Having nursed my husband post-op this week the topic of laxatives is at the fore front of my mind particularly after opioid analgesics! But also very relevant post birth particularly after a c section or instrumental delivery

What is constipation:

It’s likely to be constipation if:

• you have not had a poo at least 3 times during the last week
• the poo is often large and dry, hard or lumpy
• you are straining or in pain when you have a poo
• You may also have a stomach ache and feel bloated or sick.

The most common causes of constipation include:

• not eating enough fibre, ( fruits, vegetables and cereals)
• not drinking enough fluids
• not moving enough and spending long periods sitting or lying down
• being less active and not exercising
• often ignoring the urge to go to the toilet
• changing your diet or daily routine
• a side effect of medicine especially opioid painkillers
• stress, anxiety or depression

Constipation is also common during pregnancy and for 6 weeks after giving birth.

Even if you decide you need medication you do need to make changes to your diet and toilet habits which can be particularly challenging with a new baby who needs you 24 hours a day and under whom you may be stuck feeding or sleeping when you need “ to go”.

Management of constipation

• In the management of short-duration constipation (where dietary measures have proved ineffective) start with a bulk-forming laxative, ensuring adequate fluid intake. Eg, ispaghula husk (Fybogel ™).
• If stools remain hard, add or switch to an osmotic laxative. Osmotic laxatives increase the amount of water in the large bowel, either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with. Eg Lactulose, Macrogols(Movicol™)
• Stool softeners act by decreasing surface tension and increasing penetration of intestinal fluid into the faecal mass Eg docusate (DulcoEase™)
• If stools are soft but difficult to pass or you feel inadequate emptying, a stimulant laxative should be added. Eg Senna (Sennokot™), Bisacodyl (Dulcolax™)
• Glycerol suppositories act as a lubricant and as a rectal stimulant by virtue of the mildly irritant action of glycerol.

Laxatives and breastfeeding

• Bulk forming laxatives just add to the bulk of faeces and are not absorbed into the body
• Osmotic laxatives just increase the volume of water in the faeces and are not absorbed into the body or breastmilk. Anecdotally some babies do develop loose bowel motions but there seems to be no reason for this.
• Stool softeners are poorly orally bioavailable. There are no studies on passage into breastmilk but it is believed to be minimal and should not affect the baby. (Hale 2023)
• Senna : In one dated uncontrolled study of 23 women who received Senokot (100 mg containing 8.602 mg of sennosides A and B), no sennoside A or B was detectable in their milk.[ Werthmann MW Jr, Krees SV. Quantitative excretion of Senokot in human breast milk. Med Ann Dist Columbia. 1973;42:4–5.] Of 15 mothers reporting loose stools, two infants had loose stools. Several controlled studies using modern senna products found no effect on the infant (LactMed 2023). Senna should only be used short term to treat constipation
• Bisacodyl: Bisacodyl is not absorbed from the gastrointestinal tract, and its active metabolite, which is absorbed, is not detectable in breastmilk. Bisacodyl can be taken during breastfeeding and no special precautions are required. (LactMed 2023). It’s oral bioavailability is less than 5% (Hale 2023)

See also https://www.sps.nhs.uk/articles/using-laxatives-during-breastfeeding

SPS Using laxatives and breastfeeding

Bristol Stool Chart

Type 1: Separate hard lumps (hard to pass)

Type 2: Lumpy, hard, sausage-shaped.

Type 3: Sausage-shaped with cracks on the surface.

Type 4: Sausage-shaped or snake-like; smooth and soft.

Type 5: Soft blobs with clear-cut edges (easy to pass)

Type 6: Fluffy pieces with ragged edges; mushy.

Many women who are breastfeeding will be offered flu vaccine, and maybe also covid boosters, shortly as the NHS expect yet another difficult season ahead.

You can have both flu and covid-19 vaccines when breastfeeding as the molecules are too large to pass into breastmilk. Your nursling will however receive antibodies, which you make to the vaccine, which will help to protect them as well.

There are now numerous studies on the compatibility of the vaccines in breastfeeding which I have linked to on my facebook pages over the months.

MHRA Guidance Sept 2022 https://www.gov.uk/government/publications/covid-19-vaccination-women-of-childbearing-age-currently-pregnant-planning-a-pregnancy-or-breastfeeding/covid-19-vaccination-a-guide-for-women-of-childbearing-age-pregnant-planning-a-pregnancy-or-breastfeeding#:~:text=Getting%20pregnant,-There%20is%20no&text=There%20is%20no%20evidence%20that,your%20chances%20of%20becoming%20pregnant.

Sources of information used

Flu Vaccines

The Green Book: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1102862/Influenza-green-book-chapter-19-2September22.pdf)

A UK study of co-administration of AstraZeneca and Pfizer BioNTech COVID-19 vaccines with inactivated influenza vaccines confirmed acceptable immunogenicity and reactogenicity (Lazarus et al, 2021). Where co-administration does occur, patients should be informed about the likely timing of potential adverse events relating to each vaccine. If the vaccines are not given together, they can be administered at any interval, although separating the vaccines by a day or 2 will avoid confusion over systemic side effects.

NHS (https://www.nhs.uk/pregnancy/keeping-well/flu-jab/)

It’s safe for women who are breastfeeding to have a flu vaccine if they’re eligible (for example, because of a long-term health condition).

Hale Medications and Mother’s Milk

The influenza vaccine is prepared from inactivated, non-viable influenza viruses and infection of the neonate via milk would not be expected. There are no reported side effects, nor published contraindications for using influenza virus vaccine during lactation.[1,2] Influenza vaccine is now indicated for breastfeeding mothers and their infants by the American Academy of Pediatrics.

