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Antibiotics and Breastfeeding

Although we now try very hard to avoid prescribing antibiotics unless essential ( because of the risk that in the future we wont have antibiotics which are as effective against all infections), sometimes they are necessary. The use of antibiotics during breastfeeding often causes disquiet because most of them cause the baby to have loose bowel motions, sometimes tummy cramps, and sometimes vomiting. Is continuing to breastfeed actually causing harm and should feeding be interrupted? Do we need pre-biotics and probiotics to redress the balance in the baby’s gut?

It is hard to watch a baby in distress but it is important to remember that when we breastfeed during an infection we are also passing antibodies to that infection in breastmilk to protect the baby. Breastmilk contains all the factors to redress the balance and return the baby’s gut to its normal state far better than any probiotics derived from other sources, in my opinion.

But the ultimate choice is that of the breastfeeding mother.

January 2024 the MHRA issued guidance on fluoroquinolones : ” that fluoroquinolone antibiotics given systemically (by mouth, injection, or inhalation) must only be administered when no other antibiotics are appropriate for use, the Medicines and Healthcare products Regulatory Agency (MHRA) has announced. This means that fluoroquinolones should only be prescribed when other recommended antibiotics have failed, will not work due to resistance, or are unsafe to use in an individual patient.” https://www.gov.uk/government/news/mhra-introduces-new-restrictions-for-fluoroquinolone-antibiotics

Fluoroquinolone include ciprofloxacin, levofloxacin, moxifloxacin, and ofloxacin. If prescribed these as a first option please discuss with your prescriber. The MHRA guidance refers to use in adults only where no other antibiotic is available.

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

Metronidazole can be used during breastfeeding for most usual treatment courses. Recommendations apply to full term, healthy infants.

I hope that the information in this factsheet helps make that decision. Please email me if you want to discuss anything : wendy@breastfeeding-and-medication.co.uk

Antibiotics and breastfeeding factsheet pdf

Antibiotics are acknowledged to be overused which is one of the reasons that Multiple Resistant Staphylococcus aureus (MRSA) and Clostridium difficile have become more widespread. It is sensible to consider whether a mother needs to be treated with antibiotics before exposing both her and her breastfed baby. Babies exposed to antibiotics via their mother’s breastmilk may develop symptoms of colic, abdominal discomfort and diarrhoea. These are an inconvenience and not a reason to suspend breastfeeding. Research undertaken in Canada in 1993 (Ito et al. 1993) showed that 15% of women prescribed antibiotics chose not to take the medicine and continue to breastfeed, rather than expose their baby to a risk which they had been assured was minimal. By contrast, 7% stopped breastfeeding during therapy despite reassurance. The research team also examined the reporting of adverse effects by mothers made aware of potential diarrhoea in the child with antibiotics passing through breastmilk. Although more women warned of side effects reported clinical effects which they had noted and judged to be due to the medication, than those not made aware, the difference is not statistically significant (87% compared with 68%). No difference in compliance with the antibiotic regimen or breastfeeding pattern, were noted between the two groups (Taddio et al. 1995).

These follow recommendations from the doctor that the ‘infection’ may be self-limiting but if symptoms develop further or fail to resolve in the following 48 hours, then the course of antibiotics should be taken. Little et al. have suggested restricting the use in the treatment of otitis media, upper respiratory infection and sore throat ((Little 2002; 2005; 1997) beginning the public health message about reducing the use of antibiotics. It may also be useful in the management of mastitis.

References

• Abdellatif M e, Ghozy S, Kamel MG, Elawady SS Ghorab MMEAttia AW, Le Huyen TT, Duy DTVHirayama K, Huy NT. Association between exposure to macrolides and the development of infantile hypertrophic pyloric stenosis: a systematic review and meta-analysis. Eur J Pediatr. 2019 178(3):301-314.

• Hale T. Hale’s medications & mothers’ milk. 19th ed. New York, USA: : Springer Publishing 2021. • Ito S, Koren G, Einarson TR, Maternal non compliance with antibiotics during breastfeeding, Ann Pharmacother, 1993;27(1):40–42.

