Having had the pleasure of presenting this on Matflix it has made me think a lot about the impact of entenox for midwives, for mothers and the environment.
You can access the matflix hour here
These are the slides I used
When I was working as an independent pharmacist prescriber my main role was to look at primary prevention of cardio vascular disease – identifying factors which raised the risk of people to have a heart attack or stroke in the next 10 years. I used an online calculator using various data like BMI, smoking status, blood pressure and cholesterol ( https://qrisk.org/three/). I didnt see many breastfeeding patients and we concentrated on the over 50s. But in the process I learned a lot about managing weight and encouraging a healthy diet and portion size, smoking cessation and control of cholesterol. In many cases we managed to reduce the risk with lifetyle changes.
It seems that mothers may now have their cholesterol measure and advised that it is too high. I had 20 -30 minute appoitments to encourage lifestyle change. This isnt possible for GPs with pressures on appointments so often the mothers are offered medication to reduce cholesterol. Until recently the only drug compatible with breastfeeding was cholestryamine. This is fine if there isnt a history of familial hypercholesterolaemia and a much higher risk of a cardio vascular event.
A colleague pointed me to some data on elactancia which had a very different list of references and information on cholesterol in standard artificial formula. Thus began a journey to this factsheet over the past couple of months. It isnt a recommendation, as there are currently no studies on the use of statins during breastfeeding nor the effect on the baby . However, it looks at an evidence base which can prompt discussion with clinicians. I hope it helps.
My thanks to Sam Morris and Amanda Da Costa for their knowledge and support as pharmacists and breastfeeding helpers on the BfN Drugs in Breastmilk Information Service
See also SPS information April 2023
Breastfeeding mothers may take mebendazole and continue to breastfeed as normal
Threadworms, also known as pinworms, are tiny parasitic worms that infect the large intestine of humans. Threadworms are a common type of worm infection in the UK, particularly in children under the age of 10. European estimates have suggested that 20 to 30% of pre-school and primary-school-aged children will have threadworm infestation. The worms are white and look like small pieces of thread.
Threadworms spread easily within childcare settings when children scratch their bottoms causing the eggs which have come out of the anus, to collect underneath fingernails. They can then be transferred into the mouth or substances like PlayDough! I know it is a yucky thought bit part of toddler life!
How threadworms spread
Threadworms spread when their eggs are swallowed. They lay eggs around the bottom (anus), which make it itchy. The eggs get stuck on fingers when scratching. They can then pass on to anything touched, including:
- kitchen or bathroom surfaces
Eggs can pass to other people when they touch these surfaces and then touch their mouth. They take around 2 weeks to hatch.
Once ingested, larvae emerge from the eggs and mature within 1–2 months into adults in the small intestine. The mature adult female worm migrates through the anus and lays thousands of eggs on the peri-anal skin (typically at night) causing itching. Adult threadworms survive for about 6 weeks and infection is maintained by swallowing fresh eggs.
Complications caused by threadworm include:
- Lack of sleep (due to itching) with subsequent daytime irritability and difficulty in concentrating.
- Weight loss or loss of appetite.
- Breakdown and soreness of the skin around the back passage
- In adults, 100 mg mebendazole (Ovex ™ or Vermox ™) for 1 dose. If reinfection occurs, a second dose may be needed after 2 weeks.
- In children, aged 6 months to 17 years, 100 mg for 1 dose, if reinfection occurs, a second dose may be needed after 2 weeks.
- Amount present in milk too small to be harmful but manufacturer advises avoid (BNF).
- Oral bioavailability 2-10%, highly plasma protein bound, half life 2.8-9 hours Considering the poor oral absorption and high protein binding, it is unlikely that mebendazole would be transmitted to the infant in clinically relevant concentrations (Hale Medications and Mothers Milk accessed April 2023)
- Mebendazole is poorly excreted into breastmilk and poorly absorbed orally. Reports on the use of mebendazole during breastfeeding have found no adverse reactions in breastfed infants. (LactMed https://www.ncbi.nlm.nih.gov/books/NBK501340/ accessed April 2023)
- Based on a low oral bioavailability, concentration in the infant’s plasma should be nil or low, except in premature and newborn infants with a increased intestinal absorption capacity. (Elactancia https://www.e-lactancia.org/breastfeeding/mebendazole/product/ accessed April 2023)
Breastfeeding mothers may take the mebendazole and continue to breastfeed as normal
Things to do to stop re-infection
- wash hands and scrub under fingernails – particularly before eating, after using the toilet or changing nappies
- encourage children to wash hands regularly
- 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
- vacuum and dust with a damp cloth
- make sure children wear underwear at night – change it in the morning
Head lice are a common problem with older children. Scratching the head is normally the first sign but eggs may be seen behind the ears and nape of the neck. The breastfeeding mother may need to apply preparations to her children and usually herself. Head lice are spread by head-to-head contact common between all mums and children as well as siblings and friends, not forgetting grandparents. Headlice are not a sign of poor hygiene and in fact they prefer clean hair.
Medicated lotions should not be used unless live lice are detected after 17 days regular combing.
