I was very proud to have co written a fact sheet for BfN on anxiety and breastfeeding which affects so many new mothers, with my daughter. Beth is a CBT therapist and approached the treatment with non pharmacological methods available via IAPT and IESO (although with a waiting list sadly for most).

I looked at the relief of symptoms with long-term treatments such as SSRI drugs e.g. sertraline, citalopram, fluoxetine and paroxetine. Mothers may also be helped with propranolol to relieve palpitations and racing heart.

Recently there have been more requests from mothers with anxiety or post traumatic stress to take benzodiazepine to reduce symptoms or to treat a panic attack. Occasional use might be acceptable with monitoring of the baby for drowsiness and effective feeding. However, regular use is not encouraged – particularly of diazepam – because of its long half life and potential to accumulate in breastmilk and the baby, but also because this family of drugs is addictive with as little as 28 days treatment.

I have written this factsheet to provide as much information as possible on the use of anxiolytics diazepam, loprazolam and alparazolam during breastfeeding.

anxiolytics and breastfeeding factsheet

The information is taken from Breastfeeding and Medication which includes full references . Please consider buying the book if this information is useful

Anxiolytics can be used to relive anxiety disorders. Management of anxiety is best achieved by non-pharmacological methods such as counselling and cognitive behavioural therapy. Anxiolytics are not as useful to treat acute panic attacks which will dissipate naturally before the drug is absorbed.

Use of anxiolytics in lactating women is generally discouraged due to the possibility of sedation of the infant and consequential reduction in feeding efficacy and limited weight gain

Anti-depressants are used for generalised anxiety disorders, particularly selective serotonin re-uptake inhibitors (SSRIs). Beta blockers such as propranolol may also be beneficial if symptoms of palpitations predominate.

Diazepam ( Valium®)

Diazepam has a long half-life of 43 hours (with terminal metabolite being present for 2 to 5 days) and accumulation is possible with repeated doses. The plasma elimination is further extended in neonates due to poor hepatic function. A shorter-acting anxiolytic is preferable for use particularly in neonates.

Brandt (1976) conducted a study of four post-natal women who were given 10 mg diazepam at bedtime for six nights. He concluded that even with a neonate, a maternal dose of 10 mg produced breastmilk levels too small to cause any untoward effects in the baby. Erkkola and Kanto (1972) studied three infants whose mothers were taking 10 mg diazepam three times daily from delivery. The babies were observed for 6 days during which period no symptoms of sedation were noticed. However, Patrick et al. (1972) reported on a single mother taking the same dose. At 8 days of age (three days after the mother commenced diazepam) symptoms of lethargy, EEG changes and weight loss were apparent in the infant and attributed to the diazepam exposure. Relative infant dose quoted as 7.1% (Hale 2017 online access). It is licensed for use in children only to control convulsions.

Diazepam is also a drug which may be abused in large doses. It is also possible to become addicted with daily doses over just one month.

The BNF suggests that benzodiazepines are present in milk, and should be avoided if possible during breastfeeding.

Single doses of diazepam may also be used in situations such as fear of flying, before surgery or other anxiety provoking situations with continued breastfeeding as normal.

Avoid if possible. Use for a short a time as possible. Observe baby for drowsiness. Avoid falling asleep with the baby in bed on a settee or chair.

Lorazepam (Ativan®)

Lorazepam is 85% bound to plasma proteins and is 90% bio-available. Half-life is reported as 10 to 20 hours. A post-partum study (Summerfield and Nielsen 1985) found clinically insignificant amounts of lorazepam in breastmilk even at a dose of 2.5 mg twice daily for the first 5 days post-natally. Whitelaw et al. (1981) estimated that an exclusively breastfed infant would be exposed to 7 µg per kilogramme per day with a maternal dose of 2.5 mg twice daily The single infant studied showed no signs of sedation. The dose used is in this study is more than the usual maximum of 2 mg daily. Relative infant is dose quoted as 2.5% (Hale 2017 online access). It is licensed for use in children only to control convulsions.

The BNF suggests that benzodiazepines are present in milk, and should be avoided if possible during breastfeeding.

LactMed reports that : Lorazepam has low levels in breastmilk, a short half-life relative to many other benzodiazepines, and is safely administered directly to infants. Evidence from nursing mothers indicates that lorazepam does not cause any adverse effects in breastfed infants with usual maternal dosages and that no special precautions are required.

Using Kelly (2012) data lorazepam may be taken as one of the safer benzodiazepines if use is essential. 

