milk production. These include estrogens, ergot alkaloids, and other drugs.

General Suggestions for the Clinician

Determine if the drug is absorbed from the GI tract. Many drugs, such as the aminoglycosides, vancomycin, cephalosporin antibiotics (third generation), magnesium salts, and large protein drugs (heparin), are so poorly absorbed that it is unlikely the infant will absorb significant quantities. At the same time, observe for GI side effects from the medication trapped in the GI compartment of the infant (e.g., diarrhea).

Calculate and review the RID and compare that to the pediatric dose if known. Most older RIDs were derived using the Cmax (highest milk concentration of the drug) that was published. In current research projects, I always calculate the average (Cave) milk level throughout the dosing schedule. This estimate provides an average exposure rather than just the highest. I no longer use the milk/plasma ratio as it is virtually worthless unless you know the maternal plasma level. It does not provide the clinician with information as to the average amount of drug transferred to the infant via milk. Even if the drug has a high milk/plasma ratio, if the maternal plasma level of the medication is very small (such as with ranitidine), then the absolute amount (dose) of a drug delivered to the infant will still be quite small and often subclinical.

Be cautious of drugs (or their active metabolites) that have long pediatric half-lives as they can continually build up in the infant’s plasma over time. The barbiturates, benzodiazepines, and meperidine are classic examples where higher levels in the infant can and do occasionally occur.

If you are provided a choice, choose drugs that have higher protein binding because they are generally sequestered in the maternal circulation and do not transfer readily into the milk compartment or the infant. Remember, it’s the free drug that transfers into the milk compartment. Without doubt, the most important parameter that determines drug penetration into milk is plasma protein binding. Choose drugs with high protein binding.

Although not always true, I have generally found centrally active drugs (anticonvulsants, antidepressants, antipsychotics) frequently penetrate milk in higher (not necessarily “high”) levels simply due to their physicochemistry. If the drug in question produces sedation, depression, or

other neuroleptic effects in the mother, it is likely to penetrate the milk and may produce similar effects in the infant. Thus, with CNS-active drugs, one should always check the data in this resource closely and monitor the infant routinely.

Be cautious of herbal drugs as many contain chemical substances that may be dangerous to the infant. Numerous poisonings have been reported. Prior to using, advise the mother to contact a lactation consultant or herbalist who is knowledgeable about their use in breastfeeding mothers. Do not exceed standard recommended doses. Try to use pure forms, not large mixtures of unknown herbals. Do not overdose; use only minimal amounts.

For radioactive compounds, I have gathered much of the published data in this field into several tables. The Nuclear Regulatory Commission recommendations are quite good, but they differ from some published data. They can be copied and provided to your radiologist. They are available from the Nuclear Regulatory Commission’s web page address in the appendix.

Use the RID. In general, a RID of <10% is considered safe, and its use is becoming increasingly popular by numerous investigators.

Most importantly, it is rare that a breastfeeding mother needs to discontinue breastfeeding just to take a medication. It is simply not acceptable for clinicians to stop lactation merely because of heightened anxiety or ignorance on their part. The risks of formula feeding are significant and should not be trivialized. Few drugs have documented side effects in breastfed infants, and I know most of these.

The following review of drugs, and even diseases, is a thorough review of what has been published and what I presently know about the use of medications in breastfeeding mothers.

The authors make no recommendations as to the safety of these medications during lactation, but only review what is currently published in the scientific literature. Individual use of medications must be left up to the judgment of the physician, the patient, and other healthcare consultants.

How To Use This Resource

This section of the resource is designed to aid the reader in determining risk to an infant from maternal medications and in using the pharmacokinetic parameters throughout this reference.

Trade Name and Generic Name

Each monograph begins with the generic name of the drug. The most common trade names are provided under the Trade section. With some pharmaceuticals, there may be more than one drug added to the product. In this case I have added a table called “Combination Drugs” in the appendix where all the drugs present in that specific pharmaceutical are listed and you can then look up the individual products.

Other Trades

This resource is used all over the world. Thus, many other trade names from other countries are now included in this section.

Category

This lists the class or “family of drugs” that the medication belongs to and gives a general idea of the pharmacology, mechanism of action, and probable use of the drug.

Drug Monograph

The drug monograph lists what we currently understand about the drug, its ability to enter milk, the concentration in milk at set time intervals, and other parameters that are important to a clinical consultant. I have attempted at great length to report only what the references have documented.

DR. HALE’S LACTATION RISK CATEGORIES:

L1 Compatible

This is a drug that has been taken by a large number of breastfeeding mothers without any observed increase in adverse effects in the infant. Controlled studies in breastfeeding women fail to demonstrate a risk to the infant and the possibility of harm to the breastfeeding infant is remote, or the product is not orally bioavailable in an infant.

L2 Probably Compatible

A drug that has been studied in a limited number of breastfeeding women without an increase in adverse effects in the infant and/or the evidence of a demonstrated risk that is likely to follow use of this medication in a breastfeeding woman is remote.

L3 Probably Compatible

There are no controlled studies in breastfeeding women; however, the risk of untoward effects to a breastfed infant is possible, or controlled studies show only minimal non-threatening adverse effects. Drugs should be given only if the potential benefit justifies the potential risk to the infant. (New medications that have absolutely no published data are automatically categorized in this category, regardless of how safe they may be.)

L4 Potentially Hazardous

There is positive evidence of risk to a breastfed infant or to breast milk production, but the benefits from use in breastfeeding mothers may be acceptable despite the risk to the infant (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective).

L5 Hazardous

Studies in breastfeeding mothers have demonstrated that there is significant and documented risk to the infant based on human experience, or it is a medication that has a high risk of causing significant damage to an infant. The risk of using the drug in breastfeeding women clearly outweighs any possible benefit from breastfeeding. The drug is contraindicated in women who are breastfeeding an infant.

Adult Concerns

This section lists the most prevalent undesired or bothersome side effects listed for adults. As with most medications, the occurrence of these is often quite rare, generally less than 1-10%. Side effects vary from one patient to another, with most patients not experiencing untoward effects.

Pediatric Concerns

This section lists the side effects noted in the published literature as associated with medications transferred via human milk. Pediatric concerns are those effects that were noted by investigators as being associated with drug transfer via milk. In some sections, I have added comments that may not have been reported in the literature, but are well known attributes of this medication.

Infant Monitoring

This section provides advice to the clinician regarding potential side effects that may occur in the infant from exposure to a medication in breast milk. The infant monitoring parameters can be used by the clinician to educate the mother about potential side effects that could occur in the infant.

Relative Infant Dose (RID)

The RID is calculated by dividing the infant’s dose via milk in “mg/kg/day” by the maternal dose in “mg/kg/day.” This weight-normalizing method indicates approximately how much of the “maternal dose” the infant is receiving. Many authors now use this calculation because it gives a better indication of the relative dose transferred to the infant. I report RID ranges, as this gives the reader an estimate of all the RIDs published by the various authors.

Please understand, however, that many authors use different methods for calculating RID. Some are not weight-normalized. In these cases, their estimates may differ slightly from this resource. While I often place the authors’ estimates of RID in the text, the RID range that I calculate is weight-normalized in all instances when the maternal weight is provided. So RID may be slightly different according to how it is calculated.

Many researchers now suggest that anything less than 10% of the maternal dose is probably safe. This is usually correct. However, some drugs (metronidazole, acetaminophen) actually have much higher RIDs, but because they are quite non-toxic, they do not often bother an infant. To calculate this dose, I chose the data I felt were best, and this often included larger studies with AUC calculations of mean concentrations in milk. When maternal weights are not published, I use an average body weight of 70 kg for an adult. Thus, most of the RIDs herein are calculated assuming a maternal average weight of 70 kg and a daily milk intake of 150 mL/kg/day in the infant.

Adult Dosage

This is the usual adult oral dose provided in the package insert. While these are highly variable, I chose the dose for the most common use of the medication.

Alternatives

Drugs listed in this section may be suitable alternate choices for the medication listed. In many instances, if the patient cannot take the medication or it is a poor choice due to high milk

concentrations, these alternatives may be suitable candidates. WARNING: The alternatives listed are only suggestions and may not be at all appropriate for the syndrome in question. Only the clinician can make this judgment. For instance, nifedipine is a calcium channel blocker with good antihypertensive qualities, but poor antiarrhythmic qualities. In this case, verapamil would be a better choice.

T 1/2

This lists the most commonly recorded adult half-life (T 1/2) of the medication. It is very important to remember that short half-life drugs are preferred. Use this parameter to determine if the mother can successfully breastfeed around the medication by nursing the infant, then taking the medication. If the half-life is short enough (1-3 hours), then the drug level in the maternal plasma will be declining when the infant feeds again. This is ideal. If the half-life is significantly long (12-24 hours) and if the physician is open to suggestions, then find a similar medication with a shorter half-life (compare ibuprofen with naproxen). However, in today’s world, longer-half life drugs are preferred and we simply have to accomodate these and rely on published data.

Vd

The volume of distribution (Vd) is a useful kinetic term that describes how widely the medication is distributed in the body. Drugs with high Vd are distributed in higher concentrations in remote compartments of the body and may not stay in the blood. Marijuana is a classic example.

Another such drug, digoxin, enters the blood compartment and then rapidly leaves to enter the heart and skeletal muscles. Most of the drug is sequestered in these remote compartments (100 fold). Therefore, drugs with high volumes of distribution (1-20 L/kg) generally require much longer to clear from the body than drugs with smaller volumes (<1 L/kg). For instance, whereas it may only require a few hours to totally clear gentamycin (Vd = 0.28 L/kg), it may require weeks to clear amitriptyline (Vd = 10 L/kg). Further, some drugs may have one halflife for the plasma compartment, but may have a totally different half-life for the peripheral compartment, as half-life is a function of volume of distribution. I have found that drugs with high Vd generally produce lower milk levels. For a complete description of Vd, please consult a good pharmacology reference. In this text, the units of measure for Vd are L/kg.