LactMed (https://www.ncbi.nlm.nih.gov/books/NBK500990/)

Summary of Use during Lactation: The Centers for Disease Control and Prevention and several health professional organizations state that vaccines given to a nursing mother do not affect the safety of breastfeeding for mothers or infants and that breastfeeding is not a contraindication to either the live, attenuated (i.e., inhaled) or inactivated (i.e., injected) influenza vaccine, including H1N1 (swine) influenza vaccine. Immunization of the mother during pregnancy increases the amount of influenza antibodies and influenza-specific CD8 T cells in breastmilk and may offer added protection of their breastfed infants against influenza.[1-3] Breastmilk antibody responses are higher with the inactivated influenza vaccine than with the live oral vaccine.[4] Breastfed infants should be vaccinated according to the routine recommended schedules

COVID 19 Vaccines

The Green Book: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1102459/Greenbook-chapter-14a-4September22.pdf)

NHS (https://www.nhs.uk/conditions/coronavirus-covid-19/coronavirus-vaccination/pregnancy-breastfeeding-fertility-and-coronavirus-covid-19-vaccination/)

If you’re breastfeeding, It’s safe to get the COVID-19 vaccine if you are breastfeeding. You cannot catch COVID-19 from the vaccines and cannot pass it to your baby through your breast milk.

Hale Medications and Mother’s Milk

With much research now available on COVID-19 vaccines during breastfeeding, there is no evidence of harm to the mother or infant. Offering these vaccines to breastfeeding women is now the universal recommendation by governmental bodies and professional organizations. Compassion and understanding should be shown to moms hesitant to receive the vaccine. Their prime concerns are making the best decision during this vulnerable time and evidence should be provided to assist them in combatting their fears. The risk and benefit of the vaccine should be compared to each mother’s individual risk for getting COVID-19 as well as how well she is expected to tolerate the disease. In general, protection through any FDA authorized COVID-19 vaccination is expected to outweigh the risks associated with the injection.

No COVID-19 vaccines contain live viruses, so none of these vaccines are capable of causing COVID-19 upon administration. Neutralizing antibodies against COVID-19 have been found in the milk of breastfeeding mothers.[1-5] In a survey of 4,455 breastfeeding women, very few notable adverse effects were noted. 98% of respondents reported their vaccination had no impact on lactation. 93% of respondents noticed no impacts on their breastfeeding child. Of the 7% who reported infant adverse events, changes in fussiness or sleep, or diarrhea were the most commonly noted. Mothers also reported impacts on their ability to perform work duties, childcare duties, and household duties, particularly after the second dose.[6] Mothers considering getting these vaccines may consider timing the injection so that they may have additional support as they recover.

LactMed (https://www.ncbi.nlm.nih.gov/books/NBK565969/)

Summary of Use during Lactation: Many studies involving hundreds of women and their infants have been reported in the literature. No evidence suggests that women receiving a vaccine against SARS-CoV-2 is harmful to either the nursing mother or the breastfed infant. Antibodies and T-cells that neutralize the SARS-CoV-2 virus appear in the milk after maternal vaccination.[1-3] Nursing mothers experienced minimal disruption of breastfeeding after vaccination although a few reported to blue or blue-green discoloration of their milk.[4-8] Numerous professional organizations and governmental health authorities recommend that COVID-19 vaccines be offered to those who are breastfeeding because the potential benefits of maternal vaccination during lactation outweigh any theoretical risks.

I think we are all much more aware of the incidence of flu and its complications after the COVID pandemic. The best form of protection (although still not 100%) is flu vaccination which can be undertaken whilst breastfeeding with no risk to the baby. The symptoms of flu usually last for a week. Symptoms develop approximately 4 days after infection. Lateral flow tests should be used to differentiate between flu and covid.

Ways to try to avoid flu

• Wash hands with soap and water regularly
• regularly clean surfaces such as your computer keyboard, telephone and door handles to get rid of germs
• Wash hands before eating or touching face – the virus can be spread from door handles and other surfaces
• Try to avoid crowded venues if possible. Wearing a mask may offer protection

People with flu can spread it to others up to about 6 feet away. Most experts think that flu viruses are spread mainly by droplets made when people with flu cough, sneeze or talk. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. Less often, a person might also get flu by touching a surface or object that has flu virus on it and then touching their own mouth or nose.

Symptoms of flu include a sudden fever – a temperature of 38C or above, aching body, feeling tired or exhausted, dry or less frequently chesty cough, sore throat, headache, difficulty sleeping, loss of appetite, diarrhoea or tummy pain, nausea and being sick. You may feel too weak to get out of bed so need help to care for your baby/children. The symptoms are similar for children, but they can also get pain in their ear and appear less active. ( https://www.nhs.uk/conditions/flu/)

A cold develops more slowly and affects mainly the nose and throat. With ‘flu it is impossible to carry on with life as normal. Imagine if your favourite singer or actor knocked at your front door. If you have flu you wont care!

If you catch flu

•             Take regular paracetamol and ibuprofen

•             Keep drinking fluids

•             Rest as much as possible

•             Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the bin after you use it.

There is usually no reason to consult a doctor if you are normally fit and well, unless the symptoms have persisted for more than 7 days or you have difficulty breathing. Antibiotics do not help the flu virus itself although may be necessary for secondary infections. You are at greater risk of complications if you are pregnant.

People at high risk may be prescribed antiviral medications to help reduce the symptoms of influenza. They must be taken within two days of the start of symptoms to be effective.

