I have recently written an article for ELACTA on a subject that causes so many problems. Just this week I received this question ” I have a 30 week prem baby, I didnt want to braestfeed so they gave me a single dose of cabergoline and the baby is having donor breastmilk. I’ve changed my mind and I would love to feed her. Can I give her the milk I have expressed today?” It is such a difficult question as we have so little data on the passage of cabergoline into braestmilk, the baby is very premature so has poor kidney and liver function and expressing to get a full supply is going to be a long hard journey. On the day of delivering such a tiny precious bundle, it is so hard to take in the implications of taking the drug

ELACTA is a European Journal for European Lactation Consultants. “Lactation & Breastfeeding” is also available in the UK as an electronic version for €8 per issue ( 4 annual editions) if you are not a member of ELACTA. Single Issues (elacta-magazine.eu)

PDF of the article can be downloaded

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/01/Pharmacological-methods-of-weaning-versus-conservative-weaning.pdf

There are several different reasons why a mother may wish to wean her baby from the breast if we accept that weaning for the purpose of this article means as the  cessation of breastfeeding rather than introduction of appropriate complimentary solid foods:

• Physiological natural weaning because the mother has decided that the time is right for them and their baby to stop breastfeeding and there is a natural reduction of milk supply.
• Unintentional weaning which may include ongoing supplementation or as a side effect of medication
• The prescription of medication to reduce lactation in the puerperium such as following a stillbirth or neonatal death, a baby to be adopted or where the mother has chosen not to breastfeed
• To rapidly cease lactation at a later period because of a medical diagnosis e.g., a diagnosis of cancer,  or more rarely because of initiation of a medication which is incompatible with breastfeeding initiation of long-term methotrexate or lithium
• The use of supplementary or complimentary products to reduce lactation which may include perceived over-supply
• To discourage an older nursling who is reluctant to stop breastfeeding
• To stop lactation following a stillbirth or baby loss

Physiological weaning

For the majority of women weaning from the breast occurs gradually over a period usually after the introduction of appropriate complimentary solid foods  (). As such under the influence of the Feedback Inhibitor of Lactation (FIL) supply diminishes slowly and without symptoms or discomfort or need for medication. As the baby breastfeeds less the feedback inhibitor lowers the production of milk.

Unintentional weaning

However, some 80% of lactations in the UK ceased before the baby was 6 months old and before the mother had planned to stop, usually because of lack of support and perceived low milk supply (McAndrew et al., 2012)  In this case usually breastmilk feeds have been replaced by formula milk feeds so that breastmilk supply has gradually reduced and ceased altogether. This sadly can happen because a mother has misunderstood the way that milk supply is stimulated or that a short-term feeding plan involving top ups of formula milk or replacement of breastfeeds has been continued longer than may have been anticipated by the professionals. Not reaching the goals of breastfeeding  been shown to be associated with feelings of loss and grief (Brown,2019) ⁽.

Suppression of lactation in the puerperium when mother has chosen not to breastfeed

Some mothers of course choose not to breastfeed from birth because of personal wishes or ill health of mother or baby. In the past many of them were prescribed medication to dry up their milk. Oladapo& Fawole ⁾  conducted a review of 46 controlled trials that randomised a total of 5164 mothers to receive the treatment under investigation, no treatment or another treatment (Oladapo & Fawole, 2019). The trials were generally of limited quality, and most were conducted among healthy women who chose not to breastfeed for personal reasons at hospitals in industrialized countries before 1980. Half of the trials involved bromocriptine which is no longer recommended for routine suppression of lactation and has indeed been withdrawn in USA by the FDA due to numerous maternal deaths.

Adoption

In the past many women whose babies were to be placed for adoption were offered medication to suppress lactation presumably to diminish the grief of the separation. In some cases, where limited contact with the baby is being maintained under supervision, mothers may choose to provide some breastmilk which can either be given as expressed breastmilk by the carer or directly by the mother feeding during contact. Anecdotally there have been reports to social services (personal communications to the author) where foster mothers have reported concerns that following maternal breastfeeds the baby appeared to have loose bowel motions and that the mother may be passing unacceptable substances via breastmilk. This exemplifies a misunderstanding of the difference between the bowel motions of breast and formula milk fed babies. There appears to be little research on the subject suggesting that long term expression is rare for babies given up for fostering and adoption. Whilst breastfeeding a baby who is to be adopted seems to be more common (Gribble 2006)

Stillbirth or neonatal death

For some mothers the choice to donate their breastmilk, following loss of their baby is a comfort and seen as a tribute to the baby’s memory (Jones, 2018)  .

“When I gave birth to my stillborn daughter, I was given a dry up shot without them even mentioning donating to milk banks as an option. I would have LOVED donating my milk. ”

“It’s funny, no one told me about milk donation. I don’t know how I knew about it. I learned when I was planning the C-section, I knew donor milk was an option, but didn’t know who donated it, never suspected I would become one who would be a milk donor.”

The side effects of cabergoline, used to stop lactation are not insignificant and it can precipitate depression, already a high risk after baby death in the puerperium.

Some mothers (personal communication to the author) were encouraged to not express their milk after sick, pre-term birth “just in case” their baby didn’t survive. In each of the cases, although limited in number, the mothers expressed regret that they felt that they had been excluded from caring for their baby.

Unintentionally lowering of milk supply due to medication

Drugs known to lower milk production as a side effect of use as medication are the combined contraceptive pill and the decongestant pseudoephedrine. Use to deliberately lower supply is not supported by research and effects vary with individuals. There have been no clinical trials on use for this purpose. Side effects of the drugs may be to raise the blood pressure of the mother and cause restlessness and irritability in the baby.