Tmax

This lists the time interval from administration of the drug until it reaches the highest level in the mother’s plasma (Cmax), which I call the peak or “time to max,” hence Tmax. Occasionally, you may be able to avoid nursing the baby when the medication is at its peak and wait until the peak is subsiding or has at least dropped significantly. Remember, drugs enter breast milk as a function of the maternal plasma concentration. In general, the higher the mother’s plasma level, the greater the entry of the drug into her milk. If possible, choose drugs that have short peak intervals, and suggest that the mother not breastfeed when the drug is at Cmax.

MW

The molecular weight (MW) of a medication is a significant determinant as to the entry of that medication into human milk. Medications with small MW (<200) can easily pass into milk by traversing small pores in the cell walls of the mammary epithelium (see ethanol). Drugs with higher MWs must traverse the membrane by dissolving in the cells’ lipid membranes, which may significantly reduce milk levels. As such, the smaller the MW, the higher the relative transfer of that drug into milk. Protein medications (e.g., heparin), which have enormous MWs, transfer at much lower concentrations and are virtually excluded from human breastmilk. Therefore, when possible, choose drugs with higher MWs to reduce their entry into milk.

This lists the milk/plasma ratio. This is the ratio of the concentration of drug in the mother’s milk divided by the concentration in the mother’s plasma. If high (>1-5), it is useful as an indicator of drugs that may sequester in milk in high levels. If low (<1), it is a good indicator that only minimal levels of the drug are transferred into milk (this is preferred). While it is best to try to choose drugs with low milk/plasma ratios, the amount of drug that transfers into human milk is largely determined by the level of drug in the mother’s plasma compartment. Even with high M/P ratios and low maternal plasma levels, the amount of drug that transfers is still low. Therefore, the higher M/P ratios often provide an erroneous impression that large amounts of drug are going to transfer into milk. This simply may not be true.

PB

This lists the percentage of maternal protein binding. Most drugs circulate in the blood bound to plasma albumin and other proteins. If a drug is highly protein bound, it cannot enter the milk compartment as easily. The higher the percentage of binding, the less likely the drug is to enter the maternal milk. Try to choose drugs that have high protein binding in order to reduce the infant’s exposure to the medication. Good protein binding is typically greater than 90%.

Oral

Oral bioavailability refers to the ability of a drug to reach the systemic circulation after oral administration. It is generally a good indication of the amount of medication that is absorbed into the bloodstream of the patient. Drugs with low oral bioavailability are generally either poorly absorbed in the GI tract, are destroyed in the gut, or are sequestered by the liver prior to entering the plasma compartment. The oral bioavailability listed in this text is the adult value; almost none have been published for children or neonates. Recognizing this, these values are still useful in estimating if a mother or perhaps an infant will actually absorb enough drug to provide clinically significant levels in the plasma compartment of the individual. The value listed estimates the percent of an oral dose that would be found in the plasma compartment of the individual after oral administration. In many cases, the oral bioavailability of some medications is not listed by manufacturers, but instead terms such as “Complete,” “Nil,” or “Poor” are used. For lack of better data, I have included these terms when no data are available on the exact amount (percentage) absorbed.

pKa

The pKa of a drug is the pH at which the drug is equally ionic and nonionic. The more ionic a drug is, the less capable it is of transferring from the milk compartment to the maternal plasma compartment. Hence, the drug becomes trapped in milk (ion trapping). This information is useful because drugs that have a pKa higher than 7.2 may be sequestered to a slightly higher degree than drugs with a lower pKa. Drugs with higher pKa generally have higher milk/plasma ratios. Hence, choose drugs with a lower pKa.

With many drugs, the pharmacokinetics have not been described or published. In this case I leave this entry blank.

Common Abbreviations

ACEI Angiotensin converting enzyme inhibitor

AUCArea under the curve

BIDTwice daily

CmaxPlasma or milk concentration at peak

dDay

et al“and others”

gGram

GIGastrointestinal

hHour

LRCLactation risk category

M/PMilk/plasma ratio

MAOIMonoamine oxidase inhibitors

mg/LMilligram per liter

mLMilliliter. One cc

mmolMillimole of weight

MWMolecular weight

ng/LNanogram per liter

NRNot rated

NSAIDNonsteroidal anti-inflammatory drug

OralOral bioavailability (adult)

PBPercent of protein binding in maternal circulation

pgPicogram

PHLPediatric elimination half-life

PRNAs needed

QDDaily

QIDFour times daily

RIDRelative Infant Dose

SNRIsSerotonin norepinephrine reuptake inhibitors

SSRIsSelective serotonin reuptake inhibitors

T 1/2Adult elimination half-life

TCAsTricyclic antidepressants

TIDThree times daily

TmaxTime to peak plasma level (PK)

VdVolume of distribution

XTimes

mCiMillicurie of radioactivity

μCiMicrocurie of radioactivity

μg/LMicrogram per liter

μmolMicromole of weight

Hale’s Medications & Mothers’ Milk™

2019

A Manual of Lactational Pharmacology

ABACAVIR

Trade: Ziagen

Category: Antiviral

LRC: L5 - Limited Data-Hazardous if Maternal HIV Infection

Abacavir (ABC) is a nucleoside reverse transcriptase inhibitor (NRTI) that is used in combination with other agents for the treatment of HIV.1

In a study published in 2013, nine women receiving Trizivir (abacavir 300 mg + zidovudine 300 mg + lamivudine 150 mg) twice daily provided breast milk samples for analysis on day 30 postpartum.2 The median abacavir level was 0.057 μg/mL and the highest level was about 0.5 μg/mL. The milk/plasma ratio was found to be 0.85. A typical infant would receive 0.0086 mg/ kg/day when using the median milk sample and about 0.075 mg/kg/day when using the highest concentration. This corresponds to a relative infant dose of 0.1% and 0.9%, respectively. Of the nine infants in the study who were exposed to abacavir, only one had a detectable concentration of abacavir in plasma. No side effects were reported in these infants. However, the authors of this study raised the possibility of sub-inhibitory levels of abacavir promoting viral resistance to the drug, which could then affect the baby.

Note: This medication is an L5 to highlight the contraindication of breastfeeding when the mother is known to be infected with HIV. This medication is not an L5 based on its risk to the infant in breast milk. The Centers for Disease Control and Prevention recommend that HIVinfected mothers do not breastfeed their infants to avoid postnatal transmission of HIV.

1/2 1.54 h

Adult Concerns: Headache, fatigue, depression, changes in sleep, abnormal dreams, nausea, vomiting, diarrhea, changes in liver function, elevated triglycerides, thrombocytopenia, severe rash.

Adult Dose: 300 mg twice a day or 600 mg daily.

Pediatric Concerns: In pediatric HIV clinical studies the most common side effects that occurred when this medication was administered directly to the infant (not via milk) included: fever and/or chills, nausea, vomiting, diarrhea, skin rashes and ear/nose/throat infections.

Infant Monitoring: Breastfeeding is not recommended in mothers who have HIV.

Alternatives:

References:

1. Pharmaceutical manufacturer prescribing information, 2012.

2. Shapiro RL, Rossi S, Ogwu A, et al. Therapeutic levels of lopinavir in late pregnancy and abacavir passage into breast milk in the Mma Bana Study, Botswana. Antivir Ther. 2013;18(4):585-590.

Trade: Orencia

Category: Antirheumatic

LRC: L3 - No Data-Probably Compatible

Abatacept is a soluble fusion protein that is linked to a modified portion of human immunoglobulin G1 (IgG1).1 The apparent molecular weight of abatacept is 92 kilodaltons. Abatacept inhibits T cell activation by binding to CD80 and CD86 receptors which down regulates the T cells implicated in inflammation of rheumatic disorders. In vitro, abatacept decreases T cell proliferation and inhibits

ABATACEPT

the production of the cytokines TNF alpha, interferon-gamma and interleukin-2. There are no data on the transfer of this antibody into human milk. Due to its large molecular weight and poor oral absorption, it is not likely to enter breast milk or the infant’s systemic circulation in clinically relevant amounts; however, there is no data to confirm this at this time.

92 kDa

Adult Concerns: Headache, fever, dizziness, cough, nausea, abdominal pain, back pain or limb pain, rash, antibody formation, increased risk of infection.

Adult Dose: 500-1000 mg IV at 0, 2 and 4 weeks, then repeat every 4 weeks.

Pediatric Concerns: No adverse effects have been reported via milk at this time.

Infant Monitoring:

Alternatives: Infliximab, etanercept.

References:

1. Pharmaceutical manufacturer prescribing information, 2011.

ACARBOSE

Trade: Glucobay, Prandase, Precose

Category: Antidiabetic, Other

LRC: L3 - No Data-Probably Compatible

Acarbose is an oral alpha-glucosidase inhibitor used to delay the absorption of carbohydrates in the management of type 2 diabetes.1,2 The local action of this medication in the gastrointestinal tract reduces carbohydrate absorption and the rapid rise in glucose and insulin following a meal; hence, glycosylated hemoglobin (HbA1c) levels are reduced over time. No data are available on the transfer of acarbose into human milk. The oral bioavailability of this medication is less than 2%; thus, little medication would be expected to enter maternal milk.

T 1/2 ~2 h

~1 h

Oral 0.7- 2%

0.32 L/kg

Adult Concerns: Abdominal pain, flatulence, diarrhea, increases in liver enzymes.

Adult Dose: 50-100 mg TID.