Avoid if possible. Use for a short a time as possible. Observe baby for drowsiness. Avoid falling asleep with the baby in bed on a settee or chair. May be preferable to diazepam as it has a shorter half-life and no active metabolites.

Alprazolam (Xanax®)

Alprazolam is a benzodiazepine but preferred due to the shorter half life (12-15 hours). Oo obtained multiple milk and serum samples from  eight lactating subjects up to 36 hours after a single oral

doses of 0.5 mg alprazolam. The milk plasma ratio was determined to be 0.36 a level too low to produce clinically significant levels. No outcomes were available as the infants were not breastfed. Reports of withdrawal in infants exposed in utero and breastfed are documented (Anderson 1989).

The BNF states that all benzodiazepines are present in milk, and should be avoided if possible during breast-feeding.

Avoid if possible. Use for a short a time as possible. Observe baby for drowsiness. Avoid falling asleep with the baby in bed on a settee or chair. May be preferable to diazepam as it has a shorter half-life

For many years the standard anti coagulants to treat and prevent deep vein thrombosis (DVT) have been heparin and low molecular weight heparionoids e.g Enoxaparin (Clexane®)  or alternately but generally less frequently Tinzaparin (Innohep®), Dalteparin (Fragmin®, Fondaparinux (Arixtra®). Alternatively warfarin may be given as a tablet but generally takes too long to stabilise the clotting mechanism. All of these drugs are compatible with breastfeeding. The sub cutaneous injections are too large molecules which cannot be absorbed from breastmilk (are not orally bio-available). Because of the very low milk levels with warfarin doses less than 12 mg daily, amounts ingested by the infant are small. No adverse reactions in breastfed infants have been reported from maternal warfarin use during lactation, even with a dose of 25 mg daily for 7 days. There is a consensus that maternal warfarin therapy during breastfeeding poses little risk to the breastfed infant. No special precautions are necessary. (Lactmed https://www.ncbi.nlm.nih.gov/books/NBK501137/).

See also Using heparins during breastfeeding Jan 2024 https://www.sps.nhs.uk/articles/using-heparins-during-breastfeeding/

Although these drugs are not absorbed from milk, caution is recommended where there is donation to a milk bank of surplus breastmilk. Should any small amount reach a pre-term baby it may result in a bleed with catastrophic results. There are no studies to confirm this but the recommendation is made to protect these most vulnerable babies.

Deep vein thrombosis

Whilst DVTs are uncommon they are 5 times more common in pregnancy and in the first 6 weeks after delivery than in women who are not pregnant.

The risk of developing DVT during pregnancy is even greater if :

• there is a history or family history of DVT
• age over 35
• obese BMI >30
• a severe infection or recent serious injury, which restrict exercise
• thrombophilia
• multiple birth
• after fertility treatment
• after a caesarean section
• currently smoke
• have severe varicose veins
• dehydration

https://www.nhs.uk/pregnancy/related-conditions/complications/deep-vein-thrombosis/

If the clot breaks off into the bloodstream, it can block a blood vessel in the lungs. This is called a pulmonary embolism (PE) and needs emergency treatment. It may be investigated by a VQ or CT scan (preferably the latter as it involves no interruption of breastfeeding . See https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-after-vq-scans

The newer treatments to prevent clots are called Direct Oral Anticoagulant Medications (DOAC) which have advantages in that they are oral medications and need less frequent blood tests to confirm the INR.

UKDILAS have produced an excellent summary https://www.sps.nhs.uk/articles/using-oral-anticoagulants-in-breastfeeding-women/

Rivaroxaban  (Xarelto®): compatible with breastfeeding

• Doses from breastmilk are over 100 times lower than doses given directly to pediatric patients. (Hale).
• Several case reports consistently indicate that maternal doses of rivaroxaban of 15 to 30 mg daily produce low levels in milk that are considerably below doses required for anticoagulation in infants (Lactmed https://www.ncbi.nlm.nih.gov/books/NBK500742/.
• Its pharmacokinetic data (large volume of distribution and high percentage of protein binding) explain the very small passage to milk observed in four different cases (Zhao 2020, Muysson 2019, Saito 2019, Wiesen 2016). https://www.e-lactancia.org/breastfeeding/rivaroxaban/product/
• See also Potential treatment option of rivaroxaban for breastfeeding women: A case series 2024. https://www.sciencedirect.com/science/article/abs/pii/S0049384824001166
• This is one of the preferred choice DOACs. Milk levels are low. Although rivaroxaban has a high oral bioavailability, very low levels are expected in milk due to its other pharmacokinetic properties, so infant exposure should still be minimal. https://www.sps.nhs.uk/articles/using-oral-anticoagulants-during-breastfeeding/