In one study of eight mothers (Aljazaf et al., 2003) a single dose of 60 mg pseudoephedrine was found to reduce the breastmilk supply by 24%. The reduction appeared to be more pronounced in those with later stage lactation defined as more than 60 weeks. The authors proposed that this may be due to a reduction in the production of prolactin although the reduction did not reach statistical significance with this small study population. Theoretically the reduction is also possible with the more frequently used phenylephrine although this hasn’t been reported in studies (Hale & Krutsch 2022, ) .

Dr Jack Newman has reported that bromocriptine and cabergoline are prescribed to overcome the symptoms of engorgement and mastitis sometimes on a routine basis (Newman, 2014)  without the mother being aware of the potential effect on her long-term chances of successful breastfeeding.

Early post-partum use of the combined oral contraceptive pill has been shown to decrease milk supply in some women due to the oestrogenic activity. However, the reduction seen is not consistent and seems to vary from woman to woman. The studies available are very dated and evidence relies on anecdotal reporting by mothers and lactation specialists.

Other non-prescribed products used to reduce lactation

The herb sage has been reported to lower milk supply although without clinical research. In 2014 Eglash  stated that “Sage is the most common herb used to reduce milk supply. Sage tea or extract made from the leaves is typically recommended, although there are no studies on the use of sage for hypergalactia and very few on its effect on the nursing baby. Sage tea may be prepared by steeping 1–3 g of dried sage leaves in a cup of hot water. The mother should be advised to just use one dose of the extract or 1 cup of tea and to observe the effect on her supply, as well as any behavioural change in the baby, over the next several hours. If she does not notice a difference in supply in 8–12 hours, then she can try another, stronger dose. Once she sees a response, she should just use it as needed. Often women will use one dose every 12 hours for 3 days to keep their supply down. Sage is known to have several side effects in high doses, including nausea, vomiting, and dizziness. It can induce wheezing, lower the blood sugar, and induce seizures, so high doses should be avoided in asthmatics, diabetics, and people prone to seizures. It is considered safe when used as a food.

In a 1998 Shrivastavet al  studied  the use of topical application of jasmine flowers was compared to bromocriptine to suppress lactation immediately after birth⁽. They reported that “The efficacy of jasmine flowers applied to the breasts to suppress puerperal lactation was compared to that of Bromocriptine. Effectiveness of both regimens was monitored by serum prolactin levels, clinical evaluation of the degree of breast engorgement and milk production and the analgesic intake. While both bromocriptine and jasmine flowers brought about a significant reduction in serum prolactin, the decrease was significantly greater with bromocriptine. However, clinical parameters such as breast engorgement, milk production and analgesic intake showed the two modes of therapy to be equally effective. The failure rates of the two regimens to suppress lactation were similar; however, rebound lactation occurred in a small proportion of women treated with bromocriptine. Jasmine flowers seem to be an effective and inexpensive method of suppressing puerperal lactation and can be used as an alternative in situations where cost and nonavailability restrict the use of bromocriptine.”

KellyMom reports that other herbs can be used to decrease supply but no evidence from research is supplied to support the statement. The herbs include Peppermint, Spearmint, Parsley, Chickweed, Black Walnut, stinging nettles, Yarrow, Herb Robert Lemon Balm, Oregano, Periwinkle Herb, Sorrel (KellyMom, 2018).

Normal consumption of the herbs as foodstuffs or drinking peppermint tea would not be likely to decrease supply.

Medication to reduce lactation

Bromocriptine

In 2015, the French pharmacovigilance program( Bernard) published a review of the adverse events associated with bromocriptine use to cease lactation. This group reported 105 serious adverse reactions including cardiovascular (70.5%), neurological (14.4%) and psychiatric (8.6%) events. There were also two fatalities: one 32-year-old female had a myocardial infarction with an arrhythmia, and a 21-year-old female had an ischemic stroke. (Hale & Kutsch 2022)⁽⁸⁾

Cabergoline

If a dopamine-receptor agonist is required to suppress lactation, cabergoline is preferred at a dose one mg, to be taken as a single dose on the first day postpartum. For the suppression of established lactation, a dose of 0.25mg is taken every 12 hours for two days for a total of 1mg (BNF 2022). However, this drug also has significant side effects, including headache, dizziness, fatigue or insomnia, orthostatic hypotension, oedema, nosebleed, dry mouth, inhibition of lactation, nausea, constipation, anorexia and weakness.

The manufacturer’s summary of product characteristics (Electronics Medicines Compendium SPC) ⁽ states that:

“As with other ergot derivatives, cabergoline should not be used in women with pregnancy-induced hypertension, for example, preeclampsia or post-partum hypertension, unless the potential benefit is judged to outweigh the possible risk.

Serious adverse events including hypertension, myocardial infarction, seizures, stroke or psychiatric disorders have been reported in postpartum women treated with cabergoline for inhibition of lactation. In some patients the development of seizures or stroke was preceded by severe headache and/or transient visual disturbances. Blood pressure should be carefully monitored after the treatment. If hypertension, suggestive chest pain, severe, progressive, or unremitting headache (with or without visual disturbances), or evidence of central nervous system toxicity develop, cabergoline should be discontinued and the patient should be evaluated promptly.

In post-partum studies with cabergoline, blood pressure decreases were mostly asymptomatic and were frequently observed on a single occasion 2 to 4 days after treatment. Since decreases in blood pressure are frequently noted during the puerperium, independently of drug therapy, it is likely that many of the observed decreases in blood pressure after cabergoline administration were not drug-induced. However, periodic monitoring of blood pressure, particularly during the first few days after cabergoline administration, is advised”.