• Oseltamivir (Tamiflu ®) – oral medication

Limited data indicate that oseltamivir and its active metabolite are poorly excreted into breastmilk. Maternal dosages of 150 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 (normal dose 75mg daily). Infants over 1 year of age can receive oseltamivir directly in doses much larger than those in breastmilk (Lactmed 2023, Wentges-van HN, van EM, van der Laan JW. Oseltamivir and breastfeeding. Int J Infect Dis. 2008).

• Zanamivir (Relenza ®) – inhaled drug

No information is available on the use of zanamivir during breastfeeding. One group of authors estimated that an exclusively breastfed 5 kg infant would receive about 0.075 mg daily in breastmilk after an inhaled maternal dose of 10 mg, which is less than 1% of the dose in older children. In addition, because zanamivir is poorly absorbed orally, it is not likely to reach the bloodstream of the infant in clinically important amounts. ( LactMed 2023, Tanaka T, Nakajima K, Murashima A et al. Safety of neuraminidase inhibitors against novel influenza A (H1N1) in pregnant and breastfeeding women. CMAJ. 2009;181:55-8

The manufacturer reports that it is present in the milk of rodents although no human data are available. Due to the poor oral or inhaled absorption and the incredibly low plasma levels, it is unlikely to produce untoward effects in breastfed infants (Hale Medications & Mothers Milk 2023)

see also https://breastfeeding-and-medication.co.uk/fact-sheet/coughs-colds-flu-and-covid-when-breastfeeding

Mother and breastfed baby

• The baby should not be separated from the mother unless she is too unwell to care for it. I Her breastmilk contains antibodies against flu which can protect the baby from more serious infection just as we saw with COVID infection.
• Children under the age of 2 years are at greater risk of secondary infections and professional support should be sought. It is important that babies and children are monitored for symptoms of dehydration (dry nappies, sunken fontanel, lethargy).

References

• F.O. Uruakpa, M.A.H. Ismond, E.N.T. Akobundu Colostrum and its benefits: a review. Nutrition Research 22 (2002) 755–767

• https://www.cdc.gov/flu/
• https://www.sps.nhs.uk/articles/using-oseltamivir-and-zanamivir-during-breastfeeding/
• Schlaudecker EP, Steinhoff MC, Omer SB, McNeal MM, Roy E, Arifeen SE, et al. (2013) IgA and Neutralizing Antibodies to Influenza A Virus in Human Milk: A Randomized Trial of Antenatal Influenza Immunization. PLoS ONE 8(8): e70867. http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0070867
• Trend S de Jong E, Lloyd ML, Kok CH, Richmond P, Doherty DA, Simmer K, Kakulas F Strunk T, Currie A.Leukocyte Populations in Human Preterm and Term Breast Milk Identified by Multicolour Flow Cytometry . PLoS One. 2015 A http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0135580
• Trend S, Strunk T, Lloyd ML, Kok CH, Metcalfe J, Geddes DT, Lai CT, Richmond P, Doherty DA, Simmer K, Currie A. Levels of innate immune factors in preterm and term mothers’ breast milk during the 1st month postpartum. Br J Nutr. 2016 Apr 14;115(7):1178-93

With thanks to Dr K.J Klottrup-Rees for her help with the biomedical science aspect of this information

I am so very frustrated for breastfeeding mothers who need colonoscopies and endoscopies being told that they need to interrupt breastfeeding. I was able to engage with the national body to update national guidelines which should be released soon.

Interestingly it is the same old story – we dont see breastfeeding women needing these examinations. So how come I do?

Some 3 years ago I began working with British Society of Gastroenterology on guidelines for sedation in gastrointestinal endoscopy. Much of the review was outside of my experience but I remain an author of the paper “British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy. It was published in BMJ Gut in October 2023. As regards sedation in breastfeeding mothers it recommends:

47. We recommend that breast feeding does not need to be suspended after a single intravenous dose of midazolam, fentanyl or pethidine or when used in combination, or after administration of propofol.

Grade of evidence: Low. Strength of recommendation: Strong.

Level of agreement: 100%

This guideline superceedes the information from 2012 (Shergill et al ASGE)

What are lactating mothers currently advised following procedures?

Many mothers who are lactating are questioning information provided by their gastroenterology team about lactation (18 queries identified in 6 weeks July and August 2020 to the Breastfeeding Network Drugs in Breastmilk service). In each case the mothers had been advised in three different ways:

• To stop breastfeeding during bowel preparation
• That they should stop breastfeeding for 24 hours after sedation for either procedure
• Or that if they were unwilling to stop breastfeeding after sedation that the procedure could only be undertaken with gas and air as analgesia

Whilst it is accepted that not all patients need sedation in order to undertake colonoscopy or endoscopy these women were not offered the choice.

This data has not changed significantly from a study published as a poster at the Baby Friendly Initiative Conference 2016

In that data 19 emails to the Drugs in Breastmilk helpline over a 6-month period February – August 2016 were analysed. All 19 mothers were already diagnosed with Inflammatory Bowel Disease (Ulcerative Colitis or Crohns Disease). Details of the duration advised to interrupt breastfeeding were noted together with comments made by the mothers about their care.