Pediatric Concerns: None reported via milk.

Infant Monitoring: Flatulence, persistent diarrhea, weight gain.

Alternatives: Insulin, metformin, glyburide.

References:

1. Pharmaceutical manufacturer prescribing information, 2008.

2. Balfour JA, McTavish D. Acarbose. An update of its pharmacology and therapeutic use in diabetes mellitus. Drugs. 1993;46(6):1025-1054.

ACEBUTOLOL

Trade: Monitan, Sectral

Category: Beta Adrenergic Blocker

LRC: L3 - Limited Data-Probably Compatible

Acebutolol predominantly inhibits beta-1 receptors, but can block beta-2 receptors at high doses.1 It is low in lipid solubility, and contains intrinsic sympathetic activity (partial beta agonist activity). Studies indicate that on a weight basis, acebutolol is approximately 10-30% as effective as propranolol.

In a study of seven women receiving 200-1200 mg/day acebutolol, the highest milk concentration occurred in the women receiving 1200 mg/day and was 4,123 μg/L.2 In women receiving 200, 400 or 600 mg/day of acebutolol, milk levels were 286 μg/L, 666 μg/L and 539 μg/L, respectively. Adverse effects of beta-blockade were reported.

Acebutolol and its major active metabolite, diacetolol, appear in breast milk with a milk/plasma ratio of 1.9 to 9.2 (acebutolol) and 2.3 to 24.7 (diacetolol). These levels are considered relatively high and occurred following maternal doses of 400-1200 mg/day. When the metabolite is added, the infant dose may approach 10% of the maternal dose.

Adult Concerns: Headache, dizziness, insomnia, depression, fatigue, chest pain, bradycardia, hypotension, heart failure, wheezing, vomiting, constipation, diarrhea, myalgia.

Adult Dose: 200-400 mg BID.

Pediatric Concerns: Hypotension, bradycardia, hypoxemia and transient tachypnea have been reported.2

Infant Monitoring: Drowsiness, lethargy, pallor, poor feeding and weight gain.

Alternatives: Labetalol, metoprolol.

References:

1. Drug Facts and Comparisons 1995 ed. St. Louis, MO.

2. Boutroy MJ, Bianchetti G, Dubruc C, Vert P, Morselli PL. To nurse when receiving acebutolol: is it dangerous for the neonate? Eur J Clin Pharmacol. 1986;30(6):737-739.

ACETAMINOPHEN (PARACETAMOL)

Trade: 222 AF Extra Strength, Abenol, Actamin Maximum Strength, Aminofen, Feverall, Genapap, Panadol, Tylenol

Category: Analgesic

LRC: L1 - Extensive Data-Compatible

Acetaminophen is an analgesic/antipyretic used in the treatment of fever and pain. When taken orally, only minimal amounts are secreted into breast milk and are considered too small to be hazardous. In a study of 11 mothers who received 650 mg of acetaminophen orally, the highest milk levels reported were from 10-15 mg/L.1 The milk/plasma ratio was 1.08. In another study of three patients who received a single 500 mg oral dose, the reported milk and plasma concentrations of acetaminophen were 4.2 mg/L and 5.6 mg/L, respectively.2 The milk/plasma ratio was 0.76. The maximum observed concentration in milk was 4.4 mg/L. In another study of women

who ingested 1000 mg acetaminophen, milk levels averaged 6.1 mg/L and provided an average dose of 0.92 mg/kg/day according to the authors.3 Although there seems to be wide variation in the milk concentrations in these studies, the amount of acetaminophen an infant could ingest via breast milk is most likely significantly less than the pediatric therapeutic dose.

Acetaminophen is increasingly being used intravenously for the relief of moderate to severe pain conditions. Some reports have suggested that the analgesic efficacy of intravenous acetaminophen is equivalent to that of intravenous morphine, and is probably preferred due to its minimal side effects.4,5 Following a 1 g IV dose of acetaminophen, the peak plasma concentrations attained are in the order of 28 mg/L at the end of 15 min. According to one report, following a 2 g IV dose of acetaminophen in post-partum mothers, the plasma levels decreased from 22.5 mg/L to 3.9 mg/L within 6 hours post-dose.6 Following a single IV dose, a maternal peak plasma concentration of 28 mg/L suggests that a breastfed infant would receive a dose of 19.6-28 mg/ day (M/P ratio = 1) or about 4-6 mg/kg/day. This is far lower than the clinical doses for infants (10-15 mg/kg/dose).

The dose ingested could be higher in premature infants or younger infants, but would probably still be lower than the clinically used pediatric doses. Nevertheless, some caution is advised. IV acetaminophen has been successfully used in premature infants born at 25-32 weeks of gestation, without any reported side effects.7 The serum concentrations at the end of 8-12 doses ranged between 8-64 mg/L. The authors reported that the infants tolerated the drug well. Based on these studies it may be said that infants seem to tolerate IV acetaminophen well. The dose ingested by an infant following IV acetaminophen in a lactating mother would most probably not be clinically relevant.

There is growing evidence that acetaminophen use may be linked to an increased prevalence of asthma among children and adults. In one published paper, it has been recommended that any child with asthma or a family history of asthma avoid using acetaminophen.8 Prenatal exposure and exposure to acetaminophen in the first year of life has also been linked to development of asthma later in life.9,10,11,12,13 Subsequently, the issue of lactational exposure to acetaminophen and its association with development of asthma has also been addressed.

In one such short-term study, out of 11 wheezing, exclusively breastfed infants, mothers of 7 of the infants had admitted intake of acetaminophen at the time of onset of wheezing symptoms in the infants.14 However, these claims have been refuted by a few other authorities, based on various grounds. Nevertheless, due to the immaturity of metabolic pathways in the infant, a customary recommendation of judicious use of medications (including acetaminophen) during lactation has been advocated.

T 1/2

Adult Concerns: Few when taken in normal doses. Diarrhea, gastric upset. Note: numerous cases of liver toxicity have been reported following “chronic” use of acetaminophen at >200 mg/ kg/day. Do not exceed 3000 mg in a 24 hour period or 1000 mg/dose. Exceedingly high doses can cause severe hepatic toxicity and death.

Adult Dose: 650 mg every 4-6 hours PRN.

Pediatric Concerns: None reported via milk at this time.

Infant Monitoring: Diarrhea, gastric upset; potential for liver toxicity if maternal overdose.

Alternatives: Ibuprofen.

References:

1. Berlin CM, Jr., Yaffe SJ, Ragni M. Disposition of acetaminophen in milk, saliva, and plasma of lactating women. Ped Pharmacol.1980;1(2):135-141.

2. Bitzen PO, Gustafsson B, Jostell KG, Melander A, Wahlin-Boll E. Excretion of paracetamol in human breast milk. European J Clin Pharmacol. 1981;20(2):123-125.

3. Notarianni LJ, Oldham HG, Bennett PN. Passage of paracetamol into breast milk and its subsequent metabolism by the neonate. Brit J Clin Pharmacol. 1987 Jul;24(1):63-67.

4. Serinken M, Eken C, Turkcuer I, Elicabuk H, Uyanik E, Schultz CH. Intravenous paracetamol versus morphine for renal colic in the emergency department: a randomised double-blind controlled trial. EMJ. 2012 Nov;29(11):902-905.

5. Craig M, Jeavons R, Probert J, Benger J. Randomised comparison of intravenous paracetamol and intravenous morphine for acute traumatic limb pain in the emergency department. EMJ. 2012 Jan;29(1):37-39.

6. Kulo A, van de Velde M, de Hoon J, et al. Pharmacokinetics of a loading dose of intravenous paracetamol post caesarean delivery. Internat J Obstet Anesthesia. 2012 Apr;21(2):125-128.

7. van Ganzewinkel CJ, Mohns T, van Lingen RA, Derijks LJ, Andriessen P. Paracetamol serum concentrations in preterm infants treated with paracetamol intravenously: a case series. Journal of Medical Case Reports. 2012;6:1.

8. McBride JT. The association of acetaminophen and asthma prevalence and severity. Pediatrics. 2011 Dec;128(6):1181-1185.

9. Eyers S, Weatherall M, Jefferies S, Beasley R. Paracetamol in pregnancy and the risk of wheezing in offspring: a systematic review and meta-analysis. Clinical and Experimental Allergy: Journal of the British Society for Allergy and Clinical Immunology. 2011 Apr;41(4):482-489.

10. Etminan M, Sadatsafavi M, Jafari S, Doyle-Waters M, Aminzadeh K, Fitzgerald JM. Acetaminophen use and the risk of asthma in children and adults: a systematic review and metaanalysis. Chest. 2009 Nov;136(5):13161323.

11. Rebordosa C, Kogevinas M, Sorensen HT, Olsen J. Pre-natal exposure to paracetamol and risk of wheezing and asthma in children: a birth cohort study. Internat J Epidemiol. 2008 Jun;37(3):583-590.

12. Shaheen SO, Newson RB, Henderson AJ, et al. Prenatal paracetamol exposure and risk of asthma and elevated immunoglobulin E in childhood. Clinical and Experimental Allergy: Journal of the British Society for Allergy and Clinical Immunology. 2005 Jan;35(1):18-25.

13. Shaheen SO, Newson RB, Sherriff A, et al. Paracetamol use in pregnancy and wheezing in early childhood. Thorax. 2002 Nov;57(11):958-963.

