Secretion of the gastrokinetic agent cisapride in human milk

Summary Ten puerperal women were treated with the gastrokinetic agent Cisapride 20 mg 8-h by oral tablets. Breast milk levels of Cisapride had reached a steady state by treatment day 3. Day 4 breast milk levels were 6.2±1.3 and serum levels 137±8.1 ng/ml (mean±SEM). The breastfeeding infant of a woman on the above treatment would ingest an amount of Cisapride 600–800 times lower than the usual therapeutic dose.     

Implications of nicotine detected in autopsy cases of newborn babies and infants from the perspective of social medicine

Smoking by pregnant and parturient women is generally suspected to increase nicotine levels in fetal and infant blood. Supportive data of nicotine levels in infants is, however, inadequate. We investigated blood and muscle nicotine and cotinine levels in 14 autopsy cases of newborn babies and infants using gas chromatography. Among the 14 cases investigated, nicotine or cotinine was detected in six cases (42.9%). In each of these six cases, the mother was a smoker. Route of exposure to nicotine originating from smoking was transplacental in three cases, via breast milk in one case and secondhand smoke in two cases. Nicotine and cotinine levels in blood from the two cases with placental exposure were 10.6-84.4 ng/ml and 20.3-183 ng/ml, and levels in muscle from one case were 43.9 ng/g and 308 ng/g, respectively. Nicotine and cotinine levels in blood from exposure via breast milk were 19.1 ng/ml and 87.1 ng/ml, and from secondhand smoke were 0 ng/ml and 14.6-20.1 ng/ml. Mean concentrations of blood nicotine and cotinine in 68 autopsy cases of adult habitual smokers were 30.0 ng/ml and 247 ng/ml. Our data for nicotine and cotinine levels in infant blood seem to indicate that some infants who are born and develop under exposure to smoking by family members, particularly the mother, may show high nicotine levels in blood and experience possible health risks.     

Quantification of lorazepam and lormetazepam in human breast milk using GC-MS in the negative chemical ionization mode

Lormetazepam (Loramet is a benzodiazepine mainly used as an hypnotic to treat insomnia. Lorazepam (Temesta) is used as an anxiolytic, tranquilizer, sedative, and anticonvulsant, and it is the major metabolite of lormetazepam. In this study, we designed a method to simultaneously detect and quantify these substances in human breast milk. Solid-phase extraction of 2 mL of milk was followed by derivatization with a trimethylsilyl reagent. Separation and detection was performed using gas chromatography coupled to mass spectrometry in the negative chemical ionization mode. Calibration curves were linear in the ranges of 10-200 and 1-20 ng/mL for lorazepam and lormetazepam, respectively. Limits of detection were estimated at 0.016 ng/mL for lormetazepam and 0.100 ng/mL for lorazepam. Our method was applied to real case samples from a woman receiving both benzodiazepines. Lorazepam concentrations varied from 55.3 to 123.1 ng/mL, and lormetazepam concentrations varied from 1.7 to 7.3 ng/mL.     

The excretion of ketorolac tromethamine into breast milk after multiple oral dosing

Summary We have studied the transfer of the analgesic ketorolac tromethamine into breast milk in ten women aged between 22 and 35 years. Ketorolac administration was started between 2 and 6 days after delivery. The breast milk was not fed to the infant because of maternal antibiotic use (6 patients) or because of jaundice of the baby.10 mg of ketorolac was given four times daily for two days. Plasma and milk samples were collected on the two dosing days and on the first day after dosing. The plasma and milk were assayed for ketorolac concentrations by HPLC; the quantification limits were 10 ng·ml^–1 and 5 ng·ml^–1 respectively.The maternal plasma concentrations were within established ranges for ketorolac. In four patients the concentration of ketorolac in the milk was never above 5 ng·ml^–1. At 2 h after dosing on both Days 1 and 2 there were quantifiable concentrations of ketorolac in the milk. The range was 5.2 ng·ml^–1 to 7.9 ng·ml^–1. The ratio of breast milk: plasma concentrations of ketorolac ranged from 0.015 to 0.037.The maximum potential amount of ketorolac that an infant may be exposed to daily could range from 3.16 mg to 7.9 mg, assuming a consumption of between 400 ml and 1 l of breast milk. On a weight-adjusted basis this is equivalent to between 0.16% and 0.40% of the total daily maternal dose.Klinikum der Stadt Mannheim, Gynaecological Clinic, Mannheim, (until 1986: Krankenanstalt Rotes Kreuz, Munich)     