Cabergoline can also cause depression. They should be avoided if the mother has experienced pre-eclampsia. Both drugs can produce sudden onset sleep or excessive daytime drowsiness and driving should be avoided.

Although bromocriptine and cabergoline are licensed to suppress lactation, they are not recommended for routine suppression when women have decided not to breastfeed, or for the relief of symptoms of postpartum pain and engorgement that can be adequately treated with simple analgesics and breast support. Should the mother decide that she wants to continue to breastfeed after taking cabergoline caution is recommended as there are no studies on the effects on babies of the dose used to suppress lactation (Hale and Krutsh 2022). Elactancia suggests that “No untoward effects have been reported in breastfed infants of mothers who were treated (or erroneously had received medication) and decided to resume breastfeeding” whilst recommending waiting 3-7 half lives. The half life of cabergoline is 63-69 hours.

Weaning the reluctant nursling

Social media posts often have posts from mothers who are experiencing aversion to breastfeeding, sometimes around the time of menstruation, or because their babies are “nipple twiddling”. They report that they are desperate to stop breastfeeding whilst their nursling remains bonded and even reliant on breastfeeding. Discussions that they have felt unable to convince their little ones that milk has dried up are undermined when the nursling latches on and finds there is milk. They often question whether taking a medication to suppress lactation would be an option as a strategy of last resort!

“So, unless I can come up with a better plan, I need to dry my milk up. I bedshare with my 23-month-old (no other options), am a solo parent, and night nurse all night long (her choice, not mine). I planned to keep breastfeeding for as long as she wanted but I can’t nurse her at night anymore. I have no clue how to night wean her because I’m literally lying next to her all night long. So, I figured the easiest thing to do would be to dry my milk up with drug. “

Conclusion

In an ideal world it is better to allow the breastmilk supply to dwindle slowly, by dropping one feed at a time or expressing/feeding only when the breasts become uncomfortably full. It may however be necessary to speed up this process up, but it is still important to avoid blocked ducts and mastitis. It is possible to treat the breasts as in the early days of engorgement, using simple analgesics and cold savoy cabbage leaves in a firm but well-fitting bra. Or the mother can express just enough milk to remain comfortable, frequently changing breast pads, which may become soaked as milk leaks from the breasts. Restricting the fluids which the mother is drinking will not help the milk to dry up; nor will the use of laxatives to remove water from the body.

Whose choice should it be?

The choice should ultimately be that of the lactating mother having been provided with full information about the side effects of the drug, alternative methods of reducing supply and that this should be a final decision. So many times, mothers say that they have taken cabergoline but regret the decision and wish to return to breastfeeding, for example that formula isn’t suiting their baby. As with so many aspects of parenthood it isn’t always as easy a professionals might suggest.

References

• Aljazaf K, Hale TW, Ilett KF, et al. (2003) Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin Pharmacol. 56(1):18-24  
• Bernard N, Jantzem H, Pecriaux C, et al. Severe adverse effects of bromocriptine in lactation inhibition: a pharmacovigilance survey. BJOG. 2015;122:1244-1251.
• Brown A, Why Breastfeeding Grief and Trauma Matter Pinter and Martin 2019
• Dr Jack Newman Facebook social media https://www.facebook.com/DrJackNewman/posts/the-use-of-cabergoline-dostinex-and-bromocriptine-parlodel-in-breastfeeding-wome/311003792384007/
• Eglash A.  (2014)Treatment of maternal hypergalactia. Breastfeed Med. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216483/pdf/bfm.2014.0133.pdf
• Elactancia online database https://www.halesmeds.com/monographs/60947?q=cabergoline
• Electronics Medicines Compendium SPC  bromocriptine https://www.medicines.org.uk/emc/product/1202
• Cabergoline https://www.medicines.org.uk/emc/product/1691/smpc (accessed December 2022)
• Gribble, K.D.  (2006) Mental health, attachment and breastfeeding: implications for adopted children and their mothers. Int Breastfeed J 1: 5
• Hale TW and Krutsch K Medications and Mothers Milk online access December 2022).
• Joint Formulary Committee. (2022). British national formulary. Accessed  December 2022, fromhttps://www.medicinescomplete.com/#/browse/bnf
• Jones W Breastfeeding and Medication website lowering or stopping breastmilk supply https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-lowering-stopping-milk-supply
• KellyMom Herbs that may decrease milk supply https://kellymom.com/bf/got-milk/herbs_to_avoid/ Accessed December 2022
• McAndrew F, Thompson J, Fellows L, Large A, Speed M, Renfrew MJ (2012) Infant Feeding Survey 2010, Health and Social Care Information Centre
• Oladapo, O.T.; Fawole, B. (2009) Treatments for suppression of lactation. Cochrane Database of Systematic Reviews
• Shrivastav P, George K, Balasubramaniam N, Jasper MP, Thomas M, Kanagasabhapathy AS. Suppression of puerperal lactation using jasmine flowers (Jasminum sambac). Aust N Z J Obstet Gynaecol. 1988 Feb;28(1):68-71

There have always been so many questions from mothers and professionals about the treatment of depression during breastfeeding. So many times mothers are TOLD to stop breastfeeding without discussion about what they want. We know that not reaching breastfeeding goals can increase the risk of depression. This factsheet is intended to dispel some of the myths about antidepressants taken whilst a mother is breastfeeding. As always I am happy to answer individual questions and provide more information.