Quotes From Mothers

• My daughter will not take anything from a bottle or cup at the moment
• I am very worried that if I do not feed him for 2 days that my already tenuous supply will dwindle. (Baby 20 weeks)
• Their imaging department have been quite adamant that I cannot breastfeed for at least 24 hours but cannot explain to me why
• I also co-sleep with my baby at night and am concerned to only do this safely, this is currently the only way my baby will sleep at night.
• I am not sure I want to express that much as I do not want to mess with my supply
• The consultant I see is not very sympathetic to me wanting to continue breastfeeding and just told me I need to choose between feeding my baby or being well.
• I will proceed without any pain relief but wondered if there might be an alternative?
• I am worried I should try and cancel the procedure
• It has been suggested maybe I delay it until not breastfeeding, but I want to continue
• I had a colonoscopy today after switching hospital. It was wonderful to be treated with care and respect. I feel so much happier. I would recommend asking your GP for a referral for a different hospital if you are not happy with your care.
• It took us 8 weeks to latch and now at 15 weeks I am not going to go back to pumping all day when it is not essential.
• I know I can breast feed but not keen to starve myself for 24 hours and dehydrate myself. She then said as my little girl has turned one it is probably me feeding her that is caused this.
• Starting to doubt myself as some family members not happy

Summary Of Mother’s Comments

There are recurrent themes of:

• feeling that their breastfeeding is dismissed as unimportant by the specialist team
• concerns about supply or impact on risk of engorgement/mastitis
• Worries about how they will cope on liquid diet only when breastfeeding and caring for a baby
• That the mothers will endure pain and discomfort by coping without pain relief or just with gas and air rather than interrupt breastfeeding
• Concern from other family members about risk to the baby

There is no research to support the belittling of the importance in a breastfeeding an older baby and may represent a need to improve the education of medical professionals to the importance of breastmilk to protect mother and baby (Walters 2019). Indeed, WHO guidance supports the use of breastmilk as part of the diet of a child to 2 years and beyond. There is a link between formula feeding and IBD (Whorwell 1979, Xu 2017)

Midazolam

Matheson (1990) studied 12 women prescribed midazolam orally for sleep in the first 5 days after delivery. In 11 of the mothers the midazolam was undetectable in breastmilk 7 hours after the dose ((<3 mcg/L). However, in the first 5 days after delivery the gaps between cells are wide open to allow passage of immunoglobulins to pass through into milk with ease. This inevitably means that all other medication administered at this time will similarly pass readily into milk. That levels were below the level of detection after 7 hours at this stage supports the hypothesis that the drug does not readily transfer to the baby.

Nitsum (2006) studied 5 women 6-15 weeks post-partum given 2 mg pre- operatively (IV). The researchers estimated that the infants would receive an average of 0.016 mcg/kg in the 24 hours after a single dose of midazolam (0.06% of the maternal weight-adjusted dosage) and that this would be unlikely to affect a healthy, term baby.

Lee (1993), Spigsett (1994) and Nitsum (2006) recommend that after a single dose of midazolam that the mother may resume breastfeeding as soon as she is awake and alert following anaesthesia (LactMed).

Midazolam is extensively plasma-protein bound (97%) and poorly bioavailable (40-50%). (Brown 2019). Half life 3 hours so all removed from the body in 15 hours (5 half-lives).

Fentanyl

In Nitsum (2006) study the 5 the median amount of fentanyl recovered in milk within 24 hours post dose was 0.024 µg or 0.024% of the maternal dose women undergoing surgery and he recommended that mothers could breastfeed as normal thereafter. Oral bio availability 50-75% (Brown 2019).

Meperidine/Pethidine

Meperidine/ Pethidine has historically widely been used in labour. In a neonate the metabolite normeperidine it has a prolonged half-life (63 hours) but after 6 weeks returns to that of the adult (15-30 hours). Borgatta (1997) studied 9 women undergoing surgery for tubal ligation and concluded that a single dose for anaesthesia or conscious sedation usually does not cause problems in older breastfed infants. Meperidine/pethidine is only 50% orally bio-available (Brown 2019).

Propofol

Mitchell et al (2020) minimal amounts (0.025%) of propofol are transferred to breast milk. This is not a concern even when propofol is used by infusion for maintenance of anaesthesia. Breastfeeding may be resumed as soon as the woman has recovered sufficiently from general anaesthesia (Allegaert 2015).

Bowel preparations

Macrogols: the most commonly used laxative agents to clear the gut are Movicol ™and Laxido ™ otherwise known as polyethylene glycol- electrolyte solution. They are saline laxative which are not absorbed from the gut but pull water into the bowel to wash the contents out. Because it is not absorbed from the gut it cannot get into breastmilk and would not affect the baby. They are licensed to be used during breastfeeding

Sodium picosulfate (Picolax ™):  is not absorbed from the gastrointestinal tract, and its active metabolite, which is absorbed, is not detectable in breastmilk. Breastfeeding can continue as normal.

Macrogol 3350 (KleanPrep ™): contains, an osmotic laxative with a high molecular weight and zero oral bioavailability. Like Moviprep it accumulates water into the GI tract, where it acts as a laxative. It would be very unlikely to enter the plasma of the mother, or milk. Senna: is a stimulant laxative. Its key ingredient (anthraquinone), is believed to increase bowel activity due to secretion into the colon. It may produce abdominal cramps. In one study of 23 women who received Senokot none was detectable in their milk.[1] Of 15 mothers reporting loose

stools, two infants had loose stools (Werthmann 1973). However, in a randomized, double-blind trial comparing Senokot tablets to placebo, of the women in the study, 126 breastfed their infants and took senna while 155 control mothers breastfed their infants. There was no difference in the percentages of infants in the active and control groups with loose stools or diarrhoea (Shelton 1980). In this study 8 doses were taken. In bowel preparation a single dose only is used.

