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The menopause and breastfeeding

I’m seeing increasing numbers of questions form mums in the perimenopause who are still breastfeeding. Maybe they delivered later or maybe they have been feeding to term or maybe lots of other reasons. I remember asking for blood tests to check my hormone levels because I just couldnt think clearly anymore and my memory was poor which wasnt ideal as I was just becoming an independent pharmacist prescriber! My levels had indeed dropped and I went on to HRT. This may not be everyone’s choice or be suitable for them

I have spent many hours this year looking for guidance on HRT and breastfeeding and failed to find any studies or conclusive data. Everything is anecdotal at the moment but I hope this information helps.

One vital piece of information – please keep checking your breasts for lumps .HRT can slightly increase the risk of breast cancer. If you’ve had breast cancer you’ll usually be advised not to take HRT. The increased risk is low: there are around 5 extra cases of breast cancer in every 1,000 women who take combined HRT for 5 years. The risk increases the longer you take it, and the older you are.

As usual please message me on wendy@breastfeeding-and-medication.co.uk if you have a question

PDF of factsheet available:

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/07/the-menopause-and-breastfeeding.pdf

The Menopause And Breastfeeding

There remains no conclusive research on the passage of HRT medication into breastmilk. It appears anecdotally that there is less impact from using transdermal preparations than oral medication. There remains the possibility of reduction in lactation due to the oestrogen contact inhibiting prolactin. Anecdotally HRT has been used by breastfeeding women without impact on the nursling or supply. The decision should be that of the lactating mother after discussion with her healthcare professional.

For use of vaginal oestrogen see https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-oestrogen-cream-or-pessary

I typed “menopause and breastfeeding” into a well-known search engine and what came up first was “It is most likely that you are suffering from menopausal-like symptoms due to breastfeeding. After childbirth and during breastfeeding, women’s oestrogen levels can drop to lower levels than usual. These low levels of oestrogen can cause symptoms that mimic menopause.”

Whilst in a paper published in 2020 Langton et al found that after studying 100,000 women ages 25 to 42 years in the Nurses’ Health Study II (an analysis funded by the National Institutes of Health) “Women who breastfed their infants exclusively for seven to 12 months may have a significantly lower risk of early menopause than their peers who breastfed their infants for less than a month”.  The study also suggests that pregnancy can reduce the risk of early menopause.”

As many women now give birth later than in the past, due to changes in work and finance, and feed until they and their nursling choose to stop, questions that I have received from mothers exhibiting signs of early menopause have increased substantially. Most women begin the menopause between 45 and 55 years of age.

There is also a group who have experienced premature ovarian failure which may be hereditary. There is a further group who have had their uterus and ovaries removed surgically for a variety of reasons.

Premature ovarian insufficiency (POI)

This affects about one in a hundred women under 40 in the UK. It occurs when the ovaries no longer produce normal amounts of estrogen and therefore may not produce eggs. This means that periods will become irregular or stop altogether, with symptoms of the menopause. Many women have POI without actually realising it. Any mother under the age of 40 and having irregular periods (or if they have even stopped completely) should be talk to their doctor about having further tests. No woman is too young to be menopausal. Unlike the normal menopause when the ovaries stop working completely, in POI ovarian function can be intermittent, occasionally resulting in a period, ovulation or even pregnancy. This intermittent return of ovarian function means that 5–10% of women with POI will conceive spontaneously.

Perimenopause

The period leading up to the menopause, when hormone production decreases symptoms may start to be experienced is defined as the perimenopause. The period is rather ill defined and may vary dramatically between women. It usually suggested as beginning with irregular menstruation. There may be changes to flow with periods becoming heavier or lighter. For others it may be defined by mood swings or changes in mental function. Each person has a different awareness of their own bodies. This is the period in which most calls about breastfeeding appear to originate with a request to begin hormone replacement therapy.

Menopause

The menopause is defined as an absence of menstruation for over a year. Not all symptoms will be experienced by all women, we are all different.

Typical menopausal symptoms, include:

  • hot flushes
  • night sweats
  • vaginal dryness and discomfort during sex
  • difficulty sleeping
  • low mood or anxiety
  • reduced sex drive (libido)
  • problems with memory and concentration

However, Newson diagram shows that the menopause may affect any part of the body with a wide variety of symptoms

Reproduced from Newson, Menopause: All you need to know in one concise manual

Interestingly when Newson surveyed approximately 2,920 women about their experiences of care around the menopause. The majority of respondents had visited their usual GP:

  • 66% said they were offered antidepressants rather than HRT
  • 20% said they had been referred to a hospital for appointments and/or investigations e.g., migraine clinics, scans or heart tests with symptoms likely to be related to their perimenopause/menopause.

This suggests that medical understanding of perimenopausal symptoms may be poorly understood and probably more so if the women is breastfeeding as well, particularly outside of the perceived “normal” timeframe.

Post menopause

This is defined as the remainder of a women’s life which can present with an increased risk of osteoporosis although the risk is lowered in women who have breastfed (https://www.unicef.org.uk/babyfriendly/news-and-research/baby-friendly-research/maternal-health-research/maternal-health-research-bone-density/).

HRT and Breastfeeding

HRT contains oestrogen and sometimes a progesterone e.g., norethisterone, not that dissimilar to that in the combined oral contraceptive which can be used in breastfeeding. The ethinylestradiol content of COCs range from 20–40 micrograms whilst that in HRT products contain 1 – 4 milligrams of estradiol (there are 1000 micrograms in a milligram).