14. Verd S, Nadal-Amat J. Paracetamol and asthma and lactation. Acta paediatrica. 2011 Jul;100(7):e2-3; author reply e3.

ACETAZOLAMIDE

Trade: Acetazolam, Dazamide, Diamox, Sequels

Category: Diuretic

LRC: L2 - Limited Data-Probably Compatible

Acetazolamide is a carbonic anhydrase inhibitor dissimilar to other thiazide diuretics. There are documented suggestions that diuretics in general decrease the volume of breast milk. In a patient who received 500 mg of acetazolamide twice daily, acetazolamide concentrations in milk were 1.3 to 2.1 mg/L while the maternal plasma levels ranged from 5.2-6.4 mg/L.1 Plasma concentrations in the exposed infant were 0.2 to 0.6 μg/mL 2 to 12 hours after breastfeeding. These amounts are unlikely to cause adverse effects in the infant.

Adult Concerns: Anorexia, diarrhea, metallic taste, polyuria, muscular weakness, potassium loss. Malaise, fatigue, depression, renal failure have been reported.

Adult Dose: 500 mg BID.

Pediatric Concerns: None reported via milk.

Infant Monitoring: Observe for fluid loss, dehydration, lethargy.

Alternatives:

References:

1. Soderman P, Hartvig P, Fagerlund C. Acetazolamide excretion into human breast milk. Br J Clin Pharmacol. 1984;17(5):599-600.

ACETYLSALICYLIC ACID

Trade: ASA, Ascriptin, Aspirin, Aspirtab, Easprin, Ecotrin, Ecpirin, Entercote

Category: Analgesic

LRC: L2 - Limited Data-Probably Compatible

Acetylsalicylic acid (ASA) is an irreversible inhibitor of cyclooxygenase-1 and 2 (COX-1 and COX-2).1 At low doses, COX-1 inhibition indirectly leads to decreased platelet aggregation. Anti-inflammatory, analgesic and antipyretic effects also emerge at higher doses. ASA is rapidly metabolized to salicylic acid, which is a lower-potency, reversible inhibitor of a variety of processes. Few harmful effects have been reported with use in lactation. In one study, salicylic acid (active metabolite) penetrated poorly into milk (454 mg dose ASA), with peak levels of only 1.12 to 1.60 μg/mL, whereas maternal peak plasma levels were 33 to 43.4 μg/mL.2 In another study of a rheumatoid arthritis patient who received 4 g/day ASA, none was detectable in her milk (<5 mg/100 mL).3 Extremely high doses in the mother could potentially produce slight bleeding in the infant. Because ASA is implicated in Reye Syndrome, it is a poor choice of analgesic to use in breastfeeding mothers. However, in rheumatic fever patients, it is still one of the anti-inflammatory drugs of choice and a risk-vs-benefit assessment must be done in this case.

In a study of a patient consuming ASA chronically, salicylate concentrations in milk peaked at 3 hours at a concentration of 10 mg/L following a maternal dose of 975 mg.4 Maternal plasma levels peaked at 2.25 hours at 108 mg/L. The milk/plasma ratio was reported to be 0.08. In a study of 8 women following the use of 1 g (about three 325 mg tablets) oral doses of ASA, average milk levels of salicylic acid (active metabolite) were 2.4 mg/L at 3 hours.5 The metabolite salicyluric acid, reached a peak of 10.2 mg/L at 9 hours. Averaging total salicylates and salicyluric acid metabolites, the author suggests the relative infant dose would be 9.4% of the maternal dose.

In a new study in seven breastfeeding mothers consuming 81 mg/day, milk samples were collected at 0, 1, 2, 4, 8, 12 and 24 hours.6 Acetylsalicylic acid levels were below the limit of quantification (0.61 ng/mL) in all the milk samples, whereas salicylic acid was detected at very low concentrations. The average concentration of salicylic acid observed was 24 ng/mL and the estimated relative infant dose was 0.4%. Acetylsalicylic acid transfer into milk is so low that it is undetectable even by highly sophisticated methodology. Salicylic acid does appear in the human milk in comparatively low amounts, which are probably subclinical in infants. In one patient consuming 325 mg/day of aspirin, human milk levels of ASA were comparable with those taking 81 mg, or undetectable (< 0.61 ng/mL). In this patient, the maximum concentration of SA was observed as 744.6 ng/mL, which peaked at 1 hour. The area under the curve was 2579 ng.hr/mL and the average concentration estimated was 107.4 ng/mL. The relative infant dose calculated was 0.45% at this dose. Thus, the daily use of an 81-mg dose or 325 mg/day of aspirin should be considered safe during lactation.

While the direct use of ASA in infants and children has been associated with Reye syndrome, the use of the 81 mg/day dose, or even a single 325 mg dose, in breastfeeding mothers has not been linked to an increased risk of this syndrome in the infant. Unfortunately we do not presently know of any specific dose-response relationship between aspirin and Reye syndrome other than in older children where even low plasma levels of ASA were implicated in Reye syndrome during viral syndromes such as flu or chickenpox. Lastly, ASA is rapidly metabolized to salicylic acid. ASA is almost completely gone in 2 hours after an oral dose. A brief wait of 2-3 hours after administration would virtually eliminate all ASA transfer to milk.

Consider ibuprofen or acetaminophen as better choices for pain relief in lactating women. Avoid this medication at high doses in lactation when the infant has a viral syndrome.

T 1/2 3-10 h

Tmax 1-2 h

M/P 0.03-0.08

PB 88-93%

Oral 50-75% Vd 0.15 L/kg

MW 180

RID 2.5-10.8%

Adult Concerns: Dizziness, confusion, tinnitus, Reye syndrome, arrhythmias, dyspepsia, vomiting, stomach pain, gastrointestinal ulcers, changes in liver and kidney function, anemia, platelet dysfunction, increased risk of bleeding.

Adult Dose: 81 mg once daily; 325-650 mg q4-6 hours (max 4 g/day).

Pediatric Concerns: One 16-day-old infant developed metabolic acidosis. Mother was consuming 3.9 g/day of ASA. Thrombocytopenia, petechiae and anorexia were reported in an infant of 5 months following exposure to maternal milk containing aspirin. ASA has been associated with Reye syndrome in infants with viral fevers.

Infant Monitoring: Rare-bruising on the skin, blood in urine or stool.

Alternatives: Ibuprofen, acetaminophen.

References:

1. Pharmaceutical manufacturer prescribing information.

2. Findlay JW, DeAngelis RL, Kearney MF, Welch RM, Findlay JM. Analgesic drugs in breast milk and plasma. Clin Pharmacol Ther. 1981;29(5):625-633.

3. Erickson SH, Oppenheim GL. Aspirin in breast milk. J Fam Pract. 1979;8(1):189-190.

4. Bailey DN, Welbert RT, Naylor A. A study of salicylate and caffeine excretion in the breast milk of two nursing mothers. J Anal Toxicol. 1982;6:64-68.

5. Putter J, Satravaha P, Stockhausen H. Quantitative analysis of the main metabolites of acetylsalicylic acid. Comparative analysis in the blood and milk of lactating women. Z Geburtshilfe Perinatol. 1974;178:135-138.

6. Datta P, Rewers-Felkins K, Kallem RR, Baker T, Hale TW. Transfer of low dose aspirin into human milk. J Hum Lact. 2017 May;33(2):296-299. doi: 10.1177/0890334417695207. Epub 2017 Mar 20. PMID: 28418802.

ACITRETIN

Trade: Soriatane

Category: Antipsoriatic

LRC: L5 - Limited Data-Hazardous

Acitretin is used in the treatment of severe psoriasis. Its exact mechanism of action is unknown, but it helps to normalize cell differentiation and thin the cornified layer of the skin by reducing the rate of proliferation.1 This product produces major human fetal anomalies, and is retained in the body for long periods of time. Chronic use in breastfeeding mothers is probably not recommended. In the only study conducted on the transfer of acitretin into human milk, a 31-year-old mother was taking 40 mg once daily and had milk concentrations of 30-40 μg/L. This indicated that an infant would receive only 1.8% of the maternal dose; however, due to the toxic potential of this medication, the authors concluded that acitretin should be avoided during breastfeeding.2

Adult Concerns: Alopecia, headache, hyperesthesia, fatigue, xerophthalmia, xerostomia, cheilitis, hypercholesterolemia, hypertriglyceridemia, changes in liver function, increased WBC, arthralgias, skin peeling.

Adult Dose: 25-50 mg/day.

Pediatric Concerns: No data are available.

Infant Monitoring: Signs of jaundice- yellowing of the eyes and skin; skin rash.

Alternatives:

References:

1. Pharmaceutical manufacturer prescribing information, 2004.

2. Rollman O, Pihl-Lundin I. Acitretin excretion into human breast milk. Acta Derm Venereol. 1990; 70:487-490.

ACYCLOVIR

Trade: Aciclover, Acyclo-V, Aviraz, Zovirax, Zyclir

Category: Antiviral

LRC: L2 - Limited Data-Probably Compatible

Acyclovir is converted by herpes simplex and varicella zoster virus to acyclovir triphosphate which interferes with viral HSV DNA polymerase. It is currently cleared for use in HSV infections, Varicella-Zoster and under certain instances such as Cytomegalovirus and EpsteinBarr infections. There is virtually no percutaneous absorption following topical application and plasma levels are undetectable. The pharmacokinetics in children is similar to adults. In neonates, the half-life is 3.8-4.1 hours, and in children 1 year and older it is 1.9-3.6 hours.

Acyclovir levels in breast milk are reported to be 0.6 to 4.1 times the maternal plasma levels.1 Maximum ingested dose was calculated to be 1500 μg/day assuming 750 mL milk intake. This level produced no overt side effects in one infant. In a study by Meyer,2 a patient receiving 200 mg five times daily produced breast milk concentrations averaging 1.06 mg/L. Using these values, an infant would ingest less than 1 mg acyclovir daily. In another study, doses of 800 mg five times daily produced milk levels that ranged from 4.16 to 5.81 mg/L (total estimated infant ingestion per day = 0.73 mg/kg/day).3 Topical therapy on lesions other than nipple is probably safe. But mothers with lesions on or close to the nipple should not breastfeed on that side. Toxicities associated with acyclovir are few and usually minor. Acyclovir therapy in neonates is common and produces few toxicities. Calculated intake by infant would be less than 0.87 mg/kg/day.