Sodium phosphate enema (Fleet™): is a saline laxative which sucks water into the lumen of the bowel. Whilst some phosphate may get into the plasma, it is very unlikely to change the levels in milk. The oral bioavailability is zero to 20%. Use of phosphate enemas should not require interruption of breastfeeding (LactMed)

Bisacodyl (Dulcolax ®): is poorly absorbed from the gut (oral bioavailability <5%) and so reaches low levels in breastmilk. It is a stimulant laxative. Breastfeeding can continue as normal

Conclusion

There is no evidence to support the recommendation to delay breastfeeding after endoscopy or colonoscopy or after bowel cleansing for colonoscopy in a healthy, term infant.

References

• Allegaert K, van den Anker JN. Maternal analgosedation and breastfeeding: guidance for the pediatrician. Journal of Pediatric and Neonatal Individualized Medicine 2015; 4: e040117.
• Borgatta L, Jenny RW, Gruss L, et al. Clinical significance of methohexital, meperidine, and diazepam in breast milk. J Clin Pharmacol. 1997; 37:186–92.
• LactMed National Library of Medicine, Drugs and Lactation Database
• Lee JJ, Rubin AP. Breast feeding and anaesthesia. Anaesthesia. 1993; 48:616–25.
• Matheson I, Lunde PKM, Bredesen JE. Midazolam and nitrazepam in the maternity ward: milk concentrations and clinical effects. Br J Clin Pharmacol. 1990; 30:787–93.
• Mitchell J, Jones W, Winkley E, Kinsella. S.M Guideline on anaesthesia and sedation in breastfeeding women 2020. Guideline from the Association of Anaesthetists. First published: 01 August 2020 https://doi.org/10.1111/anae.15179
• Nitsun M, Szokol JW, Saleh HJ, et al. Pharmacokinetics of midazolam, propofol, and fentanyl transfer to human breast milk. Clin Pharmacol Ther. 2006; 79:549–57. [PubMed]
• Shelton MG. Standardized senna in the management of constipation in the puerperium. A clinical trial. S Afr Med J. 1980; 57:78-80. Brown A and Jones W A guide to supporting breastfeeding for the medical profession Routledge (2019)
• Shergill AK, Ben-Menachem T, Chandrasekhara V, et al. Guidelines for endoscopy in pregnant and lactating women GASTROINTESTINAL ENDOSCOPY 2012;76 (1): 18-24)
• Sidhu R, Turnbull D, Haboubi H, et al British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy Gut Published Online First: 10 October 2023. doi: 10.1136/gutjnl-2023-330396
• SPC Hypnovel https://www.medicines.org.uk/emc/product/10948/smpc
• Spigset O. Anaesthetic agents and excretion in breast milk. Acta Anaesthesiol Scand. 1994; 38:94–103.
• Walters, D, Phan, LTH, & Mathisen, R, (2019). The cost of not breastfeeding global results from a new tool, Health Policy and Planning, doi.org/10.1093/heapol/czz050
• Werthmann MW Jr, Krees SV. Quantitative excretion of Senokot in human breast milk. Med Ann Dist Columbia. 1973; 42:4-5.

Because I am immunocompromised myself, I am all too well aware of the information on protection from COVID 19 including the recommendations launched in December 2021 by the government on sotrovimab (Xevudy) and molnupiravir (Lagevrio) . This may affect some breastfeeding mothers e.g. those with IBD or on biologicals for other reasons . There are no simple answers but this is the information I have been able to find in one place. The factsheet was updated in April 2022 following the licence change by the FDA of sotrovimab, and added data on Evusheld and remdesivir .

In January 2023 the WHO changed guidelines on the preferred therapies and compatability with the drug which they recommend and breastfeeding. This is the information which I have been able to access

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/01/COVID-19-and-CEV-jan-2023.pdf

Update WHO Guidelines January 2023 https://www.who.int/publications/i/item/WHO-2019-nCoV-therapeutics-2023.1

NICE TA 878 March 2023 Casirivimab plus imdevimab, nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19 https://www.nice.org.uk/guidance/ta878

In October 2023 the Specialist Pharmacy Service (SPS) reported that breastfeeding can continue as normal during COVID-19 infection, even if dexamethasone, Paxlovid, sotrovimab or tocilzumab are required. COVID-19 vaccines can also be given. https://www.sps.nhs.uk/articles/managing-covid-19-and-breastfeeding

nirmatrelvir-ritonavir (Paxlovid)

• The GDG concluded that nirmatrelvir-ritonavir represents a superior choice because it may have greater efficacy in preventing hospitalization than the alternatives; has fewer concerns with respect to harms than does molnupiravir; and is easier to administer than intravenous remdesivir and the antibodies.
• Clinicians should review all medications and not consider nirmatrelvir-ritonavir in patients with possible dangerous drug interactions (note: many drugs interact with nirmatrelvir-ritonavir).
• Fully informed shared decision-making should determine whether nirmatrelvir-ritonavir should be used in pregnant or breast-feeding women, given possible benefit and residual uncertainty regarding potential undesirable effects.
• Nirmatrelvir-ritonavir should be administered as soon as possible after onset of symptoms, ideally within 5 days.
• Data on breastfeeding from expert sources is in the link but two case reports in which nirmatrelvir/ritonavir was given to breastfeeding women did not report any adverse effects in their infants.

casirivimab-imdevimab strongly recommended against use

sotrovimab strong recommendation against use because neutralization of currently circulating variants of SARS-CoV-2 and their subvariants with sotrovimab is diminished.

This is one section of the new book on chronic medical conditions and breastfeeding. It is available on Amazon as a kindle or paperback book .