• Ito S, Koren G, Einarson TR. Maternal Noncompliance with Antibiotics during Breastfeeding. Ann Pharmacother 1993;27:40–2. doi:10.1177/106002809302700110 • Jones W Breastfeeding and Medication Routledge 2018

• Jones W How to advise women on the safe use of medicines while breastfeeding The Pharmaceutical Journal, PJ, 2021, 306 (7949) https://pharmaceuticaljournal.com/article/ld/how-to-advise-women-on-the-safe-use-of-medicines-whilebreastfeeding

• LactMed https://www.ncbi.nlm.nih.gov/books/NBK501922/ • Little P, Delayed prescribing of antibiotics for upper respiratory tract infection, BMJ, 2005;331(7512):301.

• Little P, Gould C, Moore M, Warner G, Dunleavey J, Williamson I, Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial, BMJ, 2002;325(7354):22

• Little P, Williamson I, Warner G, Gould C, Gantley M, Kinmonth AL, Open randomised trial of prescribing strategies in managing sore throat, BMJ, 1997;314:722.

• Taddio A, Ito S, Einarson TR, Leeder JS, Koren G, Effect of counselling on maternal reporting of adverse effects in nursing infants exposed to antibiotics through breastmilk, Reprod

Dental Health and Breastfeeding

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 wendy@breastfeeding-and-medication.co.uk

In summary:

  • 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.” 

https://www.sdcep.org.uk/wp-content/uploads/2018/06/SDCEP-Dental-Amalgam-Information-for-Pregnant-or-Breastfeeding-Patients.pdf

  • 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.

For information on mercury fillings please see the information from InfantRisk December 2023

https://www.infantrisk.com/content/mercury-dental-fillings

Data suggests that maternal exposure to mercury vapor from dental amalgams or restoration is unlikely to have a significant impact on breastfeeding infants. 

The established baseline for mercury levels in human breastmilk is set at ≥ 1 mcg/L.15 A comprehensive study examining mercury content in breast milk from mothers with dental amalgams revealed a range of mercury concentrations in human milk samples, spanning from < 0.2 to 6.86 mcg/L, with an average of 0.37 mcg/L.16 Studies have demonstrated transfer of mercury from a mother’s bloodstream to her breastmilk. Intriguingly, mercury levels in commercial formula samples displayed a broader spectrum, varying from 0.4 to 2.5 mcg/L on average, which was actually higher than the findings in the collected breastmilk samples.16 

Remember, even if materials from mercury amalgams are orally ingested, elemental mercury is not absorbed from a healthy gastrointestinal tract. If a baby consumes miniscule mercury residues in breastmilk, it is likely that it wouldn’t be absorbed, especially as the baby ages and the GI tract matures. 

Conclusion

Breastfeeding with mercury fillings or after dental amalgam restoration is likely safe and the benefits of breastfeeding outweigh the risks. Extra-cautious mothers could choose not to breastfeed for the first three days post-amalgam restoration, but the difference in infant risk will be miniscule.

Powerpoint training for dental practitioners on the pharmacokinetics of drugs they may use in breastfeeding women

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

Delivering Better Oral Health (PHE, 2014 updated content 2017)4 recommends that:

  • 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

Powerpoint training for dental practitioners on passage of drugs in breastmilk

See also:

A Guide To Supporting Breastfeeding For The Medical Profession, Amy Brown and Wendy Jones

Prochlorperazine to treat symptoms of labarynthitis/vertigo and Breastfeeding

I am frequently asked about taking prochlorperazine (Buccastem® or Stemetil ®) to treat nausea due to labarynthitis, vertigo or dizziness. It is a drug I would be happy to prescribe and have used it myself as have my breastfeeding daughters. It seems a frequently asked question when the air pressure changes rapidly. Prochlorperazine may also be used for nausea

prochlorperazine and breastfeeding factsheet pdf

Brand names: Stemetil®, Buccastem®

Prochlorperazine is used to treat vertigo, labarynthitis or migraine particularly to treat nauseas caused by these conditions.