See also https://www.sps.nhs.uk/articles/using-duloxetine-mirtazapine-trazodone-or-venlafaxine-during-breastfeeding

BNF https://bnf.nice.org.uk/drugs/sertraline/#breast-feeding

“Specialist sources indicate that sertraline and paroxetine are the SSRIs of choice in breast-feeding based on passage into milk, half-life, and published evidence of safety. However, all SSRIs can be used in breast-feeding with caution, and since there are risks with switching an SSRI, it may be more clinically appropriate to continue treatment with an SSRI that has been effective, or restart treatment with an SSRI that has previously been effective. With all SSRIs, infants should be monitored for drowsiness, poor feeding, adequate weight gain, gastro-intestinal disturbances, irritability, and restlessness.”

Factsheet is available as a pdf :

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/01/depression-and-breastfeeding-.pdf

Depression is said to affect up to 20% of women in the perinatal period. Incidence is higher where they have had symptoms prior to pregnancy particularly if they stopped medication when planning a pregnancy fearing that they may harm their unborn baby.

Information on pregnancy can be found below the breastfeeding data.

Choice of antidepressant in breastfeeding

Whichever drug a mother has taken during or prior to pregnancy is the best choice for her, knowing that it is effective and free from troublesome adverse effects for her. Individuals react differently to medication.

If the prescription is newly prescribed post-partum it is reasonable to choose sertraline because of the pharmacokinetics of the drug which restrict passage into breastmilk. For more information see  https://breastfeeding-and-medication.co.uk/fact-sheet/sertraline-and-breastfeeding

Citalopram is also widely used during breastfeeding. Its half-life is slightly longer but does not seem to affect babies in doses < 40mg/day. There is one case of restless sleep in a baby exposed to 40mg citalopram which resolved when the dose was reduced. For more information see https://breastfeeding-and-medication.co.uk/fact-sheet/citalopram-and-breastfeeding

Paroxetine is often advocated as equally suitable as sertraline because of its shorter half-life and other pharmacokinetic properties. The difficulty with this drug is that when trying to stop there can be persistent discontinuation syndrome. It can be useful for individuals. Half-life 21 hours, Plasma protein binding 95%, Relative Infant Dose 1.2%-2.8%.

Fluoxetine is often regarded as contra-indicated in breastfeeding because of its greater transfer into breastmilk. It can also produce side effects in the baby as it withdraws from placental transfer. This can exhibit as jitteriness or excessive drowsiness but resolves in a few days. For more information see https://breastfeeding-and-medication.co.uk/fact-sheet/fluoxetine-and-breastfeeding

Monitoring of the baby exposed to SSRI through breastmilk.

Most babies do not react to the levels of SSRI in breastmilk although there are reports that mothers taking these medications may need additional support to establish breastfeeding. It is sensible to observe for growth and drowsiness but to observe these initially as breastfeeding issues needing support from a breastfeeding expert rather than an adverse effect of the medication.

SSRI medications do not cause drowsiness and there is no risk in co-sleeping according to evidence-based guidelines https://www.basisonline.org.uk/about-us/. Taking of SSRIs at night on the assumption that this precedes the longest sleep period may result in poor sleep and is ineffective due to the half lives of these drugs. For more information see https://breastfeeding-and-medication.co.uk/fact-sheet/timing-of-breastfeeds-if-taking-medication

Other antidepressants

Venlafaxine (Efexor™) is an SRNI– Infants receive venlafaxine and its active metabolite in breastmilk, and the metabolite of the drug can be found in the plasma of most breastfed infants; however, concurrent side effects have rarely been reported ( https://www.ncbi.nlm.nih.gov/books/NBK501192/). Various studies failed to show short or long-term side-effects among infants whose mothers were on Venlafaxine, both on physical or psychomotor development ( https://www.e-lactancia.org/breastfeeding/venlafaxine-hydrochloride/product/)

Plasma protein binding 27%, Oral bioavailability 45%, relative infant dose 6.8%-8.1%.

The dose transferred to the infant is relatively high although no adverse reports have been reported.   As the drug is associated with discontinuation syndrome it would be difficult for the mother to stop abruptly.  In neonates, monitoring for excessive sedation and lower than expected weight gain is advisable.

Duloxetine (Cymalta ™) is an SNRI- Little published information is available on the use of duloxetine during breastfeeding; however, the dose in milk is low and serum levels were low in two breastfed ( https://www.ncbi.nlm.nih.gov/books/NBK501470/). Because there is less experience published than with other antidepressants of the same pharmacological group, it should be preferred the use of an alternative drug that is known to be safer in the neonatal period or prematurity. However, it is excreted into breast milk in clinically non-significant amount with no side-effects being observed in breastfed infants from treated mothers ( https://www.e-lactancia.org/breastfeeding/duloxetine/product/)

Plasma protein binding >90%, Oral bioavailability >70%, relative infant dose 0.12%-1.12%.

Mirtazapine (Zispin™) – Mirtazapine maybe initiated if other antidepressants have proved ineffective or not been tolerated. It may also be invaluable when poor sleep and loss of appetite is the major symptom of depression.  Limited information indicates that maternal doses of up to 120 mg daily produce low levels in milk and would not be expected to cause any adverse effects in breastfed infants, especially if the infant is older than 2 months ( https://www.ncbi.nlm.nih.gov/books/NBK501188/). Mirtazapine produces fewer symptoms of sexual dysfunction that have been reported in SSRIs. It can initially cause drowsiness and abnormal dreams. Care should be taken with co sleeping as natural reactions will be lessened. In a study of 8 babies whose mothers were taking up to 120mg at night. Levels of mirtazapine were only identified at a low level in one baby and were undetectable after 12 hours.