Nitrendipine in human plasma and breast milk

Summary To assess the disposition of the dihydropyridine calcium antagonist, nitrendipine, in lactating mothers, we studied three breast-feeding women to determine simultaneous plasma and breast milk concentrations of nitrendipine and its inactive pyridine analog metabolite after both a single 10 mg oral dose and 5 days of continuous therapy (20 mg per day).Nitrendipine was excreted in breast milk at peak concentrations ranging from 4.3 to 6.5 ng/ml 1–2 h after acute dosing while its inactive pyridine metabolite ranged from 6.9 to 11.9 ng·ml^–1. After 5 days of dosing, C_max remained in the same range and the breast milk/whole plasma concentration ratio for nitrendipine was 0.2 to 0.5. On the fourth day of continuous dosing, average concentrations of nitrendipine from 24-h collections of the milk were 1.1 to 3.8 ng·ml^–1.Thus, nitrendipine and its metabolite are excreted in very low concentrations in human breast milk. Based on a maternal dose of 20 mg daily, a newborn infant would ingest an average of 1.7 µg of nitrendipine per day, or a relative dose of 0.095%.Presented in part at the 3rd Annual Meeting of the American Society of Hypertension, New York, N.Y., June 24, 1988     

Tacrolimus placental transfer at delivery and neonatal exposure through breast milk

Aim(s)

The current investigation aims to provide new insights into fetal exposure to tacrolimus in utero by evaluating maternal and umbilical cord blood (venous and arterial), plasma and unbound concentrations at delivery. This study also presents a case report of tacrolimus excretion via breast milk.

Methods

Maternal and umbilical cord (venous and arterial) samples were obtained at delivery from eight solid organ allograft recipients to measure tacrolimus and metabolite bound and unbound concentrations in blood and plasma. Tacrolimus pharmacokinetics in breast milk were assessed in one subject.

Results

Mean (±SD) tacrolimus concentrations at the time of delivery in umbilical cord venous blood (6.6 ± 1.8 ng ml⁻¹) were 71 ± 18% (range 45–99%) of maternal concentrations (9.0 ± 3.4 ng ml⁻¹). The mean umbilical cord venous plasma (0.09 ± 0.04 ng ml⁻¹) and unbound drug concentrations (0.003 ± 0.001 ng ml⁻¹) were approximately one fifth of the respective maternal concentrations. Arterial umbilical cord blood concentrations of tacrolimus were 100 ± 12% of umbilical venous concentrations. In addition, infant exposure to tacrolimus through the breast milk was less than 0.3% of the mother''s weight-adjusted dose.

Conclusions

Differences between maternal and umbilical cord tacrolimus concentrations may be explained in part by placental P-gp function, greater red blood cell partitioning and higher haematocrit levels in venous cord blood. The neonatal drug exposure to tacrolimus via breast milk is very low and likely does not represent a health risk to the breastfeeding infant.     

Zolpidem excretion in breast milk

Five, lactating, healthy white women were treated with a single 20 mg tablet of zolpidem 3-4 days after the delivery of a full term baby. The drug was administered at 20.00 h, 30 min after dinner, and milk samples were collected before and 3, 13 and 16 h. Venous blood 5 ml was taken before and 1.5, 3, 13, 16 h after zolpidem administration. The apparent elimination half life, estimated from plasma zolpidem concentrations was 2.6 h. The amount of zolpidem excreted in the milk at 3 h ranged between 0.76 and 3.88 micrograms, which represented 0.004 to 0.019% of the administered dose; no detectable (below 0.5 ng/ml) zolpidem was found in the milk at subsequent sampling times. The ratio of the zolpidem concentrations in breast milk and plasma at 3 h was 0.13. The apparent breast milk clearance of zolpidem, calculated from the ratio of the total amount of zolpidem excreted in milk to its AUC in plasma was 1.48 ml/h. The results show that the excretion of zolpidem in human milk is very low (below 0.02%) and that most of it takes place during the first 3 h following drug intake.     