Its oral bio-availability is low due to high first-pass metabolism.  Long-term use should be avoided in breastfeeding where possible, particularly with very young babies where there is a potential risk of apnoea (breathing problems).

However short-term acute use for vertigo and labarynthitis probably poses few risks.  It is widely used for this purpose. It is licensed for use in children over 10 kg.

Compatible with use during breastfeeding if used short term. Avoid long term or where child is at risk of apnoea.

N.B This information is based on anecdote and experience as there are no research based studies on the amount passing into breastmilk.

see also https://breastfeeding-and-medication.co.uk/fact-sheet/betahistine-and-breastfeeding

ADHD and Breastfeeding

I have shared the chapter on ADHD from my book Breastfeeding and Chronic Medical Conditions multiple times this week. Many mothers seem to be diagnosed in later life and are concerned about breastfeeding. Hope this is a useful link.

More information

ADHD and Breastfeeding Factsheet

If this is useful maybe you need the book available on Amazon. I published on Kindle to try to make this more affordable and available to mothers and breastfeeding supporters as well as professionals

I came off my medication to conceive and my baby is now 6 months old. I am really struggling to think straight now and getting really overwhelmed by the smallest of things.

Description

ADHD is a disorder that includes symptoms such as inattentiveness, hyperactivity, and impulsiveness. It is normally diagnosed in childhood, but some parents have found themselves being diagnosed when seeking a diagnosis for their children. The cause is unknown, but it seems to at least in part, genetic. It has been suggested that being born prematurely (before the 37th week of pregnancy), having a low birth weight or maternal smoking or alcohol or drug abuse during pregnancy may be linked. Attention deficit hyperactivity disorder (ADHD) is thought to affect about 1 in 20 children in the UK with incidence being three times higher in boys.

Symptoms fall into 2 categories:

inattentiveness main symptoms of which are:

  • having a short attention span and being easily distracted
  • making careless mistakes
  • appearing forgetful or losing things
  • being unable to stick to tasks that are tedious
  • appearing to be unable to listen to or carry out instructions
  • constantly changing activity or task
  • having difficulty organising tasks

hyperactivity and impulsiveness main symptoms of which are:

  • being unable to sit still and constantly fidgeting
  • being unable to concentrate on tasks
  • excessive physical movement
  • excessive talking
  • being unable to wait turn
  • acting without thinking
  • interrupting conversations
  • little or no sense of danger
  • ADHD may be linked with anxiety, autism, and several other conditions. By the age of 25, an estimated 15% of people diagnosed with ADHD as children still have a full range of symptoms, and 65% still have some symptoms that affect their daily lives. ( https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/symptoms/)
  • Treatment
  •        Methylphenidate (Ritalin ™, Concerta ™); works by increasing the amount of a dopamine in the parts of the brain responsible for self-control and attention. It is usually the first line treatment. There are side effects of loss of appetite and difficulty sleeping and mood swings. Limited evidence indicates that methylphenidate levels in milk are very low and not detectable in infant serum. The effects of methylphenidate in milk on the neurological development of the infant have not been well studied. Monitor the baby for agitation, irritability, poor sleeping patterns, changes in feeding and poor weight gain.
  •         Atomexatine is a selective noradrenaline reuptake inhibitor (SNRI), increasing levels of noradrenaline rather than dopamine. It can aid concentration and help control impulses. Side effects include rise in blood pressure and heart rate, nausea and vomiting, gastric pain, difficulty sleeping, dizziness, headaches, and irritability. More importantly it has been associated with suicidal thoughts and liver damage. There is no published experience with atomoxetine during breastfeeding, although reports from the manufacturer found no serious adverse effects in two breastfed infants (Besag 2014).
  •         Dexamphetamine. Side effects include decreased appetite, mood swings, agitation and aggression, dizziness, headaches, nausea, vomiting and diarrhoea. Only used if lisdexamphetamine is helpful but not tolerated. In dosages prescribed for medical indications, some evidence indicates that dextroamphetamine might not affect nursing infants adversely. The effect of dextroamphetamine in milk on the neurological development of the infant has not been well studied. It is possible that large dosages of dextroamphetamine might interfere with milk production.  Infant Monitoring for agitation, hyperactivity, insomnia, decreased appetite, weight gain, and tremor.
  •         Lisdexamphetamine (Vyvance ™) may be offered as first line treatment in adults. Side effects include decreased appetite, aggression or drowsiness, dizziness, headaches, nausea, vomiting and diarrhoea. Lisdexamfetamine is a prodrug of dextroamphetamine. In medicinal dosages, some evidence (5 mothers studied) indicates that dextroamphetamine might not affect nursing infants adversely. The effect of dextroamphetamine in milk on the neurological development of the infant has not been well studied. Infant Monitoring should be for agitation, irritability, poor sleeping patterns and poor weight gain.
  • The NHS website suggests that for adults with ADHD if you find it hard to stay organised, then make lists, keep diaries, stick up reminders and set aside some time to plan what you need to do
  • let off steam by exercising regularly
  • find ways to help you relax, such as listening to music or learning relaxation techniques
  • if you have a job, speak to your employer about your condition, and discuss anything they can do to help you work better
  • talk to your doctor about your suitability to drive, as you will need to tell the Driver and Vehicle Licensing Agency (DVLA) if your ADHD affects your driving
  • contact or join a local or national support group – these organisations can put you in touch with other people in a similar situation, and can be a good source of support, information, and advice