It is excreted into breast milk in a clinically non-significant amount (https://www.e-lactancia.org/breastfeeding/mirtazapine/product/)

Plasma protein binding 85%, Oral bioavailability 50%, relative infant dose 1.6% – 6.3%%.

Tricyclic antidepressants are more rarely used due to their side effect profile. Care should be taken with co sleeping as they may cause drowsiness but also urine retention, constipation and dry mouth.

Amitriptyline Plasma protein binding 94.8%, Oral bioavailability 100%, relative infant dose 1.08%-2.8%

Clomipramine Plasma protein binding 96%, Oral bioavailability 100%, relative infant dose 2.8%

Imipramine Plasma protein binding 90%, Oral bioavailability 90%, relative infant dose 0.1%-4.4%

Lofepramine BNF : The amount secreted into breast milk is too small to be harmful.

Some mothers prefer to use herbal remedies, many of which we do not have research on. One option available is St Johns Wort. For more information see

https://breastfeeding-and-medication.co.uk/fact-sheet/st-johns-wort-and-breastfeeding

What do women want healthcare professional to know about the needs of the perinatal mum with mental health challenges?

I asked the mothers who follow my Facebook Page Breastfeeding and Medication what message they wanted to pass on to professionals who see them when they have mental health challenges. I have included their responses here  as I believe that their comments should be borne in mind by all who see mothers with depression and anxiety. https://breastfeeding-and-medication.co.uk/fact-sheet/what-do-women-want-healthcare-professional-to-know-about-the-needs-of-the-perinatal-mum-with-mental-health-challenges

Pregnancy

I’m not going to include recommendations on the use of antidepressants in pregnancy but to point to the expert sites:

• https://www.medicinesinpregnancy.org/Medicine–pregnancy/
• https://www.nice.org.uk/guidance/qs115
• https://cks.nice.org.uk/topics/depression-antenatal-postnatal/management/postnatal-new-episode/#prescribing-an-antidepressant-in-the-postnatal-period
• Dubovicky M, Belovicova K, Csatlosova K, Bogi E. Risks of using SSRI / SNRI antidepressants during pregnancy and lactation. Interdiscip Toxicol. 2017 Sep;10(1):30-34. doi: 10.1515/intox-2017-0004. PMID: 30123033; PMCID: PMC6096863. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6096863/
• Sharifi F, Nouraei S, Shahverdi E. The Relation of Pre and Postnatal Depression and Anxiety with Exclusive Breastfeeding. Electron Physician. 2016 Nov 25;8(11):3234-3239. doi: 10.19082/3234. PMID: 28070257; PMCID: PMC5217816. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5217816/
• RCGP Perinatal Mental Health Toolkiit https://www.rcgp.org.uk/representing-you/policy-areas/perinatal-mental-health

However, I will point out that many women continue to take medication throughout pregnancy to maintain their mental health during what can be a very stressful period.

Labour

SSRI drugs ( sertraline, citalopram, fluoxetine and paroxetine) re known to increase bleeding risks due to their effect on platelet function. Data from observational studies suggest that the use of SSRI/SNRI antidepressants during the month before delivery may result in a small increased risk of postpartum haemorrhage. This is something which midwives and the delivery team will be observant for during and after delivery.

• https://www.gov.uk/drug-safety-update/ssri-slash-snri-antidepressant-medicines-small-increased-risk-of-postpartum-haemorrhage-when-used-in-the-month-before-delivery#:~:text=SSRIs%20and%20SNRIs%20are%20known,increased%20risk%20of%20postpartum%20haemorrhage.
• Palmsten K, Hernández-Díaz S, Huybrechts K F, Williams P L, Michels K B, Achtyes E D et al. Use of antidepressants near delivery and risk of postpartum hemorrhage: cohort study of low income women in the United States BMJ 2013; 347 :f4877 doi:10.1136/bmj.f4877 https://www.bmj.com/content/347/bmj.f4877

Gestational diabetes

Gestational diabetes is often associated with weight gain which occurs in some women who take anti-depressants but is most associated with venlafaxine(SNRI) and amitriptyline (tri-cyclic). Studies have often compared pregnant women on medication with healthy women without treatment. Depression in pregnancy itself can lead to insulin resistance. Nevertheless, as with routine antenatal monitoring a high BMI should be investigated for Gestational Diabetes.

• Lupattelli A, Barone-Adesi F, Nordeng H.  Association between antidepressant use in pregnancy and gestational diabetes mellitus: Results from the Norwegian Mother, Father and Child Cohort Study.  Pharmacoepidemiol Drug Saf. 2021 Nov 24.
• Wartko PD, Weiss NS, Enquobahrie DA, Chan KCG, Stephenson-Famy A, Mueller BA, Dublin S. Antidepressant continuation in pregnancy and risk of gestational diabetes. Pharmacoepidemiol Drug Saf. 2019 Sep;28(9):1194-1203. doi: 10.1002/pds.4799. Epub 2019 Jul 12. PMID: 31298445; PMCID: PMC6728166. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6728166/
• Antidepressants linked to heightened pregnancy related diabetes risk BMJOpen https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2018-025908

Pulmonary hypertension of the new-born

“Rarely, SSRI use in pregnancy can cause a problem in the baby, where blood flow to the lungs is too high. This is called persistent pulmonary hypertension of the new-born (PPHN). Around one in every 300 babies whose mother takes an SSRI may develop PPHN” (BUMPS https://www.medicinesinpregnancy.org/Medicine–pregnancy/Sertraline/)