Transfer of reboxetine into breastmilk, its plasma concentrations and lack of adverse effects in the breastfed infant

Objective To investigate the transfer of reboxetine into milk, the absolute and relative infant doses via milk and to assess plasma concentrations and adverse unwanted effects in the breastfed infant.Methods Multiple samples of blood and milk were obtained over a dose interval at steady-state from four women who were taking reboxetine for postnatal depression. Drug concentrations in plasma and milk were measured by high performance liquid chromatography and milk/plasma ratio (M/P), absolute infant dose and relative infant dose were estimated by standard methods. Their four, breastfed, infants were also examined clinically, and a blood sample was taken for drug analysis.Results The median (range) dose taken by the women was 6 (4-10) mg/day. There was no significant difference in reboxetine concentration between paired fore-and hind-milk samples. The mean (95% CI) M/P was 0.06 (0.03, 0.09). Absolute infant dose was 1.7 (0.7, 2.4) μg/kg/day for reboxetine while the relative infant dose was 2.0% (1.3, 2.7%). Three of the infants met normal developmental milestones and no adverse effects were seen in any infant. The fourth infant had developmental problems that were not associated with the maternal reboxetine therapy. The concentrations of reboxetine in plasma from the four infants were <4 μg/l, 2.6 μg/l, 2.3 μg/l and 5 μg/l, respectively.Conclusion The study suggests that reboxetine use by lactating women is safe for the breastfed infant. Nevertheless, our study had only four mother/baby pairs, and each decision to breastfeed should always be made on the basis of an individual risk/benefit analysis.     

Accumulation of atenolol and metoprolol in human breast milk

Summary Passage of the cardioselective beta adrenoceptor antagonists atenolol and metoprolol from serum to breast milk was assessed in 7 lactating women treated with atenolol due to hypertension developing during pregnancy, and in 3 healthy women who agreed to take metoprolol at cessation of lactation. For both drugs, the concentration in breast milk was higher than that in serum at every time studied, and the resulting AUC values were 1.5–6.8 times (atenolol) and 2.6–3.7 times (metoprolol) greater in milk than in serum. Assuming ingestion of 75 ml milk per meal, and as the maximum milk concentrations recorded were 6.35 µmol/l (atenolol) and 2.58 µmol/l (metoprolol), the data indicate that the dose following a meal at the time of maximum maternal drug concentration would not exceed 0.13 mg atenolol and 0.05 mg metoprolol, and would be considerably less after the other meals. In the only infant from whom serum samples could be obtained, the plasma atenolol concentration ranged between 0 and 0.26 µmol/l. None of the atenolol-exposed infants had any sign of an effect of the beta blocker. It would seem likely that, unless renal (atenolol) or hepatic (metoprolol) function in the infant were pronouncedly impaired, breast feeding need not be interrupted due to maternal medication with ordinary doses of either of these drugs. However, the infants should be observed for signs of beta blockade.     

Pharmacokinetics of Duloxetine in Breast Milk and Plasma of Healthy Postpartum Women

OBJECTIVE: The purpose of this study was to characterize duloxetine pharmacokinetics in the breast milk and plasma of lactating women and to estimate the duloxetine dose that an infant might consume if breastfed. METHODS: This open-label study included six healthy women aged 22-35 years who stopped nursing during and after the study. Duloxetine 40 mg was given orally every 12 hours for 3.5 days; seven plasma and milk samples over 12 hours were obtained after the seventh dose. Plasma and milk samples were analysed using validated liquid chromatography-tandem mass spectrometry methods. Safety measures included vital signs, ECGs, laboratory tests, adverse event monitoring and depression rating scales. RESULTS: The mean steady-state milk-to-plasma duloxetine exposure ratio was 0.25 (90% CI 0.18, 0.35). The amount of duloxetine in the breast milk was 7 microg/day (range 4-15 microg/day). The estimated infant dose was 2 microg/kg/day (range 0.6-3 microg/kg/day), which is 0.14% of the maternal dose. Dizziness, nausea and fatigue were commonly reported adverse events. No clinically important changes in safety measures occurred. CONCLUSION: Duloxetine is detected in breast milk, and steady-state concentrations in breast milk are about one-fourth of those in maternal plasma. As the safety of duloxetine in infants is unknown, prescribers should carefully assess, on an individual basis, the potential risks of duloxetine exposure to infants and the benefits of nursing an infant when the mother is on duloxetine therapy.     

