Betahistine (Serc ) is prescribed for dizzines and vestibular problems. There is little research available on it, because it isnt marketed in USA where most of the research studies are conducted. Anecdotally it is quite widely used without apparent problems. Observe the nursing baby for signs of drowsiness/ poor feeding in case
This is the entry I made for Breastfeeding and Medication 2018
“Betahistine is prescribed for vertigo, tinnitus and hearing loss associated with Ménière’s disease. There is no data on the amount that passes into breastmilk . It is an analogue of histamine and is believed to work by improving the microcirculationn of the labarynth. Side effects are reported to include gastro-intestinal disturbances, headache, pruritus and rashes. Prochlorperazine or cinnarazine would be the preferred to drug to treat dizziness. If betahistine use is perceived as essential the baby should be observed for drowsiness, GI disturbance and rash. There are no animal studies on use during lactation. Plasma levels of betahistine are very low. Plasma protein binding <5% (manufacturer SPC) Anecdotally it has been used without problems in breastfed babies “
Botox injections are used for many medical purposes including migraine, anal fissures. The amount of botox getting into milk is low based on the research on one mother who caught botulism from eating fermented salmon eggs. She continued to breastfeed. No botulinum toxin or botulism was found in the breastmilk or the baby. The doses that are used medically are far lower than that which would have caused the mother’s botulism so the amount in breastmilk is assumed to be too low to produce adverse effects.
Hale also comments that when Botox is injected into the muscle, it produces a partial chemical denervation resulting in paralysis of the muscle. When injected properly, and directly into the muscle, the toxin does not enter the systemic circulation. Thus levels in maternal plasma, and milk are very unlikely. Waiting a few hours for dissipation of any toxin would all but eliminate any risk to the infant. Also, avoid use of generic or unknown sources of botulinum toxin, as some are known to produce significant plasma levels in humans. (Hale TW Medications and Mothers Milk online version accessed May 2020)
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.
In August 2022 the summary of product characteristics for Infliximab was changed to state that live vaccines should not be administered to the babies of mothers on Infliximab in pregnacy or breastfeeding, before 12 months of age. https://breastfeeding-and-medication.co.uk/wp-content/uploads/2022/10/Infliximab-exposure-in-pregnancy-and-breastfeeding-Aug-2022-update.pdf
The Torento consensus statement recommended 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.”
- 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
- Public Health England. Immunisation against infectious disease. Contraindications and Special Considerations. Chapter 6.
- Nguyen GC, Seow CH, Maxwell C, Huang V, Leung Y, Jones J, Leontiadis GI, Tse F, Mahadevan U, van der Woude CJ The Toronto Consensus Statements for the Management of IBD in Pregnancy. Gastroenterology. 2016;150:734-57
- Julsgaard M, Christensen LA, Gibson PR, Gearry RB, Fallingborg J, Hvas CL, Bibby BM, Uldbjerg N, Connell WR, Rosella O, Grosen A, Brown SJ, Kjeldsen J, Wildt S, Svenningsen L, Sparrow MP, Walsh A, Connor SJ, Radford-Smith G, Lawrance IC, Andrews JM, Ellard K, Bell SJ. Concentrations of Adalimumab and Infliximab in Mothers and Newborns, and Effects on Infection. Gastroenterology. 2016 Jul;151(1):110-9. doi: 10.1053/j.gastro.2016.04.002. Epub 2016 Apr 8. PMID: 27063728.
- Fritzsche J, Pilch A, Mury D, Schaefer C, Weber-Schoendorfer C. Infliximab and adalimumab use during breastfeeding. J Clin Gastroenterol. 2012 Sep;46(8):718-9. doi: 10.1097/MCG.0b013e31825f2807. PMID: 22858514.
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.
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)
- 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.
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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.
- 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/
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 email@example.com uk.
If it is useful there are 2 books you might find valuable.