I have updated the information in view of the information shared by Specialist Pharmacy Service October 2023 https://www.sps.nhs.uk/articles/treating-bipolar-disorder-during-breastfeeding/

“I was only diagnosed with bipolar during my first pregnancy so breastfeeding was very much uncertain and a lot of healthcare professionals maybe weren’t so keen but I fed my eldest until he was 13 months when he self-weaned as I was pregnant with my second. I would love to be able to help anyone I can, I am very passionate about breastfeeding and honestly think it has been a real stabilising factor in my mental health!”

“Medication to control the symptoms of bipolar disorder is complicated. If we add in the emotional turmoil that occurs post-delivery and lack of sleep, there may need to be regular review. Mothers have been known to come off their medication in order to breastfeed with dire consequences. We need to provide them with evidence-based information to understand the risks and benefits of the treatment regime. (A professional viewpoint)”

Description

Bipolar disorder is a mental health condition that affects moods. The latter can swing from one extreme of lethargy and depression to a feeling of being high and overactive hence the original name of manic depression.

During bouts of depression it is not uncommon to feel suicidal or worthless and it is important to recognise this and seek a place of safety or a person you trust as quickly as possible. During a manic phase there may be feelings of having lots of energy, ambitious plans and idea. It is not uncommon to spend large amounts of money on expensive, unwanted goods and some people ask their banks to block spending above a certain level to avoid debt. It is also common to not feel like eating or sleeping, to talk quickly and become easily annoyed. For some this phase is a positive experience and a time of creativity so may reject medication. It may also become a psychotic phase where things which do not exist may be seen and heard (voices controlling actions). It is a complex condition which may need adjustments. Around one in every 100 people will be diagnosed with it at some point in their life. It frequently develops between 15 and 19 years of age but rarely after 40. The incidence is the same in men and women. The pattern of mood swings in bipolar disorder varies widely. Some people only have a couple of episodes in their lifetime and are stable in between, while others have many episodes.

Diagnosis is made only after one episode of mania as well as the depression.  In this state the mother may have an elated mood or alternatively she may feel irritable and angry.  She may experience racing thoughts rapidly changing from one area to another.  It may be impossible for her to be still, but the activity may be unproductive.  It is reported to affect a higher proportion of intelligent people with gifted creativity.

Treatment

Anti-depressants: See Section on Depression

mood stabilisers :

carbamazepine: reaches relatively high levels in breastmilk but does not appear to affect growth or development. Sedation, poor feeding, withdrawal reactions and 3 cases of hepatic dysfunction have been reported but maybe due to placental transfer

valproate: If valproate is taken during pregnancy, around 1 in 10 babies are born with birth defects and up to 4 in 10 babies will have developmental problems. It is no longer recommended in pregnancy and has in consequence fallen out of use in breastfeeding. If this is the best suited drug it is compatible with breastfeeding, but the mother should take adequate contraceptive precautions. Valproic acid levels in breastmilk are low and infant serum levels range from undetectable to low. theoretically it is recommended that the baby should be monitored for jaundice and liver damage if clinical symptoms present (Hale online). Valproate can be used during breastfeeding in the management of bipolar disorder (SPS) but with adequate contraceptive methods.

Resources for healthcare professionals and patients https://www.rpharms.com/resources/pharmacy-guides/valproate-and-the-pregnancy-prevention-programme

• Patient card – to be given by pharmacists to all female patients who are dispensed valproate medicines to inform them of the risks
• Patient guide – to be provided to girls (of any age) and women of childbearing potential (or their parent/caregiver/responsible person) taking any medicine containing valproate
• Guide for healthcare professionals – for all prescribers, pharmacists, and other healthcare providers involved in the care of women and girls of childbearing potential using valproate medicines
• Annual risk acknowledgement form – (revised  November 2019) for the specialist and patient (or their parent/caregiver/responsible person) to sign at initiation and at treatment reviews at least every year – the patient should receive a copy of the form; one copy should be filed in the specialist notes, and one copy sent to the patient’s GP.

lamotrigine: Relatively high plasma levels have been reported in breastfed babies. Neonates are particularly susceptible due to their inability to metabolise the drug if the dosage is not reduced to the pre-pregnancy dosage in the immediate post-partum period. Relative infant dose is quoted as 9.2-18.3%. Page-Sharp (2006) studied six breastfeeding women taking a mean dose of 400 mg per day of lamotrigine. Five of the babies were exclusively breastfed and the remaining one fed with half breastmilk and half artificial milk feeds. No adverse events were noted in any of the infants. In general infants should be monitored for sedation, feeding difficulties, adequate weight gain and developmental milestones.

lithium: Has historically been described as not compatible with breastfeeding unless baby can be monitored with monthly blood tests. However October 2023 SPS reported that “Lithium can also be used for the management of bipolar disorder, but must be with extreme caution, under specialist supervision, and with strict infant monitoring conditions.” Lactmed (https://www.ncbi.nlm.nih.gov/books/NBK501153) states that “Lithium excretion into breastmilk and concentrations in infant serum are highly variable, and that numerous reports exist of infants who were breastfed during maternal lithium therapy without any signs of toxicity or developmental problems. Most were breastfed from birth and some continued to nurse for up to 1 year of maternal lithium therapy. The baby would need regular blood tests to monitor, just as the mother does . The infant should be monitored for Neurobehavioral development, drowsiness, irritability, dry mouth or excessive salivation, thyroid function, vomiting, constipation, hydration, renal function, urination, tremor. The decisions should be taken with full information

.

