Products to support hair growth/ thickness

It is normal during lactation to notice that your hair becomes thinner or may even appear to drop out in significant levels. In pregnancy we grow more hair and the apparent loss is usually just a return to normal.

It may however, be a sign of thyroid deficiency so always worth checking with your doctor and requesting a blood test to check levels, just in case.

Most of the commercially available products which claim to thicken, strengthen, promote growth of hair contain biotin in addition to the normal vitamins and minerals.

Symptoms of biotin deficiency include thinning hair, skin rash, and depression. The recommended daily dose of biotin for a lactating woman is 35 µg/day. Levels of biotin in human milk range from 5 to 9 µg/L, indicating that there is active transport of biotin into milk. No adverse effects have been found. (Hale Medications and Mother’s Milk)

Biotin (vitamin B7) is needed in very small amounts to help the body break down fat. The bacteria that live naturally in the bowel synthesise biotin, so it’s  unclear whether supplements are necessary if a varied and balanced diet is eaten.. Biotin is also found in a wide range of foods, but only at very low levels. There’s not enough evidence to know what the effects might be of taking high daily doses of biotin supplements. Taking 0.9mg or less a day of biotin in supplements is unlikely to cause any harm. ( NHS Vitamin B https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-b/)

Vitamin and Mineral content compatible with breastfeeding https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-multivitamin-and-mineral-supplements

Protein Shakes and Breastfeeding

During the “lockdown” I have had more questions than usual about using protein shakes as part of a return to fitness/ exercise programme. Great to see so many people getting fit but sadly I cant help on the use of protein shakes as there is no research that I have found to prove safety. I’m not happy to comment without evidence to back what I say which I am sure you understand.

Live vaccinations and Immunosuppressant medication taken by breastfeeding mothers

To finish the posts on immunosuppresant medications the final most frequently asked question is about the administration of live vaccinations to the baby. This is particularly a problem with the rotavirus vaccine.

The Torento consensus statement also suggested that live vaccinations are not recommended within the first 6 months of life in the offspring of women who were on anti-TNF therapy during pregnancy. The babies of mothers taking immunosupressant drugs eg azathioprine and infliximab have not been shown to be immunocompromised because of the limited passage of medication through breastmilk.

However, if live vaccinations, particularly rotavirus are used then the mother with IBD should use precautions like wearing gloves when changing the baby’s nappy for 2 weeks after the vaccination to avoid picking up the particles of live virus shed in faeces.

The Rotavirus Vaccination Programme Public Health England

” There is a potential for transmission of the live attenuated virus in Rotarix vaccine from the infant to severely immunocompromised contacts through faecal material for at least 14 days. However, vaccination of the infant will offer protection to household contacts from wild-type rotavirus disease and outweigh any risk from transmission of vaccine virus to any immunocompromised close contacts. Those in close contact with recently immunised infants should, as always, observe good personal hygiene which should include handwashing after changing the infant’s nappy”

” Rotavirus vaccine should not be given to infants of mothers that used immunosuppressive biological therapy during their pregnancy because of the potential that these will have a postnatal influence on the infants’ immune status. It is recommended that immunisation with live vaccines should be delayed for 6 months in children born to mothers who were on immunosuppressive biological therapy (TNFα antagonists and other biological medicines such as Infliximab) during pregnancy. As Rotarix vaccine is contraindicated in infants presenting for the first dose after 15
weeks of age (beyond 14 weeks and 6 days), infants whose mothers received such treatment during pregnancy will therefore not be eligible to receive Rotarix vaccine, but they should benefit from herd (indirect) protection.”

” Infants born to mothers who received non-biological immunosuppressive therapy such as steroids, cyclosporine, tacrolimus or azathioprine at any time during their pregnancy can safely have the rotavirus vaccine at the appropriate age.


A recent review of the literature concluded that it is safe for mothers to breastfeed while on immune suppression that includes steroids, cyclosporine, tacrolimus or azathioprine. Breastfed infants of mothers taking immunosuppressive therapy can receive rotavirus vaccine at the appropriate age. Rotarix vaccine should not be administered to breastfeeding infants whose mothers are using biological medicines such as Infliximab.”