References

  • Attention deficit hyperactivity disorder: diagnosis and management; NICE guideline (March 2018, updated September 2019)
  • Attention deficit hyperactivity disorder; NICE CKS, May 2018
  • Besag FM. ADHD treatment and pregnancy. Drug Saf. 2014; 37:397-40
  • NHS ADHD https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/living-with/
  • Further Information
  • AADUK https://aadduk.org/

Low dose aspirin and breastfeeding

It is not uncommon for breastfeeding mothers to need to take low dose aspirin, sometimes for reasons in pregnancy or after cardiac events. Whilst it isnt recommended regularly as a painkiller at a dose of 600mg four times a day it is compatible with breastfeeding in low dose of 75-150mg daily. There are no reported cases of Reye syndrome associated with the amount of low dose aspirin passing through breastmilk and it is widely used, particularly during pregnancy.

low dose aspirin and breastfeeding pdf

If accidentally taken at an analgesic dose see https://breastfeeding-and-medication.co.uk/fact-sheet/accidentally-taking-one-dose-of-aspirin-when-breastfeeding

Aspirin 75 -150mg acts by decreasing platelet adhesiveness irreversibly inhibiting aggregation. It is not used during treatment of thrombosis but may be used in cases of recurrent miscarriage or with risk of pre-eclampsia. In more serious conditions it is used post myocardial infarction (MI) and stroke or to decrease cardiovascular risk. There is little evidence that enteric-coated tablets are less likely to increase the risk of GI bleeds and may be less effective in their anti-platelet activity as well as more expensive. Although aspirin is not recommended during breastfeeding at analgesic doses of 600 mg four times a day, due to its association with Reye’s syndrome, use of the small dose in these circumstances may be considered to be acceptable. In the absence of the risk of association of Reye’s syndrome, aspirin would be a drug compatible with lactation due to its pharmacokinetic properties.

Before the link with Reye’s syndrome was identified, the children’s dose of aspirin was 75 mg four times a day. Relative infant dose is quoted as 2.5–10.8% (Hale 2017 online access). The BNF states that it should be avoided due to possible risk of Reye’s syndrome. Regular use of high doses could impair platelet function and produce hypo-prothrombinaemia in infant if neonatal vitamin K stores are low. After 2-4 hours there is virtually no aspirin in milk Compatible with breastfeeding if necessary at 75 -150mg mg daily, avoid as an analgesic Reye’s syndrome This is a rare syndrome, characterized by acute encephalopathy and fatty degeneration of the liver, usually after a viral illness or chickenpox. The incidence is falling but sporadic cases are still reported. It was often associated with the use of aspirin during the prodromal illness. Few cases occur in white children under 1 year although it is more common in black infants in this age group. Many children retrospectively examined show an underlying inborn error of metabolism.

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