Infants exposure to aflatoxin M1 as a novel foodborne zoonosis

Occurrence of aflatoxin M₁ (AFM₁) in infant formula milk powder (IFMP) and maternal breast milk (MBM) was investigated as a risk factor affects the health of newborns in Egypt. A total of 125 IFMP and 125 MBM samples were collected and examined for the presence of AFM₁ using competitive ELISA test. The results indicated that the relative risk (RR) of exposure to AFM₁ via consumption of MBM was higher than IFMP (RR; 1.6, 95% CI; 1.28–2.03, p = 0.0001). The mean concentrations of AFM₁ were significantly differed (p < 0.0001) between MBM (74.413 ± 7.070 ng/l) and IFMP (9.796 ± 1.036 ng/l). High frequency distributions were detected within the range of 5–25 ng/l and >50–100 ng/l in IFMP and MBM, respectively. The average daily exposure of newborns to AFM₁ via consumption of MBM and IFMP was 52.684 and 8.170 ng, respectively, with a significant difference at p < 0.0001. Consumption of raw milk by lactating mothers exhibited a significant correlation (p < 0.0001) with the presence of AFM₁ in their milk. In conclusion, this work established a pioneering concept that AFM₁ may be considered as an etiological factor for a novel foodborne zoonosis identified as Aflatoxicosis M₁.     

Exposure of infants to ochratoxin A with breast milk

The nephrotoxic and carcinogenic mycotoxin ochratoxin A (OTA) is a worldwide contaminant in food commodities and also found frequently in human biological fluids. Dietary contaminants ingested by nursing mothers can appear in breast milk. But the rate of lactational transfer of OTA has not been investigated so far at various stages of breastfeeding. Therefore, and to investigate OTA exposure of Chilean infants, we conducted a longitudinally designed study in mother–child pairs (n = 21) with parallel collection of maternal blood, milk and of infant urine samples over a period of up to 6 months. Validated analytical methods were applied to determine OTA concentrations in all biological samples (n = 134). OTA was detected in almost all maternal blood plasma, at concentrations ranging between 72 and 639 ng/L. The OTA concentrations in breast milk were on average one quarter of those measured in plasma (M/P ratio 0.25). Interestingly, a higher fraction of circulating OTA was excreted in colostrum (M/P 0.4) than with mature milk (M/P ≤ 0.2). Infants exposure was calculated as daily intake from our new data for OTA levels in breast milk, and taking into account milk consumption and body weight as additional variables: Chilean infants have an average intake of 12.7 ± 9.1 ng/kg bw during the first 6 days after delivery while intake with mature milk results in average values close to 5.0 ng/kg bw/day. Their OTA exposure is discussed in the context of tolerable intake values suggested by different scientific bodies. Moreover, the study design enabled a comparison of OTA intake and infant urine concentrations over the breastfeeding period. The statistical analysis of n = 27 paired values showed a good correlation (r = 0.57) for this type of studies and thereby confirms that urinary OTA analysis in infants is a valid biomarker of exposure.     

Measurement of ethyl methanesulfonate in human plasma and breast milk samples using high-performance liquid chromatography–atmospheric pressure chemical ionization-tandem mass spectrometry

Ethyl methanesulfonate (EMS) is a mesylate ester, which is known to be a potent mutagen, teratogen, and possibly carcinogen. Mesylate esters have been found in pharmaceuticals as contaminants formed during the manufacturing process and may potentially pose an exposure hazard to humans. We have developed and validated a method for detection of trace amounts (ng/ml levels) of EMS in human plasma and breast milk. The samples were extracted by matrix solid-phase dispersion with ethyl acetate using Hydromatrix™ and the ASE 200 Accelerated Solvent Extractor. The extracts were separated by high-performance liquid chromatography (HPLC) using a HILIC column. The detection was performed with a triple quadrupole mass spectrometer (TSQ Quantum Ultra, Thermo Electron Corporation) using atmospheric pressure chemical ionization in negative-ion mode and multiple reaction monitoring. The use of a surrogate internal standard in combination with HPLC–MS/MS provided a high degree of accuracy and precision. The extraction efficiency was greater than 70%. Repeated analyses of plasma and breast milk samples spiked with high (100 ng/ml), medium (50 ng/ml) and low (5 ng/ml) concentrations of the analytes gave relative standard deviations of less than 12%. The limits of detection were in the range of 0.5–0.9 ng/ml for both matrices.     

Tinidazole milk excretion and pharmacokinetics in lactating women.

Five women undergoing acute Caesarean section were given an i.v. dose of 1600 mg tinidazole preoperatively as prophylaxis against anaerobic infection. Blood and breast milk samples were collected at 8 and 4 h intervals, respectively, for 120 h. Tinidazole concentrations were measured by means of high performance liquid chromatography (h.p.l.c). The concentration of tinidazole in breast milk was highly related to the concentration in serum (r = 0.969). Tinidazole concentrations in serum declined monoexponentially with an average half-life of 11.4 h (range 8.7-13.1). The milk/serum concentration ratio varied between 0.62 and 1.39. Seventy-two hours after the Caesarean section the milk concentration exceeded 0.5 microgram/ml in only one woman. It may be calculated that at this time the maximum daily dose to the infant would be 0.1 mg/kg body weight (assuming 3.5 kg body weight and 400 ml milk consumed). We conclude that until tinidazole has been proven harmless to the neonate breast feeding following i.v. administration of 1600 mg should not be initiated earlier than 72 h after the dose.     

Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk

AIMS: To assess the effects of pseudoephedrine on breast blood flow, temperature and milk production, and to estimate the likely infant dose during breastfeeding. METHODS: Eight lactating women (mean age 35 years and weight 69 kg) participated in a single-blind randomized crossover study of 60 mg pseudoephedrine hydrochloride vs placebo. Breast blood flow and surface temperature were measured from 0 to 4 h following the dose, and change in plasma prolactin was measured as the difference between predose and 1 h postdose concentrations. Milk production was measured for 24 h following placebo and pseudoephedrine. Infant dose of pseudoephedrine for a 60-mg dose administered four times daily to the mother was quantified as the product of average steady-state drug concentration in milk and an estimated milk production rate of 0.15 l x kg(-1) x day(-1) and expressed relative to the maternal weight-adjusted dose. RESULTS: There were no physiologically significant changes in breast blood flow or temperature between the placebo and pseudoephedrine periods. The mean change in plasma prolactin was slightly (13.5%), but not significantly lower (t = 1.245, P = 0.253) after pseudoephedrine (1775 mU x l(-1)) compared with placebo (2014 mU x l(-1)). However, the mean milk volume was reduced by 24% from 784 ml x day(-1) in the placebo period to 623 ml x day(-1) in the pseudoephedrine period (difference between means 161 ml x day(-1) (95% CI: 63, 259 ml x day(-1)); t = 3.9, P = 0.006). Assuming maternal intake of 60 mg pseudoephedrine hydrochloride four times daily, the estimated infant dose of pseudoephedrine was 4.3% (95% CI, 3.2, 5.4%) of the weight-adjusted maternal dose. CONCLUSIONS: A single dose of pseudoephedrine significantly reduced milk production. This effect was not attributable to changes in blood flow, but depression of prolactin secretion may be a contributing factor. At the maximum recommended pseudoephedrine doses, the calculated infant dose delivered via milk was < 10% of the maternal dose, and is unlikely to affect the infant adversely. The ability of pseudoephedrine to suppress lactation suggests a novel use for the drug.     

Evaluation of Mycotoxins in Infant Breast Milk and Infant Food,Reviewing the Literature Data

In this review, an analysis focusing on mycotoxin determination in infant breast milk and infant food has been summarised for the last fifteen years of research focused on the intended population group of 1–9 months. The objective was to know the level of exposure of the child population to an estimated daily intake (EDI) of mycotoxins from the consumption of habitual foods. The EDI was compared with the tolerable daily intake (TDI) established by EFSA to estimate risk. In breast milk, the high prevalence and levels were for samples from Africa (Egypt and Tanzania) with aflatoxin M1 (1.9 μg/L and 10%), and Asia (Iran) with ochratoxin-A (7.3 μg/L and 100%). In infant formulas, high incidences and values were for samples with aflatoxin M1 from Burkina Faso (167 samples, 84%, 87 μg/kg). In cereal products, the highest incidence was for DON from the United States (96 samples), and the highest value was an Italian sample (0.83 μg/kg of enniatin B). In fruit products, patulin was the most detected in Italian (78) and Spanish (24) samples. The highest risk was observed in breast milk during the first month of age, the highest EDI for aflatoxin M1 was reported for Egypt (344–595 ng/kg bw/day) and ochratoxin-A for Iran (97–167ng/kg bw/day), representing a public health problem.     

Low levels of tenofovir in breast milk support breastfeeding in HBV-infected mothers treated with tenofovir disoproxil fumarate