• Kieler H, Artama M, Engeland A, Ericsson /span>, Furu K, Gissler M et al. Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the new-born: population based cohort study from the five Nordic countries BMJ 2012; 344 :d8012 doi:10.1136/bmj.d8012 https://www.bmj.com/content/344/bmj.d8012#:~:text=Exposure%20to%20SSRIs%20in%20late,confidence%20interval%201.5%20to%203.0).
• Ng QX, Venkatanarayanan N, Ho CYX, Sim WS, Lim DY, Yeo WS. Selective Serotonin Reuptake Inhibitors and Persistent Pulmonary Hypertension of the Newborn: An Update Meta-Analysis. J Womens Health (Larchmt). 2019 Mar;28(3):331-338. doi: 10.1089/jwh.2018.7319. Epub 2018 Nov 8. PMID: 30407100. https://pubmed.ncbi.nlm.nih.gov/30407100/
• Bérard A, Sheehy O, Zhao JP, Vinet É, Bernatsky S, Abrahamowicz M. SSRI and SNRI use during pregnancy and the risk of persistent pulmonary hypertension of the newborn. Br J Clin Pharmacol. 2017 May;83(5):1126-1133. doi: 10.1111/bcp.13194. Epub 2017 Jan 18. PMID: 27874994; PMCID: PMC5401975. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5401975/

Autism after exposure in pregnancy

“Some studies have suggested that up to three out of every 100 children born to women taking an SSRI may develop autism spectrum disorder (ASD). In comparison, around one in every 100 children in the background population is diagnosed with ASD. Other studies have found no links between SSRI exposure and ASD.” (BUMPS https://www.medicinesinpregnancy.org/Medicine–pregnancy/Sertraline/)

• Morales, D.R., Slattery, J., Evans, S. et al. Antidepressant use during pregnancy and risk of autism spectrum disorder and attention deficit hyperactivity disorder: systematic review of observational studies and methodological considerations. BMC Med 16, 6 (2018). https://doi.org/10.1186/s12916-017-0993-3 https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0993-3#Sec6
• Rai D, Lee B K, Dalman C, Newschaffer C, Lewis G, Magnusson C et al. Antidepressants during pregnancy and autism in offspring: population based cohort study BMJ 2017; 358 :j2811 doi:10.1136/bmj.j2811 https://www.bmj.com/content/358/bmj.j2811
• Morales DR, Slattery J, Evans S, Kurz X. Antidepressant use during pregnancy and risk of autism spectrum disorder and attention deficit hyperactivity disorder: systematic review of observational studies and methodological considerations. BMC Med. 2018 Jan 15;16(1):6. doi: 10.1186/s12916-017-0993-3. PMID: 29332605; PMCID: PMC5767968. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5767968/
• Maloney  SE, Rogers CE, Constantino JN Antidepressants, Pregnancy, and Autism: Setting the Record(s) Straight Published Online:1 Jun 2020https://doi.org/10.1176/appi.ajp.2020.20040418 https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2020.20040418

Neonatal withdrawal

Some withdrawal from placental transfer occurs with the longer acting SSRIs (particularly fluoxetine) and the SNRI quetiapine. The resolves within a few days without treatment in most cases. The mother may be supported to initiate hand expression to stimulate her supply and to feed the expressed milk to the baby if it is too drowsy to feed effectively. It does not mean that commercial formula needs to be substituted for breastmilk.

It has been suggested that up to 40% of children get threadworms at some stage. The whole family needs to be treated, even the breastfeeding mother. The joys of being a mum!

Factsheet pdf available here:

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/01/threadworms-and-breastfeeding-.pdf

Symptoms of threadworms

Threadworms are very common in toddlers and primary school age children who can sadly infect the rest of the family. They are not a sign of poor hygiene. The exact prevalence is not known but it has been estimated that up to 40% of children in the UK will have threadworm infestation at some time in their lives. The symptoms are:

• Intense itching around the anus, typically worse during the night.
• Some people may not experience itching but  small white thread-like worms (which may be slowly moving) are seen on the perianal skin or in the stools.
• In females, there may be itching around the vulva/vagina.
• Night-time itching may lead to disturbed sleep and irritability.

Treatment

Everyone in the household needs to be treated with mebendazole ( available over the counter as Ovex™ or on prescription as Vermox™. Mebendazole can be given at a dose of 100mg to everyone over the age of 6 months. Mebendazole kills the worms but not the eggs which can survive for up to 2 weeks. If reinfection occurs, second dose may be needed after 2 weeks.

Prevention of re-infection

https://www.nhs.uk/conditions/threadworms/

• wash hands and scrub under fingernails – particularly before eating, after using the toilet or changing nappies
• encourage children to wash hands regularly particularly under nails
• bathe or shower every morning
• rinse toothbrushes before using them
• keep fingernails short
• wash sleepwear, sheets, towels and soft toys (at a hot temperature)
• disinfect kitchen and bathroom surfaces (particularly the area behind the toilet as eggs may spread if the child scratches
• vacuum and dust with a damp cloth
• make sure children wear underwear at night – change it in the morning
• change toys such as Playdough which can get behind fingernails and become infected with eggs if the child has scratched and not washed hands

Eggs can pass to other people when they touch contaminated surfaces and then touch their mouth. They take around 2 weeks to hatch.

Threadworms in pregnancy

https://www.medicinesinpregnancy.org/Medicine–pregnancy/Mebendazole/

Babies under 6 months

Treat with hygiene measures only and watch for signs when changing nappies

Treating Babies 6 months to 2 years

Unlicensed so may need to be prescribed https://bnf.nice.org.uk/drugs/mebendazole/

Threadworms when breastfeeding

Oral bio availability poor 2-10%, Highly plasma protein bound, Relative Infant Dose 0.06%.