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770826/Rotavirus_vaccination_programme__information_document_Nov_2018.pdf

  • Sameh M, Mohsen EK, Jon JK, Halawa A, Sharma Al. Safety of Breastfeeding by Mothers on Immunosuppressive
    Medication for Renal Transplantation: Obsession, Myth and Truth. JOJ Uro & Nephron. 2017; 3(3): 555612. Available at
    www.juniperpublishers.com/jojun/pdf/JOJUN.MS.ID.555612.pdf
  • Public Health England. Immunisation against infectious disease. Contraindications and Special Considerations. Chapter 6.
    www.gov.uk/government/publications/contraindications-and-special-considerations-the-green-book-chapter-6

Infliximab and breastfeeding

Following on from the page on Azathioprine I thought it would be useful to add data on infliximab which is also widely used by breastfeeding mothers. Like most of the biologicals the molecules are too large to pass into milk.

This information is taken from Breastfeeding and Medication

In 2002, the NICE (NICE 2002) recommended that this drug be only used for the treatment of severe, active CD when treatment with immunosuppressant drugs and corticosteroids is not tolerated or has failed.

It is now much more commonly prescribed to pregnant and breastfeeding women.

Infliximab is a large molecular weight antibody and preliminary results suggest it is too large to pass into breastmilk and it is not orally bio-available. It is distributed primarily in the vascular compartment and has a terminal elimination half-life of 8 to 9.5 days.

It is suggested that use by a mother should not preclude breastfeeding based on this data (Peltier 2001; Forger 2004; Mahadevan 2005; Basilisks 2006).

The BNF states that the amount in breastmilk is too small to be harmful.

Compatible with breastfeeding due to poor bio-availability and hence low-level absorption by the infant.

Infliximab is usually either not detectable in breastmilk or detectable at very low levels. Absorption of the drug from milk by the infant is minimal. Follow-up of infants exposed in utero and breastfed during maternal infliximab therapy have found no adverse effects and normal development. The measurement of minute concentrations in the milk of some women raises the possibility of local immune suppression in the gastrointestinal tact, but levels were not high enough to be of concern for systemic immunosuppression (LactMed)

References

  • Forger F, Matthias T, Oppermann M Becker H, Helmke KInfliximab in breastmilk, Lupus, 2004;13:753. Abstract NICE Crohns Disease – infliximab 2002
  • Mahadevan U, Kane S, Intentional infliximab use during pregnancy for induction or maintenance of remission in Crohn’s disease, Aliment Pharmacol Ther, 2005;21:733–8.
  • Peltier M, James D, Ford J, Wagner C, Davis H, Hanauer S Infliximab levels in breastmilk of a nursing Crohn’s patient, Am J Gastroenterol, 2001;96(9 Suppl. 1):S312. Abstract.
  • Vasiliauskas EA, Church JA, Silverman N, Barry M, Targan SR, Dubinsky MC, Case report: evidence for transplacental transfer of maternally administered infliximab to the new born, Clin Gastroenterol Hepatol, 2006;4:1255–8.

Any queries please contact me on wendy@breastfeeding-and-medication.co.uk

If you have IBD or have an interest in it please join the facebook page https://www.facebook.com/groups/BreastfeedingIBD/

Azathioprine and breastfeeding

I frequently get asked about the compatibility of azathioprine during breastfeeding . It is used for several auto-immune diseases including inflammatory bowel disease and sometimes rheumatoid arthritis. It is actually quite widely taken by breastfeeding mothers from the questions I receive.

This information is taken from Breastfeeding and Medication

“Azathioprine is an immunosuppressive anti-metabolite. It is converted to mercaptopurine in the body. It has a corticosteroid-sparing effect and is widely used to produce and maintain remission in IBD, as well as conditions such as lupus and rheumatoid arthritis.

Traditionally, breastfeeding by mothers have been discouraged from continuing to breastfeed if taking azathioprine because of the theoretical risks of infant bone marrow suppression, susceptibility to infection, growth retardation and pancreatitis.

According to recent research (Gardiner et al. 2007) breastfeeding need not be withheld in infants whose mothers are taking azathioprine. Gardiner et al. studied four mothers taking azathioprine. The metabolites 6-MP and 6-TGN were undetectable in neonatal blood and no clinical signs of immunosuppression were observed in the infants. Similarly Moretti et al. (2006) studied four babies and measured levels of 6-MP in breastmilk and neonatal blood for drug levels, white cell and platelet counts. Levels of metabolites were below the level of detection in the neonates and no clinical signs of immunosuppression were observed. Sau et al. (2007) studied ten women and similarly found no immunosuppression. Women taking azathioprine should therefore not be discouraged from breastfeeding.

It is licensed to be given to children over the age of 2 years at a dose of 2 mg per day initially for severe UC and CD. Relative infant dose is quoted as 0.07% to 0.3% (Hale 2017 online access).