T 1/2 2.4 h

Adult Concerns: Nausea, vomiting, diarrhea, sore throat, edema and skin rashes.

Adult Dose: 200-800 mg every 4-6 hours.

Pediatric Concerns: None reported via milk in several studies.

Infant Monitoring: Vomiting, diarrhea.

Alternatives: Valacyclovir.

References:

1. Lau RJ, Emery MG, Galinsky RE. Unexpected accumulation of acyclovir in breast milk with estimation of infant exposure. Obstet Gynecol. 1987;69(3 Pt2):468-471.

2. Meyer LJ, de Miranda P, Sheth N, Spruance S. Acyclovir in human breastmilk. Am J Obstet Gynecol. 1988;158(3Pt1):586-588.

3. Taddio A, Klein J, Koren G. Acyclovir excretion in human breastmilk. Ann Pharmacother. 1994;28(5):585587.

Another random document with no related content on Scribd:

nevertheless, there also a parliamentary sanction was obtained for the preliminary steps.

In May 1706, the Commissioners, thirty from each nation, met at Westminster, to deliberate on the terms of the proposed treaty. It was soon agreed upon that the leading features of the act should be— a union of the two countries under one sovereign, who, failing heirs of the queen, should be the Electress of Hanover or her heir; but each country to retain her own church establishment and her own laws— Scotland to send sixteen representative peers and forty-five commoners to the British parliament—Scottish merchants to trade freely with England and her colonies—the taxes to be equalised, except that from land, which was to be arranged in such a way that when England contributed two millions, Scotland should give only a fortieth part of the sum, or forty-eight thousand pounds; and as the English taxes were rendered burdensome by a debt of sixteen millions, Scotland was to be compensated for its share of that burden by receiving, as ‘an Equivalent,’ about four hundred thousand pounds of ready money from England, which was to be applied to the renovation of the coin, the discharge of the public debts, and a restitution of the money lost by the African Company.

When these articles were laid before the Scottish Estates in October, they produced a burst of indignant feeling that seemed to overspread the whole country. The Jacobite party, who saw in the union only the establishment of an alien dynasty, were furious. The clergy felt some alarm at the prelatic element in the British parliament. The mass of the people grieved over the prospect of a termination to the native parliament, and other tokens of an ancient independence. Nevertheless, partly that there were many men in the Estates who had juster views of the true interests of their country, and partly that others were open to various influences brought to bear upon their votes, the act of union was passed in February 1707, as to take effect from the ensuing 1st of May. The opposition was conducted principally by the Duke of Hamilton, a Jacobite, and, but for his infirmity of purpose, it might have been more formidable. The Duke of Queensberry, who acted on this occasion as the queen’s commissioner to parliament, was rewarded for his services with an English dukedom. The Privy Council, the record of whose proceedings has been of so much importance to this work, now came

to an end; but a Secretary of State for Scotland continued for the next two reigns to be part of the apparatus of the central government in the English metropolis.

Of the discontent engendered on this occasion, the friends of the exiled Stuarts endeavoured to take advantage in the spring of 1708, by bringing a French expedition to the Scottish coasts, having on board five thousand men, and the son of James II., now a youth of twenty years of age. It reached the mouth of the Firth of Forth, and many of the Jacobite gentry were prepared to join the young prince on landing. But the Chevalier de St George, as he was called, took ill of small-pox; the British fleet under Admiral Byng came in sight; and it was deemed best to return to France, and wait for another opportunity.

The Tory ministry of the last four years of Queen Anne affected Scotland by the passing of an act of Toleration for the relief of the persecuted remnant of Episcopalians, and another act by which the rights of patrons in the nomination of clergy to charges in the Established Church were revived. The Whigs of the Revolution felt both of these measures to be discouraging. During this period, in Scotland, as in England, the Cavalier spirit was in the ascendency, and the earnest Whigs trembled lest, by complicity of the queen or her ministers, the Pretender should be introduced, to the exclusion of the Protestant heir. But the sudden death of Anne on the 1st of August 1714, neutralised all such schemes, and the son of the then deceased Electress Sophia succeeded to the British throne, under the name of George I., with as much apparent quietness as if he had been a resident Prince of Wales.

1702. J.

On the principle that minute matters, which denote a progress in improvement, or even a tendency to it, are worthy of notice, it may be allowable to remark at this time an advertisement of Mr George Robertson, apothecary at Perth, that he had lately set up there ‘a double Hummum, or Bath Stove, the one for men, and the other for women, approven of by physicians to be of great use for the cure of several diseases.’ A hummum is in reality a Turkish or hot-air bath. We find that, within twenty years after this time, the chirurgeons in Edinburgh had a bagnio, or hot bath, and the physicians a cold bath,

for medical purposes.

The Edinburgh Gazette which advertises the Perth hummum, also announces the presence, in a lodging at the foot of the West Bow of Edinburgh, of Duncan Campbell of Ashfield, chirurgeon to the city of Glasgow, who had ‘cutted nine score persons [for stone] without the death of any except five.’[313] There was also a mysterious person, styled ‘a gentleman in town,’ and ‘to be got notice of at the Caledonian Coffee-house,’ who had ‘had a secret imparted to him by his father, an eminent physician in this kingdom, which, by the blessing of God, certainly and safely cures the phrenzie’—also ‘convulsion-fits, vapours, and megrims—in a few weeks, at reasonable rates, and takes no reward till the cure is perfected.’

In the same sheet, ‘G. Young, against the Court of Guard, Edinburgh,’ bespoke favour for ‘a most precious eye-water, which infallibly cures all distempers in the eyes, whether pearl, web, catracht, blood-shot dimness, &c., and in less than six times dressing has cured some who have been blind seven years.’

The custom of vending quack medicines from a public stage on the street—of which we have seen several notable examples in the course of the seventeenth century—continued at this time, and for many years after, to be kept up. Edinburgh was occasionally favoured with a visit from a famous practitioner of this kind, named Anthony Parsons, who, in announcing his arrival in 1710, stated the quality of his medicines, and that he had been in the habit of vending them on stages for thirty years. In October 1711, he advertised in the Scots Postman—‘It being reported that Anthony Parsons is gone from Edinburgh to mount public stages in the country, this is to give notice that he hath left off keeping stages, and still lives in the Hammermen’s Land, at the Magdalen Chapel, near the head of the Cowgate, where may be had the O, a famous antidote against infectious distempers, and helps barrenness, &c.’ Four years later, Parsons announced his design of bidding adieu to Edinburgh, and, in that prospect, offered his medicines at reduced rates; likewise, by auction, ‘a fine cabinet organ.’[314]

1702.

In April 1724, one Campbell, commonly called (probably from his ragged appearance) Doctor Duds, was in great notoriety in Edinburgh as a quack mediciner. He does not seem to have been in

great favour with the populace, for, being seen by them on the street, he was so vexatiously assaulted, as to be obliged to make his escape in a coach. At this time, a mountebank doctor erected a stage at the foot of the Canongate, in order to compete with Doctor Duds for a share of business; but a boy being killed by a fall from the fabric the day of its erection, threw a damp on his efforts at wit, and the affair appears to have proved a failure.[315]

The author just quoted had a recollection of one of the last of this fraternity—an Englishman, named Green—who boasted he was the third generation of a family which had been devoted to the profession. ‘A stage was erected in the most public part of a town, and occupied by the master, with one or two tumblers or ropedancers, who attracted the multitude. Valuable medicines were promised and distributed by a kind of lottery. Each spectator, willing to obtain a prize, threw a handkerchief, enclosing one or two shillings, on the stage. The handkerchief was returned with a certain quantity of medicines. But along with them, a silver cup was put into one to gratify some successful adventurer.’

‘Doctor Green, younger of Doncaster’—probably the second of the three generations—had occasion, in December 1725, to advertise the Scottish community regarding his ‘menial servant and tumbler,’ Henry Lewis, who, he said, had deserted his service with a week’s prepaid wages in his pocket, and, as the doctor understood, ‘has resorted to Fife, or some of the north-country burghs, with design to get himself furnished with a play-fool, and to set himself up for a doctor experienced in the practice of physic and chirurgery.’ Doctor Green deemed himself obliged to warn Fife and the said burghs, whither he himself designed to resort in spring, against ‘the said impostor, and to dismiss him as such.’[316]

1702.

We have this personage brought before us in an amusing light, in May 1731, in connection with the King’s College, Aberdeen. He had applied to this learned sodality for a diploma as doctor of medicine, ‘upon assurances given under his hand, that he would practise medicine in a regular way, and give over his stage.’ They had granted him the diploma accordingly. Finding, afterwards, that he still continued to use his stage, ‘the college, to vindicate their conduct in the affair, and at the same time, in justice to the public, to expose Mr

Green his disingenuity, recorded in the Register of Probative Writs his letter containing these assurances.’ They also certified ‘that, if Mr Green give not over his stage, they will proceed to further resentment against him.’[317]

Down to this time there was still an entire faith among the common sort of people in the medical properties of natural crystals, perforated stones, ancient jet ornaments, flint arrow-heads, glass beads, and other articles. The custom was to dip the article into water, and administer the water to the patient. The Stewarts of Ardvorlich still possess a crystal which was once in great esteem throughout Lower Perthshire for the virtues which it could impart to simple water. A flat piece of ivory in the possession of Campbell of Barbreck—commonly called Barbreck’s Bone—was sovereign for the cure of madness. This article is now deposited in the Museum of the Scottish Antiquaries in Edinburgh. The Lee Penny—a small precious stone, set in an old English coin, still possessed by the Lockharts of Lee—is another and highly noted example of such charms for healing.