It is unlikely that mebendazole is  transmitted to the infant in clinically relevant concentrations and breastfeeding can continue as normal even if the nursling is also receiving a dose.

Other sources of information

A-Z NHS Conditions

https://www.nhs.uk/conditions/threadworms/

Elactancia https://www.e-lactancia.org/breastfeeding/mebendazole/product/

BNF Mebendazole  https://bnf.nice.org.uk/drugs/mebendazole/ “Amount present in milk too small to be harmful but manufacturer advises avoid”

McCormick, A., Fleming, D. and Charlton, J. (1995) Morbidity statistics from general practice. Fourth national study 1991-1992. Office of Population Censuses and Surveys. http://www.statistics.gov.uk

CKS Threadworm https://cks.nice.org.uk/topics/threadworm/

Eczema is hard to deal with: the constant itching, soreness, appearance is tough. Breastfeeding can help to prevent eczema but is not a total preventative as my daughter keeps telling me!

Wang J, Ramette A, Jurca M, Goutaki M, Beardsmore CS, Kuehni CE. Association between breastfeeding and eczema during childhood and adolescence: A cohort study. PLoS One. 2017 Sep 25;12(9):e0185066.

Lodge, C., Tan, D., Lau, M., Dai, X., Tham, R., Lowe, A., Bowatte, G., Allen, K. and Dharmage, S. (2015), Breastfeeding and asthma and allergies: a systematic review and meta-analysis. Acta Paediatr, 104: 38-53. 

Hicks SD, Beheshti R, Chandran D, Warren K, Confair A. Infant consumption of microRNA miR-375 in human milk lipids is associated with protection from atopy. Am J Clin Nutr. 2022 Dec 19;116(6):1654-1662.

Factsheet pdf is available :

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/01/eczema-and-breastfeeding.pdf

The information is taking from Breastfeeding and Chronic Medical Conditions (available on Amazon)

“I was attending dermatology weekly for months with a new-born. Full body bandage clothing with nipple holes cut out so that my topical treatments would not affect my son. I actually think they did very slightly. He ended up getting a few facial spots at weeks old that have never gone away, he is almost 4. I had to weight up a lot of risk/benefits My condition is reasonably under control, but it has taken 31 years to get here.“

“I have had chronic severe eczema since I was a baby. About a few months after having my son, I had a flare up on my breasts that would not go away no matter what I tried. It made breastfeeding so uncomfortable. Imagine having the itchiest rash imaginable and then nursing a baby on that wound. I battled with being raw, skin being so dry that it cracked around my nipples etc. I fought through it. It made it really hard to nurse when we were in public or around other people because people stare, and my poor breasts were bright red and inflamed constantly. Breastfeeding was my number one goal of early motherhood and I was not going to let pain get in the way. We are happily nursing still at 18 months postpartum.“

Description

Eczema often develops for the first time during the first year of life even with exclusive breastfeeding. About 2 in 3 children with atopic eczema grow out of it by their mid-teens. The skin becomes itchy, dry, and sore. It may also lead to cracking of the skin. It most often appears in the folds of the elbows and knees but also on the face, back and scalp. It often runs in families and may precede other atopic conditions such as asthma. There is no cure, but treatment can usually control or ease symptoms. Approximately one in 30 adults has eczema.

Some breastfeeding mothers find that they are allergic so some brands of breast pads or find that their breasts have more eczema than normal. Using an extra rinse cycle can help with modern washing machines which use less water.

Treatment: Emollients and topical steroids are compatible with breastfeeding. If applying to the breast apply after feeds and rub well in so that baby does not rub the product into eyes.

Emollient, moisturising creams: everyone reacts differently to emollients and it may be necessary to try several brands to find the one that helps. Lotions, creams, gels, ointments, and sprays are available. Some can be used as soap substitutes.

Topical steroids used to reduce itching and dryness in an area which has flared. Application of too much or too frequently may thin the skin and produce damage.

Identification of triggers can be useful – common ones include laundry conditioner, animal fur, shower products or soaps

Trying not to scratch will reduce severity but can be VERY difficult. Avoiding bath/showers in too hot water helps some people.

Oral antihistamines may be useful. The non- sedating ones are preferred in breastfeeding.

Tacrolimus  and Pimecrolimus

In severe eczema, which is unresponsive to topical steroids, topical tacrolimus ointment and pimecrolimus cream may be used. While the absolute transcutaneous bioavailability of tacrolimus is unknown, it is apparently very low. Combined with the poor oral bioavailability of this product, it is not likely a breastfed infant will receive enough following topical use (maternal) to produce adverse effects. No data are available on pimecrolimus transfer to human milk, but because the maternal plasma levels are so low, it is extremely remote that this agent would penetrate milk in clinically relevant amounts. (Hale)

References

Hale TW Medications and Mothers Milk online access

Further information

National Eczema Association https://nationaleczema.org/eczema/

British skin foundation https://www.britishskinfoundation.org.uk/eczema

Mammograms dont come into the routine screening for most mothers who are breastfeeding but may sometimes be recommended for those with a family history or where there is a breast lump which needs to be investigated. Usually ultrasounds are preferred as they are easier to interpret but I this question came up on the Facebook page.

The pdf can be found here:

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/01/mammograms-and-breastfeeding-.pdf

A mammogram is an X ray and breastfeeding  as normal can be resumed immediately after the procedure. If a lump is found on the mammogram and further investigation is necessary  you can feed as normal after fine needle aspiration. The local anaesthetic does not get absorbed from breastmilk. Some clinicians have been concerned that the proximity of the injection of local to the milk ducts affects the absorption, but it cannot affect the pharmacokinetics of the drug which remains poorly orally bioavailable and with a short half-life.