Atypical antipsychotics:

risperidone (Risperidal™): Limited information indicates that maternal risperidone doses of up to 6 mg daily produce low levels in milk. Observe baby for drowsiness but no adverse events reported to date.

olanzapine (Zyprexa™): Maternal doses of olanzapine up to 20 mg daily produce low levels in milk and undetectable levels in the serum of breastfed infants. Monitor the baby for drowsiness and effective feeding.

quetiapine (Seroquel™): Maternal quetiapine doses of up to 400 mg daily produce low levels in milk. Monitor the baby for drowsiness and effective feeding.

ariprazole (Ablify ™): Limited information indicates that maternal doses of aripiprazole up to 15 mg daily produce low levels in milk. However, it inhibits prolactin levels and despite expert advice it may not be possible to achieve a full milk supply ((Mendhekar 2006, Nordeng 2014).

Choice of medication must be guided by clinical need, but it is usually, depending on the dose, possible to continue to breastfeed.  If it is not possible, the mother and her family should be consulted in making an informed choice.  

References

• Hale TW Medications and Mothers Milk Online access
• Mendhekar DN, Sunder KR, Andrade C. Aripiprazole use in pregnant schizoaffective woman. Bipolar Disord 2006; 8:229-300
• Nordeng H, Gjerdalen G. BRede WR, Michelsen LS, Spigset O. Transfer of aripiprazole to breast milk: a case report. J Clin Psychopharamcology 2014;34(2):272-75.
• Page-Sharp M, Kristensen JH, Hackett LP, Beran RG, Rampono J, Hale TW, Kohan R, Ilett KF, Transfer of lamotrigine into breastmilk, Ann Pharmacother, 2006;40:1470–1, Letter.
• SPS Treating bipolar disorder during breastfeeding https://www.sps.nhs.uk/articles/treating-bipolar-disorder-during-breastfeeding

Further information:

MIND https://www.mind.org.uk/

BiPolar UK www.bipolaruk.org

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

It may however, be a sign of thyroid deficiency so always worth checking with your doctor and requesting a blood test to check levels, just in case. Biotin can interfere with thyroid tests so better avoided until this has been ruled out as a cause of hair thinning (October 2023 https://www.nice.org.uk/guidance/ng145/chapter/Update-information).

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

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

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

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

I’ve realised that the information I wrote long ago now, on loss of a pregnancy and breastfeeding is not very detailed so I have written a more detailed factsheet. My heart goes out to everyone who has to go through the loss of a baby through miscarriage. We don’t talk about it openly often enough considering how common it is .

If the baby is lost whilst you are still breastfeeding an older child your milk supply may suddenly increase. If your child isn’t feeding as frequently you may risk mastitis so please be aware if you suffer engorgement and your nursling doesn’t remove the full supply.

If the miscarriage is late in pregnancy then milk production may still begin and this may come as a shock see https://breastfeeding-and-medication.co.uk/fact-sheet/stillbirth-and-milk-supply

Sending hopeful rainbows for the future

miscarriage and breastfeeding factsheet

Sometimes longed-for pregnancies end in miscarriage. The signs of miscarriage may be vaginal bleeding and cramps in the lower abdomen. You may need to take painkillers as you would for period pains. Sometimes not all the ‘products of conception’ may be expelled. You may be monitored by the early pregnancy unit who will scan your uterus and advise accordingly. You may be treated elsewhere in the hospital.

However, you may find yourself in the heart-breaking situation of attending for a scan to be told that your baby has no heartbeat and died some time ago. You may not have had any symptoms that a problem has occurred but with hindsight may recognise that symptoms of morning sickness had eased.  This is called a missed or silent miscarriage.

You may be given drugs to bring on the miscarriage (medical management) or you may be offered an operation to make sure the womb is clear (surgical management), You may prefer to wait for nature to take its course and your body to expel the baby in its own time – this happens in around 50% of cases. The decision is yours after a fully informed discussion with those caring for you and your family.

Medical management

You can continue to feed as normal after misoprostol and after mifepristone https://www.sps.nhs.uk/articles/medically-terminating-a-pregnancy-during-breastfeeding/

Some units use mifepristone tablets to break down the lining of the uterus and you can feed as normal after taking that drug. Normally you return for the second tablets after 48 hours, but this alone may bring on the miscarriage in some women.

You may alternatively be given a single dose of misoprostol vaginally. Or you may be offered a two-stage medication procedure: a mifepristone 200mg tablet orally followed 24–48 hours later by misoprostol 800 micrograms. This is usually given as a pessary but can be a tablet under the tongue (sub lingually). You may also be given painkillers, anti-sickness tablets and antibiotics. You can continue to breastfeed an older baby 4 hours after the misoprostol to avoid risks of diarrhoea in your nursling although Hale suggests that this may be unnecessary. The misoprostol helps the neck of the womb (cervix) to open and lets the remaining pregnancy come away.

Pain and bleeding usually occur within one to two hours of using misoprostol. Often bleeding is heavy with clots. It is not unusual to soak four to six pads in the first hour. You may see the pregnancy sac when it passes, but you will probably not see a recognisable baby if it is still very early in the pregnancy. Most women experience strong cramps and abdominal pains. These pains are usually strongest while the bleeding is heavy and should ease off quite quickly once the pregnancy remains have passed. You can use pain relief medication such as ibuprofen, paracetamol and dihydrocodeine.

If bleeding does not start within 24 hours you need to contact the unit looking after you.