It was also still customary to resort to certain wells and other waters, on account of their supposed healing virtues, as we have seen to be the case a century earlier. Either the patient was brought to the water, and dipped into it, or a fragment of his clothing was brought and cast into, or left on the side of it, a shackle or tether of a cow serving equally when such an animal was concerned. If such virtues had continued to be attributed only to wells formerly dedicated to saints, it would not have been surprising; but the idea of medicinal virtue was sometimes connected with a lake or other piece of water, which had no such history. There was, for example, on the high ground to the west of Drumlanrig Castle, in Nithsdale, a small tarn called the Dow [i. e. black] Loch, which enjoyed the highest medical repute all over the south of Scotland. People came from immense distances to throw a rag from a sick friend, or a tether from an afflicted cow, into the Dow Loch, when, ‘these being cast in, if they did float, it was taken for a good omen of recovery, and a part of the water carried to the patient, though to remote places, without saluting or speaking to any one they met by the way; but, if they did sink, the recovery of the party was hopeless.’[318] The clergy exerted themselves strenuously to

1702.

put down the superstition. The trouble which the presbytery of Penpont had, first and last, with this same Dow Loch, was past expression. But their efforts were wholly in vain.[319]

1702. J 3.

‘It pleased the great and holy God to visit this town [Leith], for their heinous sins against him, with a very terrible and sudden stroke, which was occasioned by the firing of thirty-three barrels of powder; which dreadful blast, as it was heard even at many miles distance with great terror and amazement, so it hath caused great ruin and desolation in this place. It smote seven or eight persons at least with sudden death, and turned the houses next adjacent to ruinous heaps, tirred off the roof, beat out the windows, and broke out the timber partitions of a great many houses and biggings even to a great distance. Few houses in the town did escape some damage, and all this in a moment of time; so that the merciful conduct of Divine Providence hath been very admirable in the preservation of hundreds of people, whose lives were exposed to manifold sudden dangers, seeing they had not so much previous warning as to shift a foot for their own preservation, much less to remove their plenishing.’ So proceeded a petition from ‘the distressed inhabitants of Leith’ to the Privy Council, on the occasion of this sore calamity. ‘Seeing,’ they went on to say, ‘that part of the town is destroyed and damnified to the value of thirty-six thousand nine hundred and thirty-six pounds, Scots money, by and attour several other damages done in several backcloses, and by and attour the household plenishing and merchant goods destroyed in the said houses, and victual destroyed and damnified in lofts, and the losses occasioned by the houses lying waste; and seeing the owners of the said houses are for the most part unable to repair them, so that a great part of the principal seaport of the nation will be desolate and ruinous, if considerable relief be not provided,’ they implored permission to make a charitable collection throughout the kingdom at kirk-doors, and by going from house to house; which prayer was readily granted.[320]

J 8.

The Earl of Kintore, who had been made Knight Marischal of Scotland at the Restoration, and afterwards raised to the peerage for his service in saving the regalia from the English in 1651, was still living.[321] He

petitioned the Privy Council at this date on account of a pamphlet published by Sir William Ogilvie of Barras, in which his concern in the preservation of the regalia was unduly depreciated. His lordship gives a long recital on the subject, from which it after all appears that his share of the business was confined to his discommending obedience to be paid to a state order for sending out the regalia from Dunnottar Castle—in which case it was likely they might have been taken—and afterwards doing what he could to put the English on a false scent, by representing the regalia as carried to the king at Paris. He denounces the pamphlet as an endeavour ‘to rob him of his just merit and honour, and likewise to belie his majesty’s patents in his favour,’ and he craved due punishment. Sir William, being laid up with sickness at Montrose, was unable to appear in his own defence, and the Council, accordingly, without hesitation, ordered the offensive brochure to be publicly burnt at the Cross of Edinburgh by the common hangman.

David Ogilvie, younger of Barras, was soon after fined in a hundred pounds for his concern in this so-called libel.[322]

There is something unaccountable in the determination evinced at various periods to assign the glory of the preservation of the regalia to the Earl of Kintore, the grand fact of the case being that these sacred relics were saved by the dexterity and courage of the unpretending woman—Mrs Grainger—the minister’s wife of Kineff, who, by means of her servant, got them carried out of Dunnottar Castle through the beleaguering lines of the English, and kept them in secrecy under ground for eight years. See under March 1652.

1702. A.

The arrangements of the Post-office, as established by the act of 1695, were found to be not duly observed, in as far as common carriers presumed to carry letters in tracts where post-offices were erected, ‘besides such as relate to goods sent or to be returned to them.’ A very strict proclamation was now issued against this practice, and forbidding all who were not noblemen or gentlemen’s servants to ‘carry, receive, or deliver any letters where post-offices are erected.’

Inviolability of letters at the Post-office was not yet held in respect as a principle. In July 1701, two letters from Brussels, ‘having the cross upon the back of them,’ had come with proper addresses under cover to the Edinburgh postmaster. He ‘was surprised with them,’ and brought them to the Lord Advocate, who, however, on opening them, found they were ‘of no value, being only on private business;’ wherefore he ordered them to be delivered by the postmaster to the persons to whom they were directed.

1702.

Long after this period—in 1738—the Earl of Ilay, writing to Sir Robert Walpole from Edinburgh, said: ‘I am forced to send this letter by a servant twenty miles out of town, where the Duke of Argyle’s attorney cannot handle it.’ It sounds strangely that Lord Hay should thus have had to complain of his own brother; that one who was supreme in Scotland, should have been under such a difficulty from an opposition noble; and that there should have been, at so recent a period, a disregard to so needful a principle. But this is not all. Lord Ilay, in time succeeding his brother as Duke of Argyle, appears to have also taken up his part at the Edinburgh Post-office. In March 1748, General Bland, commander of the forces in Scotland, wrote to the Secretary of State, ‘that his letters were opened at the Edinburgh Post-office; and I think this is done by order of a noble duke, in order to know my secret sentiments of the people and of his Grace. If this practice is not stopped, the ministers cannot hope for any real information.’ Considering the present sound administration of the entire national institution by the now living inheritor of that peerage, one cannot without a smile hear George Chalmers telling[323] how the Edinburgh Post-office, in the reign of the second George, was ‘infested by two Dukes of Argyle!’

It will be heard, however, with some surprise, that the Lord Advocate may still be considered as having the power, in cases where the public interests are concerned, to order the examination of letters in the Post-office. So lately as 1789, when the unhappy duellist, Captain Macrae, fled from justice, his letters were seized at the Postoffice by order of the Justice-clerk Braxfield.

The sport of cock-fighting had lately been introduced into Scotland, and a cock-pit was now in operation in Leith Links, where

the charges for admission were 10d. for the front row, 7d. for the second, and 4d. for the third. Soon after, ‘the passion for cockfighting was so general among all ranks of the people, that the magistrates [of Edinburgh] discharged its being practised on the streets, on account of the disturbances it occasioned.’[324]

1702.

William Machrie, who taught in Edinburgh what he called ‘the severe and serious, but necessary exercise of the sword,’ had also given a share of his attention to cock-fighting—a sport which he deemed ‘as much an art, as the managing of horses for races or for the field of battle.’ It was an art in vogue over all Europe—though ‘kept up only by people of rank, and never sunk down to the hands of the commonalty’—and he, for his part, had studied it carefully: he had read everything on the subject, conversed and corresponded on it with ‘the best cockers in Britain,’ carefully observing their practice, and passing through a long experience of his own.

Thus prepared, Mr Machrie published in Edinburgh, in 1705, a brochure, styled An Essay on the Innocent and Royal Recreation and Art of Cocking, consisting of sixty-three small pages; from which we learn that he had been the means of introducing the sport into Edinburgh. The writer of a prefixed set of verses evidently considered him as one of the great reformers of the age:

‘Long have you taught the art of self-defence, Improved our safety then, but now our sense, Teaching us pleasure with a small expense. ’

For his own part, considering the hazard and expense which attended horse-racing and hawking, he was eager to proclaim the superior attractions of cocking, as being a sport from which no such inconveniences arose. The very qualities of the bird recommended it —namely, ‘his Spanish gait, his Florentine policy, and his Scottish valour in overcoming and generosity in using his vanquished adversary.’ The ancients called him an astronomer, and he had been ‘an early preacher of repentance, even convincing Peter, the first pope, of his holiness’s fallibility.’ ‘Further,’ says he, ‘if variety and change of fortune be any way prevalent to engage the minds of men, as commonly it is, to prefer one recreation to another, it will beyond all controversy be found in cocking more than any other. Nay, the

eloquence of Tully or art of Apelles could never with that life and exactness represent fortune metamorphosed in a battle, as doth cocking; for here you’ll see brave attacks and as brave defiances, bloody strugglings, and cunning and handsome retreats; here you’ll see generous fortitude ignorant of interest,’ &c.

Mr Machrie, therefore, goes con amore into his subject, fully trusting that his treatise on ‘this little but bold animal could not be unacceptable to a nation whose martial temper and glorious actions in the field have rendered them famed beyond the limits of the Christian world;’ a sentence from which we should have argued that our author was a native of a sister-island, even if the fact had not been indicated by his name.

1702.