During  breastfeeding breast tissue is denser than usual and can make the results of the mammogram harder to interpret and may need to be seen by an expert to interpret the results. The density is also affected by the frequency of breastfeeding and the stage of lactation.

During the procedure the breasts are squeezed between 2 metal plates to “flatten” them as much as possible. This may of course result in leakage of milk so feeding just before the mammogram or expressing milk as much as possible may help. The leakage should not be a source of embarrassment to either the patient or technician.

Some breast experts recommend an ultrasound  or MRI which can be easier to interpret.

The 2023 guidelines from the NHS  https://www.gov.uk/government/publications/breast-screening-higher-risk-women-surveillance-protocols/protocols-for-surveillance-of-women-at-higher-risk-of-developing-breast-cancer#screening-women-in-pregnancy-and-lactation state:

“Screening with mammography can be safely performed during pregnancy but as mammographic density increases during pregnancy and lactation, its effectiveness is reduced. Women can be screened during lactation but are advised to breastfeed or express milk prior to the examination. Shielding is not considered necessary due to the low radiation dose of mammography.”

Needle biopsy

There appears to be a concern from some clinicians that a needle biopsy may result in a milk fistula. The risk of milk fistula, which is chronic milk leakage, is very rare. There is no research on the incidence of milk fistulas with biopsies, but it is  reported to be rare.

Other sources of information

La Leche League Lumps and Mammograms

https://www.llli.org/breastfeeding-info/lumps-and-mammograms/#:~:text=X%2Drays%20do%20not%20affect,a%20biopsy%20or%20other%20surgery.

NHS breast screening: Helping you decide https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/440798/nhsbsp.pdf

This document can be downloaded as a pdf here

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/01/liraglutide-and-bf-.pdf

Liraglutide binds to, and activates, the GLP-1 (glucagon-like peptide-1) receptor to increase insulin secretion, suppress glucagon secretion, and slow gastric emptying.

Saxenda™  is given as an adjunct in weight management [in conjunction with dietary measures and increased physical activity in individuals with a body mass index (BMI) of 30 kg/m2 or more, or in individuals with a BMI of 27 kg/m2 or more in the presence of at least one weight-related co-morbidity] by self-administered subcutaneous injection (BNF).

Victoza™ is given for Type 2 diabetes mellitus as monotherapy (if metformin inappropriate or not tolerated), or in combination with other antidiabetic drugs, (including insulin) if existing treatment fails to achieve adequate glycaemic control (BNF).

Compatibility with breastfeeding

• It is currently not known if liraglutide is excreted in human milk.  The molecular weight of this medication means that it would have great difficulty entering breast milk. It is described as having zero oral bioavailability which is why it is given subcutaneously as a drug. In consequence very little of this medication would be absorbed by the infant orally even  if found in breast milk. The risk of this in a breastfed infant would be expected to be very low (Hale and Krutsch).
• The manufacturer advises it is avoided in lactation due to lack of studies so its use in a lactating mother would be outside of the product licence. However, animal studies suggest that transfer into milk is low, but excretion into human milk not known (a tertiary source confirms lack of information in human lactation, but also states that risk to infants appears to be negligible. Blood glucose monitoring of the infant should be considered) (BNF)
• No information is available on the excretion of liraglutide int milk or its clinical use during breastfeeding. Because liraglutide is a large peptide molecule with a molecular weight of 3751 daltons, the amount in milk is likely to be very low and absorption is unlikely because it is probably destroyed in the infant’s gastrointestinal tract. Until more data become available, liraglutide should be used with caution during breastfeeding, especially while nursing a new-born or preterm infant. (https://www.ncbi.nlm.nih.gov/books/NBK500977/)
• Elactancia cites liraglutide as of very low risk in lactation ( https://www.e-lactancia.org/breastfeeding/liraglutide/product/). Due to its protein nature, it deteriorates in the gastrointestinal tract, not being absorbed. Its pharmacokinetic data (high molecular weight and high percentage of plasma protein binding) make it very unlikely that significant amounts will pass into breast milk except in preterm infants and in the immediate neonatal period when there may be increased permeability.

Common or very common side effects

Appetite decreased; asthenia; burping; constipation; diarrhoea; dizziness; dry mouth; gallbladder disorders; gastrointestinal discomfort; gastrointestinal disorders; headache; increased risk of infection; insomnia; nausea; skin reactions; taste altered; toothache; vomiting (BNF).

Monitoring of nursling for side effects

Although adverse effects have not been noted the baby should be monitored for Vomiting, diarrhoea and signs of hypoglycaemia- drowsiness, lethargy, pallor, sweating, tremor (Hale and Krutsch)

Can my GP prescribe Saxenda™  in the UK for weight loss?

Saxenda™ is approved for use within the NHS in the UK. However, your GP or family doctor is unlikely to be able to prescribe it to you and it is usually only available but only through a specialist weight management service or privately.

References

Drugs and Lactation Database (LactMed) https://www.ncbi.nlm.nih.gov/books/NBK501922/

Hale TW and Krutsch K Hale’s Medications & Mothers’ Milk™ 2023: A Manual of Lactational Pharmacology (online access HalesMeds.com January 2023)

Joint Formulary Committee (2022) British National Formulary. [Online]. London: British Medical Association and  Royal Pharmaceutical Society of Great Britain. Available at: Medicines Complete Database, [Accessed January 2023].

 Elactancia Is it compatible with breastfeeding? https://www.e-lactancia.org/