Prevention is best achieved by regular combing with a fine-toothed comb. For further information see https://www.nhs.uk/conditions/head-lice-and-nits/ and https://www.chc.org/for-parents-2/ for a video.
Head lice may be mechanically removed by meticulous combing of wet, well-conditioned hair with a fine-toothed detection comb. Combing needs to be undertaken for at least 30 minutes at four-day intervals for a minimum of two weeks. Conditioner facilitates combing particularly of long hair. If there are still live headlice then suitable chemical treatment should be used.
Treatments with lotions or liquids are preferable to shampoos which are diluted below an effective therapeutic concentration. Aqueous solutions are recommended for children with eczema or asthma. Rotation of treatments is no longer recommended. A mosaic approach is considered advisable however, whereby the child or adult is treated with a different chemical at each infestation or if a treatment fails.
Absorption of the products through the skin for sufficient quantities to pass into breastmilk is unlikely although the patient information leaflet in the box may suggest otherwise. If a breastfeeding mother has to treat several children’s heads it may be sensible to use gloves to protect her hands and to ensure the room is well ventilated.
There are a variety of products available to treat head lice E.g., Vamousse™, Lyclear™, Full Marks™, Hedrin™
Treatments not recommended as evidence suggests that they are ineffective (https://www.nhs.uk/conditions/head-lice-and-nits/) :
- products containing permethrin
- head lice “repellents”
- electric combs for head lice
- tree and plant oil treatments, such as tea tree oil, eucalyptus oil and lavender oil herbal remedies
As with most professionals, my own included, dentistry seems to lack education on breastfeeding as part of undergraduate training if questions sent to this page exemplify a wider issue. I have tried to provide information for CPD inline with that written for other healthcare professionals.
I have developed this powerpoint presentation on the pharmacokinetics of drugs which dentists may use or prescribe for CPD information in an effort to break down the barriers of continuation of breastfeeding.
I am happy to answer individual questions or training. Please contact firstname.lastname@example.org
- Breastfeeding mothers can have local anaesthetic injections with/without adrenaline and continue to breastfeed as normal
- Breastfeeding mothers can take analgesics for dental pain and continue to breastfeed as normal
- Breastfeeding mothers can have antibiotics and continue to breastfeed as normal
- Breastfeeding mothers can use mouthwashes, gels and liquids for mouth ulcers ( e.g. Anbesol®, Bonjela®, Medijel®, Rinstead®, Iglu®, Orajel®) and fluoride toothpastes e.g. Durophat® and continue to breastfeed as normal
- Breastfeeding mothers can have dental sedation for procedures and continue to breastfeed as normal.
- White fillings: In some parts of the UK white fillings are recommended in pregnancy and lactation following an EU Directive (July 2018) but have to be paid for by the patient rather than being part of free NHS treatment. The information states that “These restrictions on the use of dental amalgam aim to help reduce environmental mercury pollution and are not a result of any safety concerns about amalgam fillings for dental patients.”
- Tooth Whitening: There appears to be no information available on the use of tooth whitening agents during lactation. Whilst it is unlikely that any significant transfer of the agents used into breastmilk will take place, if it can be delayed until breastfeeding has finished naturally, that would be preferable but there are many questions from mothers about to get married who dont want to wait. Unless the products spill from the bath in which the liquid is placed, resulting in burns to the mother’s mouth absorption into breastmilk is unlikely.
In a report Public Health England have made recommendations on dental health and breastfeeding. Full information can be accessed at : www.gov.uk/government/publications/breastfeeding-and-dental-health/breastfeeding-and-dental-health#breastfeeding-and-dental-health
- dental teams should continue to support and encourage mothers to breastfeed
- not being breastfed is associated with an increased risk of infectious morbidity (for example gastroenteritis, respiratory infections, middle-ear infections)
- breastfeeding up to 12 months of age is associated with a decreased risk of tooth decay
- breast milk is the only food or drink babies need for around the first 6 months of their life, first formula milk is the only suitable alternative to breast milk
- bottle-fed babies should be introduced to drinking from a free-flow cup from the age of 6 months and bottle feeding should be discouraged from 12 months old
- only breast or formula milk or cooled, boiled water should be given in bottles
- only milk or water should be drunk between meals and adding sugar to foods or drinks should be avoided
Recent systematic reviews such as that by Tham and others (2015)6 included studies where children were breastfed beyond 12 months. When infants are no longer exclusively breast or formula fed, confounding factors, such as the consumption of potentially cariogenic drinks and foods and tooth brushing practices (with fluoride toothpaste), need to be taken into account when investigating the impact of infant feeding practices on caries development. Tham and others (2015) noted that several of the studies did not consider these factors and concluded that with regard to associations between breastfeeding over 12 months and dental caries “further research with careful control of pertinent confounding factors is needed to elucidate this issue and better inform infant feeding guidelines”. Good quality evidence on breastfeeding and oral health is an area with significant methodological challenges which have been outlined by Peres and others (2018)7.
Of course I would also have to highlight that dental procedures, including sedation, local and general anaesthetic and use of antibiotics and analgesics need not interrupt breastfeeding