Mr Machrie gives many important remarks on the natural history of the animal—tells us many secrets about its breeding; instructs us in the points which imply strength and valour; gives advices about feeding and training; and exhibits the whole policy of the pit. Finally, he says, ‘I am not ashamed to declare to the world that I have a special veneration and esteem for those gentlemen, within and about this city, who have entered in society for propagating and establishing the royal recreation of cocking (in order to which they have already erected a cock-pit in the Links of Leith); and I earnestly wish that their generous and laudable example may be imitated in that degree that, in cock-war, village may be engaged against village, city against city, kingdom against kingdom, nay, the father against the son, until all the wars in Europe, wherein so much Christian blood is spilt, be turned into the innocent pastime of cocking.’

Machrie advertised, in July 1711, that he was not the author of a little pamphlet on Duelling, which had been lately published with his name and style on the title-page—‘William Machrie, Professor of both Swords.’ He denounced this publication as containing ridiculous impossibilities in his art, such as ‘pretending to parry a pistol-ball with his sword.’ Moreover, it contained ‘indiscreet reflections on the learned Mr Bickerstaff [of the Tatler],’ ‘contrary to his [Machrie’s] natural temper and inclination, as well as that civility and good manners which his years, experience, and conversation in the world have taught him.’[325]

1702.

The amusement of cock-fighting long kept a hold of the Scottish people. It will now be scarcely believed that, through the greater part of the eighteenth century, and till within the recollection of persons still living, the boys attending the parish and burghal schools were encouraged to bring cocks to school at Fasten’s E’en (Shrove-tide), and devote an entire day to this barbarising sport. The slain birds and fugies (so the craven birds were called) became the property of the schoolmaster. The minister of Applecross, in Ross-shire, in his account of the parish, written about 1790, coolly tells us that the schoolmaster’s income is composed of two hundred merks, with payments from the scholars of 1s. 6d. for English, and 2s. 6d. for Latin, and ‘the cockfight dues, which are equal to one quarter’s payment for each scholar.’[326]

A Short Account of Scotland, written, it is understood, by an English gentleman named Morer, and published this year, presents a picture of our country as it appeared to an educated stranger before the union. The surface was generally unenclosed; oats and barley the chief grain products; wheat little cultivated; little hay made for winter, the horses then feeding chiefly on straw and oats. The houses of the gentry, heretofore built for strength, were now beginning to be ‘modish, both in fabric and furniture.’ But ‘still their avenues are very indifferent, and they want their gardens, which are the beauty and pride of our English seats.’ Orchards were rare, and ‘their apples, pears, and plums not of the best kind;’ their cherries tolerably good; ‘for gooseberries, currants, strawberries, and the like, they have of each, but growing in gentlemen’s gardens; and yet from thence we sometimes meet them in the markets of their boroughs.’ The people of the Lowlands partly depended on the Highlands for cattle to eat; and the Highlanders, in turn, carried back corn, of which their own country did not grow a sufficiency.

Mr Morer found that the Lowlanders were dressed much like his own countrymen, excepting that the men generally wore bonnets instead of hats, and plaids instead of cloaks; the women, too, wearing plaids when abroad or at church. Women of the humbler class generally went barefoot, ‘especially in summer.’ The children of people of the better sort, ‘lay and clergy,’ were likewise generally

without shoes and stockings. Oaten-cakes, baked on a plate of iron over the fire, were the principal bread used. Their flesh he admits to have been ‘good enough,’ but he could not say the same for their cheese or butter. They are ‘fond of tobacco, but more from the snishbox than the pipe.’ Snuff, indeed, had become so necessary to them, that ‘I have heard some of them say, should their bread come in competition with it, they would rather fast than their snish should be taken away. Yet mostly it consists of the coarsest tobacco, dried by the fire, and powdered in a little engine after the form of a tap, which they carry in their pockets, and is both a mill to grind and a box to keep it in.’

1702.

Stage-coaches did not as yet exist, but there were a few hackneys at Edinburgh, which might be hired into the country upon urgent occasions. ‘The truth is, the roads will hardly allow them those conveniences, which is the reason that the gentry, men and women, choose rather to use their horses. However, their great men often travel with coach-and-six, but with so little caution, that, besides their other attendance, they have a lusty running-footman on each side of the coach, to manage and keep it up in rough places.’

Another Englishman, who made an excursion into Scotland in 1704, gives additional particulars, but to the same general purport.

Dresses of the People of Scotland. From Speed’s Atlas, 1676.

At Edinburgh, he got good French wine at 20d., and Burgundy at 10d. a quart. The town appeared to him scarcely so large as York or Newcastle, but extremely populous, and containing abundance of beggars. ‘The people here,’ he says, ‘are very proud, and call the ordinary tradesmen merchants.’ ‘At the best houses they dress their victuals after the French method, though perhaps not so cleanly, and a soup is commonly the first dish; and their reckonings are dear enough. The servant-maids attended without shoes or stockings.’

At Lesmahago, a village in Lanarkshire, he found the people living on cakes made of pease and barley mixed. ‘They ate no meat, nor drank anything but water, all the year round; and the common people go without shoes or stockings all the year round. I pitied their poverty, but observed the people were fresh and lusty, and did not seem to be under any uneasiness with their way of living.’

1702.

In the village inn, ‘I had,’ says he, ‘an enclosed room to myself, with a chimney in it, and dined on a leg of veal, which is not to be had at every place in this country.’ At another village—CrawfordJohn—‘the houses are either of earth or loose stones, or are raddled, and the roofs are of turf, and the floors the bare ground. They are but one story high, and the chimney is a hole in the roof, and the fireplace is in the middle of the floor. Their seats and beds are of turf earthed over, and raddled up near the fireplace, and serve for both uses. Their ale is pale, small, and thick, but at the most common minsh-houses [taverns], they commonly have good French brandy, and often French wine, so common are these French liquors in this country.’

Our traveller, being at Crawford-John on a Sunday, went to the parish church, which he likens to a barn. He found it ‘mightily crowded, and two gentlemen’s seats in it with deal-tops over them. They begin service here about nine in the morning, and continue it till about noon, and then rise, and the minister goes to the minshhouse, and so many of them as think fit, and refresh themselves. The rest stay in the churchyard for about half an hour, and then service begins again, and continues till about four or five. I suppose the reason of this is, that most of the congregations live too far from the church to go home and return to church in time.’[327]

The general conditions described by both of these travellers exhibit little, if any advance upon those presented in the journey of the Yorkshire squire in 1688,[328] or even that of Ray the naturalist in 1661.[329]

1703. 1703. J. 24.

George Young, a shopkeeper in the High Street of Edinburgh, was appointed by the magistrates as a constable, along with several other citizens in the like capacity, ‘to oversee the manners and order of the burgh and inhabitants thereof.’ On the evening of the day noted, being Sunday, he went ‘through some parts of the town, to see that the Lord’s Day and laws made for the observance thereof were not violat.’ ‘Coming to the house of Marjory Thom, relict of James Allan, vintner, a little before ten o’clock, and finding in the house several companies in different rooms, [he] did soberly and Christianly expostulate with the mistress of the house for keeping persons in her house at such unseasonable hours, and did very justly threaten to delate her to the magistrates, to be rebuked for the same. [He] did not in the least offer to disturb any of her guests, but went away, and as [he was] going up the close to the streets, he and the rest was followed by Mr Archibald Campbell, eldest son to Lord Niel Campbell, who quarrelled him for offering to delate the house to the magistrates, [telling him] he would make him repent it.’ So runs George Young’s own account of the matter. It was rather unlucky for him, in his turn at this duty, to have come into collision with Mr Campbell, for the latter was first-cousin to the Duke of Argyle, and a person of too much consequence to be involved in a law which only works sweetly against the humbler classes, being, indeed, mainly designed for their benefit.

To pursue Young’s narrative. ‘Mr Archibald came next day with some others towards the said George his shop, opposite to the Guard [house], and called at his shop, which was shut by the hatch or halfdoor: “Sirrah, sirrah!” which George not observing, nor apprehending his discourse was directed to him, Mr Archibald called again to this purpose: “I spoke to you, Young the constable.” Whereupon, George civilly desiring to know his pleasure, he expressed himself thus: “Spark, are you in any better humour to-day than you was last night?” George answered, he was the same to-day

he was last night. “I was about my duty last night, and am so to-day. I hope I have not offended you; and pray, sir, do not disturb me.” Mr Archibald, appearing angry, and challenging George for his taking notice of Mrs Allan’s house, again asked him if he was in any better temper, or words to that purpose; [to which] George again replied, He was the same he was, and prayed him to be gone, because he seemed displeased. Whereupon Mr Archibald taking hold of his sword, as [if] he would have drawn it, George, being within the halfdoor, fearing harm, threw open the door, and came out to Mr Archibald, and endeavoured to catch hold of his sword. Mr Archibald did beat him upon the eye twice or thrice, and again took hold of his sword to draw and run at him; which he certainly had done, if not interrupted by the bystanders, who took hold of his sword and held him, till that the Town-guard seized Mr Archibald, and made him prisoner.’

Mr Campbell, being speedily released upon bail, did not wait to be brought before the magistrates, but raised a process against Young before the Privy Council, ‘intending thereby to discourage all laudable endeavours to get extravagancy and disorder [repressed].’ In the charge which he brought forward, Mr Campbell depicts himself as walking peaceably on the High Street, when Young attacked him, seized his sword, and declared him prisoner, without any previous offence on his part. The Guard thereafter dragged him to their house, maltreating him by the way, and kept him a prisoner till his friends assembled and obtained his liberation. The process went through various stages during the next few weeks, and at length, on the 9th of March, the Council found Young guilty of a riot, and fined him in four hundred merks (upwards of £22 sterling), to be paid to Mr Campbell for his expenses; further ordaining the offender to be imprisoned till the money was forthcoming.

1702.

To do the Duke of Argyle justice, his name does not appear in the list of the councillors who sat that day.