Surgical management

As soon as you are awake and alert following surgery you can continue to breastfeed your nursling as normal

You may be offered, or ask for, surgical removal of the miscarriage although this is much less common due to the effectiveness of the medication and that you can take that at home.. Surgery will involve a general or local anaesthetic and you can feed as normal as soon as you are awake and alert. This procedure can be called a D and C or an ERPC when performed under GA but an MVA when under a local anaesthetic The pregnancy is removed through the cervix. You may be given tablets to swallow or vaginal pessaries before the operation to soften your cervix. These do not affect breastfeeding. Surgery will usually take place within a few days of your miscarriage, but you may be advised to have surgery immediately if you are bleeding heavily and continuously or there

are signs of infection. It may also be offered if medical treatment to remove the pregnancy has been unsuccessful.

Following the miscarriage

It is important to give yourself time to grieve – this was the loss of a dream as well as a baby. It is common to feel guilty as well as sad. Many families don’t share the news of a pregnancy until after the 12-week scan ‘just in case’, but if something happens you need friends to care for you, so consider letting them know what’s happened.

The reasons for miscarriage are many and varied. in women under 30, 1 in 10 pregnancies will end in miscarriage. It is common but something we rarely talk about openly. Just because it has happened once does not increase the chances of it happening again but quite naturally you will worry. Most people are advised to wait a full cycle before trying to conceive again to give mind and body time to heal. It also makes dating of the next pregnancy easier if conception does occur rapidly.

See https://www.nhs.uk/conditions/miscarriage/causes/ for more information.

Prevention of recurrent miscarriage

Some women experience recurrent miscarriages and need to take medication in order to protect the foetus. This may include the use of 75 -150mg aspirin, progesterone pessaries and low molecular weight heparin injections. All of these are compatible with normal breastfeeding. About 1 in 100 women experience recurrent miscarriages (3 or more in a row) and many of these women go on to have a successful pregnancy

What happens to the remains of the pregnancy?

Many people pass the pregnancy sac whilst on the toilet. Some people choose to just flush the toilet or do so automatically. Some want to look more closely first. Others choose to bury it in the garden maybe near a shrub or flowers. All these reactions are normal and individual. There is no right or wrong. Do what feels the right thing for you. You will not ever forget this day, this baby or this little one’s due date. Hopefully in the future you will have your Rainbow baby (a baby born subsequent to a miscarriage, stillbirth, or the death of an infant from natural causes).

References and Resources

• Breastfeeding and Medication. Jones W Routledge 2017
• BPAS Medical management of miscarriage. Accessible from: https://www.bpas.org/more-services-information/miscarriage-care/medical-management/
• Guys and St Thomas Medical Management of Miscarriage. Accessible from: https://www.guysandstthomas.nhs.uk/resources/patient-information/gynaecology/medical-management-of-miscarriage.pdf
• Hale TW Medications and Mothers milk (online access)
• LactMed https://www.ncbi.nlm.nih.gov/books/NBK501922/
• NHS Miscarriage: Accessible from: https://www.nhs.uk/conditions/miscarriage/
• NICE NG 126 Ectopic pregnancy and miscarriage: diagnosis and initial management. Accessible from https://www.nice.org.uk/guidance/ng126
• Royal College of Obstetrics and Gynaecology Early Miscarriage patient information leaflet. Accessible from: https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-early-miscarriage.pdf
• The Miscarriage Association https://www.miscarriageassociation.org.uk/
• The Miscarriage Association Management of Miscarriage. Accessible from: https://www.miscarriageassociation.org.uk/wp-content/uploads/2016/10/Management-of-Miscarriage-April-2019.pdf
• “Why Mothers Medication Matters” Jones W Pinter and Martin 2017

This information is dedicated to the two grandchildren I never got to meet

Continuing to work down the list of frequently asked questions and adding information from Breastfeeding and Medication 2018

If you are a professional or a volunteer frequently encountering questions from mothers or other members of the family maybe you would like to treat yourself to a copy!

The ear drops I am asked about most frequently asked about are OTOMIZE and LOCORTEN VIOFORM but this fact sheet contains many others. Hope it puts everyone’s mind at rest. I remember a consultant many years ago telling a mother she couldn’t breastfeed for 2 weeks after using anti inflammatory ear drops. Unless she was going to drip excess out of the ear canal onto her nipples I could see no logic for this. I hope things have moved on but the patient information leaflet still causes concern.

pdf of factsheet available ear drops and breastfeeding

Absorption of ear drops is unlikely to reach clinical significance in breastmilk as there is virtually no means of absorption into the systemic system from the external ear canal.

Ear drops generally include corticosteroids to reduce inflammation, antibiotics to reduce otitis external, antifungals, local anaesthetics for pain and ingredients to soften and remove earwax. Treatment of otitis media with ear drops is generally ineffective and is better treated by simple analgesia and, if necessary, antibiotics. Almond oil, olive oil and sodium bicarbonate solution are all used to soften ear wax.

Examples of ear drops and their ingredients:

Betnesol N® Betamethasone And Neomycin)

Betnesol® (Betamethasone),

Cerumol® (Chlorbutanol),

Gentisone HC®  (Gentamicin And Hydrocortisone)

Gentisone® (Gentamicin)

Locorten-Vioform® (Flumetasone And Clioquinol)

Neo-Cortef® (Hydrocortisone And Neomycin)

Otex® (Urea Hydrogen Peroxide)

Otomize® (Dexamethasone, Neomycin And Acetic Acid)

Otosprorin® (Polymyxin B Neomycin Hydrocortisone)

Predsol N® (Prednisolone And Neomycin)

Predsol® (Prednisolone)

Sofradex® (Dexamethasone Framycetin Gramicidin)