ObjectiveTenofovir disoproxil fumarate (TDF) is recommended for the prevention of mother-to-infant transmission of the hepatitis B virus (HBV). This study investigated the safety of infants whose mothers continued to receive TDF while breastfeeding.Patients and methodThirty women taking TDF daily from the second or third trimester of pregnancy to three months postpartum were enrolled. Tenofovir (TFV) concentrations in breast milk were determined and compared with those in umbilical cord (UC) blood and amniotic fluid. Infant growth parameters were assessed at birth, and at 3, 6, and 12 months. TFV uptake experiments were conducted in vitro to elucidate the mechanisms of TFV exposure via breast milk.ResultsTFV concentrations in breast milk ranged from 1.4 to 11.7 ng/mL within 24 h after dosing in the third month postpartum. The median trough concentration of TFV in breast milk was 3.7 (interquartile range, 2.6–6.2) ng/mL, which is lower than that in UC blood (median = 53.5 ng/mL) and amniotic fluid (median = 531.0 ng/mL). The low permeability of TFV in MCF-10A cells may explain the minimal exposure to TFV in breast milk. Body weights, body lengths, and head circumferences of the breastfed infants were comparable to the national standards for physical development.ConclusionInfant exposure to TFV from breast milk is much lower than the exposure from placental transfer and swallowing from amniotic fluid. The physical growth parameters of all infants in this study were normal. The findings indicate that breastfeeding is safe for infants of HBV-infected mothers who continue to receive TDF through three months postpartum.     

Excretion of indomethacin in breast milk.

1. The excretion of indomethacin into breast milk and subsequent exposure of infants was studied in 16 women and seven of their infants. The median milk:plasma ratio in seven patients where there were measurable drug concentrations in both milk and plasma was 0.37. 2. Total infant dose, assuming a daily milk intake of 150 ml kg-1 and 100% absorption, ranged from 0.07% to 0.98% (median = 0.18%) of the weight adjusted maternal dose. 3. Plasma samples were obtained in seven infants. In six of these, indomethacin concentrations were below the sensitivity of the assay (less than 20 micrograms l-1), while one infant had a plasma indomethacin concentration of 47 micrograms l-1. 4. No adverse effects due to indomethacin were reported in the infants.     

Different pharmacokinetics of tramadol in mothers treated for labour pain and in their neonates

Objective The aim of the present study was to investigate the pharmacokinetic profile of tramadol hydrochloride in neonates, born from mothers who underwent analgesia with tramadol for the relief of labour pain.Methods Intramuscular tramadol (100–250 mg) was administered to 22 mothers giving birth who requested pain relief. At the time of birth (1.5–6.0 h after last tramadol dose), maternal and umbilical blood samples were taken. Another venous blood sample was drawn from each neonate, and at the same time from its mother, at 1, 2, 3, 6 or 12 h post-partum, providing the data for a population pharmacokinetic evaluation of tramadol and its metabolite M1. Routine APGAR scores and a standard neurological and adaptive capacity test were considered for evaluation of the effect of tramadol on the neonates.Results Serum tramadol concentrations at the time of birth (t₀) were 243±102 ng/ml (mean±SD, umbilical vein), 258±103 ng/ml (umbilical artery) and 250±113 ng/ml (maternal vein). Serum M1 concentrations were 52±27 ng/ml (umbilical vein), 47±24 ng/ml (umbilical artery) and 56±21 ng/ml (maternal vein). The two-compartment type elimination profiles during the first 12 h post-partum for neonates (and mothers, respectively) were characterised by terminal t_1/2 (tramadol)=7.0 (7.2) h and t_1/2 (metabolite M1)=85.0 (5.5) h.Conclusion The intramuscular application of tramadol in birth-giving mothers almost freely reaches the neonate, confirming a high degree of placental permeability. The neonates already possess the complete hepatic capacity for the metabolism of tramadol into its active metabolite. However, the renal elimination of the active tramadol metabolite M1 is delayed, in line with the slow maturation process of renal function in neonates. Despite this difference in pharmacokinetics between neonates and adults, the intramuscular application of tramadol at the recommended dosage range during delivery appears to effective in the relief of labour pain.     

Stability and pharmacokinetics of flumazenil in the rat

The pharmacokinetics of flumazenil in the rat were determined after 2.5 mg/kg intravenous and 25 mg/kg oral administration. Following intravenous administration flumazenil was rapidly eliminated with an extremely short terminal half-life (mean±SE,n=8) of 8.3±0.3 min due to a large total blood clearance of 147±7 ml/kg/min combined with a relatively small volume of distribution at steady-state of 1.33±0.07 l/kg. After oral administration flumazenil was rapidly absorbed; however, the bioavailability was low (28±4%) and variable. Flumazenil was found to be unstable in rat blood in vitro and disappeared with a half-life (mean±SE,n=5) of 8.3±1 min and 31±4 min at body and room temperature, respectively. The blood samples were stabilized by addition of sodium fluoride (NaF) and cooling to 0°C. The samples had to be stored at –35°C when analyzed at later times. Presumably esterases in rat blood are responsible for the observed instability. A sensitive HPLC assay to measure flumazenil concentrations in small blood samples is also described.