M. 6.

Sir John Bell, a former magistrate of Glasgow, kept up a modest frame of Episcopal worship in that Presbyterian city, having occasionally preachers, who were not always qualified by law, to officiate in his

1703. house. On the 30th of January, a boy-mob assailed the house while worship was going on, and some windows were broken. However, the magistrates were quickly on the spot, and the tumult was suppressed.

A letter from the queen to the Privy Council, dated the 4th February, glanced favourably at the Episcopalian dissenters of Scotland, enjoining that the clergy of that persuasion should live peaceably in relation to the Established Church, and that they should, while doing so, be protected in the exercise of their religion. It was a sour morsel to the more zealous Presbyterians, clergy and laity, who, not from any spirit of revenge, but merely from bigoted religious feelings, would willingly have seen all Episcopalians banished at the least. At Glasgow, where a rumour got up that some Episcopalian places of worship would be immediately opened under sanction of her majesty’s letter, much excitement prevailed. Warned by a letter from the Lord Chancellor, the magistrates of the city took measures for preserving the peace, and they went to church on the 7th of March, under a full belief that there was no immediate likelihood of its being broken. The Episcopalians, however, were in some alarm about the symptoms of popular feeling, and it was deemed necessary to plant a guard of gentlemen, armed with swords, in front of the door of Sir John Bell’s house, where they were to enjoy the ministrations of a clergyman named Burgess. Some rude boys gathered about, and soon came to rough words with this volunteer guard, who, chasing them with their swords, and, it is said, violent oaths, along the Saltmarket, roused a general tumult amongst all who were not at church. The alarm soon passed into the churches. The people poured out, and flocked to the house where they knew that the Episcopalians were gathered. The windows were quickly smashed. The worshippers barricaded and defended themselves; but the crowd broke in with fore-hammers, though apparently hardly knowing for what purpose. The magistrates came with some soldiers; reasoned, entreated, threatened; apprehended a few rioters, who were quickly rescued; and finally thought it best to limit themselves to conducting the scared congregation to their respective homes—a task they successfully accomplished. ‘Afterwards,’ say the magistrates, ‘we went and did see Sir John Bell in his house, where Mr Burgess, the minister, was; and, in the meantime, when we were

regretting the misfortune that had happened to Sir John and his family, who had merited much from his civil carriage when a magistrate in this place, it was answered to us by one of his sons present, that they had got what they were seeking, and would rather that that had fallen out than if it had been otherways.’

The Privy Council, well aware how distasteful any outrages against the Episcopalians would be at court, took pains to represent this affair in duly severe terms in their letters to the secretaries of state in London. They also took strong measures to prevent any similar tumult in future, and to obtain reparation of damages for Sir John Bell.

Generally, the condition of Episcopal ministers continued to be uncomfortable. In February 1705, Dr Richard Waddell, who had been Archdean of St Andrews before the Revolution, and was banished from that place in 1691, but had lately returned under protection of her majesty’s general indemnity, became the subject of repressive measures on the part of the Established Church. Letters of horning were raised against him by ‘John Blair, agent for the kirk,’ and, notwithstanding strong protestations of loyalty to the queen, he was ordained by the Privy Council once more ‘to remove furth of the town and parochine of St Andrews, and not return thereto.’[330]

1703. A.

An elderly woman named Marion Lillie, residing at Spott, in East Lothian, was in the hands of the kirk-session, on account of the general repute she lay under as a witch. Amidst the tedious investigations of her case in the parish register, it is impossible to see more than that she occasionally spoke ungently to and of her neighbours, and had frightened a pregnant woman to a rather unpleasant extremity by handling her rudely. The Rigwoodie Witch, [331] as a neighbour called her, was now turned over to a magistrate, to be dealt with according to law; but of her final fate we have no account.

Spott is a place of sad fame, its minister having basely murdered his wife in 1570,[332] and the estate having belonged to a gentleman named Douglas, whom we have seen concerned in the slaughter of Sir James Home of Eccles, and who on that account became a forfeited outlaw.[333] The wife of a subsequent proprietor, a gambler named Murray, was daughter to the Lord Forrester, who was stabbed with his own sword by his mistress at Corstorphine in 1679.[334]

There is extant a characteristic letter of this lady to Lord Alexander Hay, son of the Earl of Tweeddale, on his bargaining, soon after this time, for the estate, with her husband, without her consent—in which she makes allusion to the witches of Spott:

‘THES TO LORD ALEXANDER HAY.

‘S, 19 May.

‘This way of proceeding, my lord, will seem verey abrupte and inconsiderat to you; but I laye my count with the severest censer you or may malicious enemies can or will saye of me. So, not to be tedious, all I have to speak is this: I think you most absurd to [have] bought the lands of Spott from Mr Murray without my consent, which you shall never have now; and I hope to be poseser of Spott hous when you are att the divel; and believe me, my childrin’s curse and mine will be a greater moth in your estate than all your ladey and your misirable wretchedness can make up and pray [pay].

‘This is no letter of my lord Bell Heavins, and tho you saye, in spite of the divell, you’le buy it befor this time twell month, you may come to repent it; but thats non of my bisnes. I shall only saye this, you are basely impertinent to thrust me away in a hurrey from my houss at Whitsunday, when I designed not to go till Martinmis: and I wish the ghosts of all the witches that ever was about Spott may haunt you, and make you the unfortountest man that ever lived, that you may see you was in the wrong in makeing aney such bargain without the consent of your mortal enemy,

C M.’[335]

1703.

J 1.

The country was at this time in a state of incandescent madness regarding its nationality, and the public feeling found expression through the medium of parliament. By its order, there was this day burned at the Cross of Edinburgh, by the hangman, a book entitled Historia AngloScotica, by James Drake, ‘containing many false and injurious reflections upon the sovereignty and independency of this nation.’ In August 1705, when the passion was even at a greater height, the same fate was awarded by the legislature to a book, entitled The Superiority and Direct Dominion of the Imperial Crown of England over the Crown and Kingdom of Scotland; also to a pamphlet, called The Scots Patriot Unmasked, both being the production of William Atwood. On the same day that the latter order was given, the parliament decreed the extraordinary sum of £4800 (Scots?) to Mr

James Anderson, for a book he had published, A Historical Essay shewing that the Crown and Kingdom of Scotland is Imperial and Independent. Nor was this all, for at the same time it was ordered that ‘Mr James Hodges, who hath in his writings served this nation,’ should have a similar reward.[336]

S. 3.

The Scottish parliament at this time patronised literature to a considerable extent, though a good deal after the manner of the poor gentleman who bequeathed large ideal sums to his friends, and comforted himself with the reflection, that it at least shewed good-will. Alexander Nisbet had prepared a laborious work on heraldry,[337] tracing its rise, and describing all its various figures, besides ‘shewing by whom they are carried amongst us, and for what reasons,’ thus instructing the gentlefolk of this country of their ‘genealogical pennons,’ and affording assistance to ‘curious antiquaries’ in understanding ‘seals, medals, historie, and ancient records.’ But Alexander was unable of his own means to publish so large a work, for which it would be necessary to get italic types, ‘whereof there are very few in this kingdom,’ and which also required a multitude of copper engravings to display ‘the armorial ensigns of this ancient kingdom.’ Accordingly, on his petition, the parliament (September 3, 1703), recommended the Treasury to grant him £248, 6s. 8d. sterling ‘out of what fund they shall think fit.’[338]

1703.

A. 9.

In 1695, the Scottish parliament forbade the sale of rum, as interfering with the consumpt of ‘strong waters made of malt,’ and because the article itself was ‘rather a drug than a liquor, and highly prejudicial to the health of all who drink it.’ Now, however, Mr William Cochrane of Kilmaronock, John Walkenshaw of Barrowfield, John Forbes of Knaperna, and Robert Douglas, merchant in Leith, designed to set up a sugar-work and ‘stillarie for distilling of rum’ in Leith, believing that such could never be ‘ more necessary and beneficial to the country, and for the general use and advantage of the lieges, than in this time of war, when commodities of that nature, how necessary soever, can hardly be got from abroad.’ On their petition, the

designed work was endowed by the Privy Council with the privileges of a manufactory.

S. 10.

The steeple of the Tolbooth of Tain had lately fallen in the night, to the great hazard of the lives of the prisoners, and some considerable damage to the contiguous parish church. On the petition of the magistrates of this poor little burgh, the Privy Council ordained a collection to be made for the reconstruction of the building; and, meanwhile, creditors were enjoined to transport their prisoners to other jails.

Nearly about the same time, voluntary collections were ordained by the Privy Council, for erecting a bridge over the Dee at the Black Ford; for the construction of a harbour at Cromarty, ‘where a great quantity of the victual that comes to the south is loadened;’ and for making a harbour at Pennan, on the estate of William Baird of Auchmedden, in Aberdeenshire, where such a convenience was eminently required for the shelter of vessels, and where ‘there is likewise a millstone quarry belonging to the petitioner [Baird], from which the greatest part of the mills in the kingdom are served by sea.’

1703. N. 11.

Amidst the endless instances of misdirected zeal and talent which mark the time, there is a feeling of relief and gratification even in so small and commonplace a matter as an application to the Privy Council, which now occurs, from Mr William Forbes, advocate, for a copyright in a work he had prepared under the name of A Methodical Treatise of Bills of Exchange. The case is somewhat remarkable in itself, as an application by an author, such applications being generally from stationers and printers.

D.

Usually, in our day, the opposing solicitors in a cause do not feel any wrath towards each other. It was different with two agents employed at this time in the Court of Session on different interests, one of them being Patrick Comrie, who acted in the capacity of ‘doer’ for the Laird of Lawers. To him, one day, as he lounged through the Outer House, came up James Leslie, a ‘writer,’ who entered into some conversation with him about Lawers’s business, and so provoked him, that he

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