Dabigatran (Pradaxa ®) compatible with breastfeeding

• There are no studies on the transfer of dabigatran to breast milk. The molecular weight is large (628 Daltons) and the oral bioavailability is low (6.5%); therefore, clinically relevant levels are not expected to occur in a breastfed infant. (Hale).
• In adults, less than 7% of dabigatran is absorbed orally in its prodrug form of dabigatran etexilate mesylate; dabigatran itself is not absorbed orally. Preliminary data from 2 individuals indicate that dabigatran is poorly excreted into breastmilk and unlikely to affect the breastfed infant. If the mother requires dabigatran, it is not a reason to discontinue breastfeeding. Because data are limited, monitor preterm or newborn infants for signs of bleeding. (Lactmed https://www.ncbi.nlm.nih.gov/books/NBK500744/
• Its low oral bioavailability (EMA 2018, Blech 2008) hinders transfer to infant plasma via breastmilk, except in premature infants and the immediate neonatal period when there may be increased intestinal permeability.It is the oral anticoagulant with the lowest excretion in breast milk (Daei 2021). https://www.e-lactancia.org/breastfeeding/dabigatran-etexilate/product/
• This is one of the preferred choice DOACs. Milk levels are likely to be low. Dabigatran etexilate is one of the largest of the DOAC molecules and has a large volume of distribution, therefore it would be expected to pass into breast milk in low amounts. Milk levels were tested from two breastfeeding women who took dabigatran etexilate 220mg as a single dose. The relative infant dose was calculated to be between 0.01 and 0.07%. The infants did not receive any breast milk during this time. Infant absorption is likely to be low. Dabigatran etexilate also has very low oral bioavailability, so the infant is unlikely to absorb clinically significant amounts from the breast milk. It is therefore very unlikely that the infant would get any side-effects.https://www.sps.nhs.uk/articles/using-oral-anticoagulants-during-breastfeeding/

Apixaban(Eliquis®) and Edoxaban (Lixiana®) due to limited research should not be prescribed during breastfeeding.

More breastfeeding mums seem to have taken up running again or for the first time. We have all needed to take exercise in this strange world the past few years.

This is the information on glucosamine and chondroitin during breastfeeding – enjoy your running. Yes it is safe in breastfeeding :

https://kellymom.com/bf/can-i-breastfeed/lifestyle/mom-exercise/

Glucosamine

Glucosamine is either derived from shellfish or synthetically produced. The shellfish derived product should be avoided by anyone with a shellfish allergy.

It is most commonly used to treat osteoarthritis and joint pain or to prevent joint damage. A glucosamine derivative, N-acetylglucosamine, is a normal component of human breastmilk. Glucosamine occasionally causes stomach discomfort in adults  but is generally well tolerated. There are no studies on levels in breastmilk but it is poorly absorbed and metabolised in the liver so levels absorbed by the breastfed baby are likely to be very low.

Chondroitin

Chondroitin is a  mixture of large glycosaminoglycans and disaccharide polymers, usually derived from shark or bovine cartilage. It is most commonly used to treat osteoarthritis because it acts as a flexible connecting material between the protein filaments in cartilage.

Chondroitin is poorly absorbed orally with a bioavailability of about 10%. Its molecular weight averages 50,000 Daltons so is unlikely to be absorbed by breastfed babies at all.

 It is well tolerated in mothers with occasional gastrointestinal upset reported. Although no studies exist on the use of chondroitin sulphate supplements during breastfeeding, small amounts occur naturally in breastmilk. Mothers of preterm infants excrete greater amounts of chondroitin into breastmilk than mothers of fullterm infants.The use of chondroitin by a nursing mother is unlikely to adversely affect the breastfed infant.

References

Coppa GV, Gabrielli O, Zampini L et al. Glycosaminoglycan content in term and preterm milk during the first month of lactation. Neonatology. 2011;101:74-76. https://pubmed.ncbi.nlm.nih.gov/21934331/

Hale TW Medications and Mothers Milk

LactMed https://www.ncbi.nlm.nih.gov/books/NBK501922/

Collagen seems to be another frequent supplement I get asked about . Collagen is found in connective tissue and can be used during exercise routines but also in the prevention and treatment of wrinkles as well as to strengthen hair I believe.

There are no studies on passage into breastmilk and it would therefore be unethical for me to comment.