The BNF states that it is present in milk in low concentrations, that there is no evidence of harm in small studies and the drug may be considered if the potential benefit outweighs the risk.

Compatible with breastfeeding according to more recent studies; metabolites undetectable in infant’s blood and no signs of immunosupression in studies.

  • Gardiner SK, Gearry RB, Roberts RL, Zhang M, Barclay ML, Begg EJ, Exposure to thiopurine drugs through breastmilk is low based on metabolite concentrations in mother-infant pairs, Br J Obstet Gynecol, 2007;114:498–501.
  • Sau A, Clarke S, Bass J, Kaiser A, Marinaki A, Nelson-Piercy C, Azathioprine and breastfeeding – is it safe?, BJOG, 2007;114:498–501.
  • Moretti ME, Verjee Z, Ito S, Koren G, Breastfeeding during maternal use of azathioprine, Ann Pharmacother, 2006;40:2269–72.
  • Hale TW Medications and Mother’s Milk”

Any queries please contact me on wendy@ breastfeeding-and-medication.co.uk

For mothers with IBD, or professionals with an interest please join our Facebook page https://www.facebook.com/groups/BreastfeedingIBD/

Perinatal Mental Health in pregnancy and breastfeeding

I saved this presentation to share during UK Maternal Mental Health Awareness Week which is this week. It is a presentation which I have on my last study day on my birthday this year. I hope it covers many of the things I have tried to pass on over the years.

I also post it today in honour of my daughter who is a CBT therapist and has helped me learn so much along my own journey into understanding mental health. She gave birth to a gorgeous, if tiny, little girl this morning – my sixth grandchild who I cannot see in person during this crazy, demanding time in our lives. I think the COVID-19 pandemic has played with the minds of many of us.

I hope this presentation helps with CPD and I am happy to answer any questions via email wendy@breastfeeding-and-medication.co uk.

Mental health in pregnancy and breastfeeding powerpoint

If it is useful there are 2 books you might find valuable.

Dihydrocodeine and breastfeeding

I keep being asked about strong analgesics in breastfeeding. Lots of people seem unaware that codeine and dihydrocodeine sound similar but do not have the same risk in breastfeeding. Although many babies dont exhibit drowsiness when exposed to codeine during breastfeeding, dihydrocodeine is preferred.

This explains why:

The analgesic effect of dihydrocodeine appears to be mainly due to the parent compound. The oral bio availability of dihydrocodeine is 20% due to substantial first pass metabolism. The half life is quoted as 3.5-5h . It is metabolised in the liver by CYP2D6 to dihydromorphine, which has potent analgesic activity. However, the CYP2D6 pathway only represents a minor route of metabolism, with other metabolic pathways being involved.

The metabolism of dihydrocodeine is not affected by individual metabolic capacity as the analgesic effect is produced by the parent drug compared to codeine which is a pro drug.

Dihydrocodeine may be the preferred weak opioid for postoperative use in the breastfeeding woman, because of its cleaner metabolism compared with codeine and wide experience of use after caesarean section

Carbimazole in women of childbearing age

As for the valproate fact sheet this information on carbimazole taken for over active thyroid is included so that women who may become pregnant are aware of potential risks . https://www.gov.uk/drug-safety-update/carbimazole-increased-risk-of-congenital-malformations-strengthened-advice-on-contraception

This factsheet gives further information

carbimazole and pregnancy

Valproate and pregnancy

I know that this page is about breastfeeding and medication but I think that is important to share this too. I started writing it for another organisation a year ago but it hasnt gone anywhere so now it is here.

Anyone who is on sodium valproate (Epilim) should be taking adequate contraceptive protection https://www.fsrh.org/news/mhra-contraception-drugs-birth-defects-fsrh-guidance/ . It could be for epilepsy or it could be as a mood stabiliser but it is essential that you do not become pregnant. This factsheet explains why

valproate in pregnancy

Caffeine and Breastfeeding

Several questions have come up recently about caffeine intake and breastfeeding. With spending more time indoors we are probably all drinking more caffeinated beverages.

Most of us drink caffeine in one form or another. Women who drink a significant amount of caffeinated drinks who notice that their babies are jittery and restless, may find reduction in caffeine consumption leads to resolution of symptoms. This does not mean that all breastfeeding women need to restrict their consumption of tea and coffee A baby who appears restless may benefit from lowered caffeine intake by the mother but for the average consumption there is little evidence to support restricting intake. From research maternal consumption below 300 milligrammes a day should not cause issues for breastfed babies.

Extract reproduced from Breastfeeding and Medication 2018 by Jones W (Routledge, London)