Elactancia however, designates it as very low risk:

“A fibrous-protein type which is a component of the mammalian connective tissue forming the attachment fibers of all tissues in the organism (bone, cartilage, tendons, skin, muscles, etc.). It represents one-third of total body’s protein content and is composed by amino acids.

Collagen has a great variety of medical, surgical, nutritional and industrial uses such as grafts, sutures, hemostatic products, subcutaneous implants and fillers, pill and capsule covering, glue and cement manufacturing, parts of musical instrument, cosmetic gels, food, photographic and pharmaceutical industry.

Collagen, because of its fibrous nature, is very difficult to chew and digest. To be used as a food it needs to be boiled and treated with various chemicals that break down the bonds and convert it into the so-called hydrolyzed, denatured collagen or gelatin, which is marketed as powder or tablets for various medicinal or health uses like arthritis, joint pains, weight loosing, anti-aging, strengthening of the hair or nails, improvement of the physical fitness and so on, all of them without any serious scientific basis that would guarantee effectiveness.^{(MedlinePlus Supplements 2015, Revenga 2015, EFSA 2013, EFSA 2011)}

Since the last update we have not found any published data on its excretion in breast milk.

Because of a protein nature it is digested by the gastrointestinal tract and absorbed itself as a form of amino acids as those of any other meat. This prevents both the passage to breast milk as a hypothetical plasma absorption by the nursing infant.

Collagen as a supplement is not necessary at all whenever a healthy and balanced diet is followed. https://juanrevenga.com/2015/09/diga-colage-no-o-la-tonteria-de-los-suplementos-de-este-tipo/”

As a new mum I remember how hard I found it holding my babies whilst they had their immunisations and hearing them cry. I always breastfed them as soon as I could to comfort them. I recalled a paper which mentioned using sucrose to relieve the pain during painful procedures. I recall it being in the BMJ but have it may not have been but may have been Abad (1996).

No one ever suggested that I could breastfeed during the immunisation because my babies were born back in the 1980s when breastfeeding was far from the norm after 6 weeks.

However, this paper has looked data from 10 trials, with results for 1,066 babies, mostly between one and six months old, following their normal immunisation schedule. They found that babies who were breastfed before and during routine childhood immunisations cried on average for 38 seconds less and had lower pain scores compared to babies not breastfed. Thirty-eight seconds may not sound a lot but to a mum witnessing her baby’s distress it definitely matters.

The authors noted “There is good evidence that breastfeeding during blood tests reduces pain in new-born babies (up to 28 days old), but the evidence was unclear for older babies. There were no evidence reviews looking at whether breastfeeding might help during painful procedures in babies aged one month to one year” which made me sad. It suggests that we still don’t consider breastfeeding is the norm and is about so much more than nutrition.

They mention that The good practice in postoperative and procedural pain management guideline from the Association of Paediatric Anaesthetists of Great Britain and Ireland, published in 2012, recommends that breastfeeding (along with swaddling, pacifiers, and sugar) should be considered for babies being vaccinated.

None of the included studies reported any adverse effects such as choking, gagging, spitting or coughing. No studies reported on the acceptability of breastfeeding, from the mothers’ or healthcare professionals’ perspective. The studies didn’t report on the practicalities of breastfeeding in the immunisation clinics but surely this isnt impossible to arrange?

So next time your baby needs an immunisation or you as a professional need to immunise a baby maybe this is something to think about?

References

Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. Sucrose for analgesia in new-born infants undergoing painful procedures. Cochrane Database Syst Rev. 2016 Jul 16;7(7):CD001069. doi: 10.1002/14651858.CD001069.pub5. PMID: 27420164; PMCID: PMC6457867. https://pubmed.ncbi.nlm.nih.gov/27420164/

Abad F, Díaz NM, Domenech E, Robayna M, Rico J. Oral sweet solution reduces pain-related behaviour in preterm infants. Acta Paediatr. 1996 Jul;85(7):854-8. doi: 10.1111/j.1651-2227.1996.tb14167.x. PMID: 8819554.

The good practice in postoperative and procedural pain management guideline from the Association of Paediatric Anaesthetists of Great Britain and Ireland

https://www.apagbi.org.uk/news/considerations-acute-and-chronic-pain-management-children-paediatric-anaesthesia-tutorial

Harrison D, Reszel J, Bueno M, et al. Breastfeeding for procedural pain in infants beyond the neonatal period. Cochrane Database Syst Rev. 2016;10:CD011248.

NHR Evidence Breastfeeding reduces crying during baby immunisation https://evidence.nihr.ac.uk/alert/breastfeeding-reduces-crying-during-baby-immunisation/