However, Hale says “Although small amounts of Conjugated estrogens may pass into breastmilk, the effects of estrogens on the infant appear minimal. Early postpartum use of estrogens may reduce volume of milk produced and the protein content, but it is variable and depends on dose and the individual.”

“Conjugated estrogens comprise more than 90% of the total estrogen content of human milk and plasma (McGarrigle) Estriol glucosiduronates were the predominant oestrogen metabolites (63%) in plasma”

His conclusion is that low levels pass into milk confirmed in a query to the InfantRisk forum (https://www.infantrisk.com/forum/forum/medications-and-breastfeeding-mothers/medications-and-mothers-milk/339-hormone-replacement-therapy )

Martindale (39th Ed) states that estradiol has been detected in breastmilk after the use of pessaries containing estradiol 50 or 100mg (Nilsson 1978) and that the American Academy of Pediatrics (2001) considers that it is compatible with breastfeeding

Pharmacokinetics of HRT (Taken from Hale)

Conjugated estrogens:  Milk plasma ratio 0.08, Plasma Protein Binding 98%

References

  • American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001 Sep;108(3):776-89.
  • Chollet, J. A., G. Carter, et al. (2009). “Efficacy and safety of vaginal estriol and progesterone in postmenopausal women with atrophic vaginitis.” Menopause 16(5): 978-983.
  • Hale TW Medications and Mothers Milk online access
  • Langton CR, Whitcomb BW, Purdue-Smithe AC, et al. Association of Parity and Breastfeeding With Risk of Early Natural Menopause. JAMA Netw Open. 2020;3(1): e1919615)
  • Martindale The Complete Drug Reference 39 Ed. Pharmaceutical Press
  • McGarrigle HH, Lachelin GC. Oestrone, oestradiol and oestriol glucosiduronates and sulphates in human puerperal plasma and milk. J Steroid Biochem. 1983May;18(5):607-11.
  • Newson, Dr Louise. Menopause: All you need to know in one concise manual. Kindle
  • Nilsson S, Nygren KG, Johansson ED. Transfer of estradiol to human milk. Am J Obstet Gynecol. 1978 Nov 15;132(6):653-7

Breast cancer and breastfeeding

This information came from a tag on Twitter at the weekend from a mum newly diagnosed with cancer weaning her baby from the breast prior to starting chemo. Hard enough I know but after the surgery she had been prescribed domperidone to control nausea – it stimulates milk production and no one seemed to know or have thought about this. She was prescribed ondansetron instead but only after providing her team with the information about domperidone.

I havent included lots of facts about the drugs as the data can change with research but it contains some of the things I have heard from mothers over the years and some sources of support.

If you need more information please contact me. I will do all I can to support your journey as cancer has raised its ugly head too often in my own family.

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2022/08/breast-cancer-and-breastfeeding-.pdf

Breastfeeding can significantly reduce the risk of triple negative breast cancer (TNBC, the most aggressive breast cancers), probably in pre-menopausal women.

Breastfeeding may not affect the incidence or risk of hormone receptor positive disease (oestrogen and/or progesterone receptors) or HER2 disease.

https://gpifn.org.uk/breast-cancer-risk-reduction/)

Breastfeeding can lower breast cancer risk, especially if a woman breastfeeds for longer than 1 yearhttps://www.breastcancer.org/risk/factors/breastfeed_hist

Evidence on cancer and other diseases shows that sustained, exclusive breastfeeding is protective for the mother as well as the child https://www.wcrf.org/dietandcancer/recommendations/breastfeed-your-baby

Breastfeeding lowers the risk of developing breast cancer, particularly if you have your children when you are younger. The longer you breastfeed, the more the risk is reduced. It is not completely clear why this is. But the reduced risk might be because the ovaries don’t produce eggs so often during breastfeeding. Or it might be because breastfeeding changes the cells in the breast so they might be more resistant to changes that lead to cancer. https://www.cancerresearchuk.org/about-cancer/breast-cancer/risks-causes/protective-factors

So why have you been diagnosed with breast cancer?

A small number of women (approximately 100-120 each year in the UK) who breastfeed will still develop aggressive breast cancers (https://gpifn.org.uk/breast-cancer-risk-reduction/).  There are no certainties in life unfortunately and definitely no absolute protection against cancer because you are breastfeeding. Each year I hear from women who have been given the diagnosis that we all fear and are being forced to wean their babies in order to have treatment. So, a double loss is often described – the loss of life as it had been and the feelings around breastfeeding which is about so much more than milk.

Over the years I have “spoken” with many mothers who are looking for information on how long it takes for the chemotherapy drugs to leave their systems so that they can return to breastfeeding. That data is available particularly from the online database I can access Medications and Mothers Milk by Dr T H Hale, as well as LactMed.

Some mothers are determined to maintain their supply by pumping and dumping throughout treatment. That is a hard thing to do especially when dealing with the side effects of the drugs but I would do all in my power to support that choice. It is possible to relactate at the end of treatment when the drugs have left the body. The possible difficulty is that the baby may be reluctant to resume breastfeeding particularly if older as they can lose their suck. But who knows? Every mother and baby pair are individuals.

The decisions should always be those of the mother with as much information as can possible be ascertained from evidence-based sites and research.

Sources of support

You may feel lonely in the face of the diagnosis. Everyone will be focussing on your treatment and you may find that the advice to stop breastfeeding is almost a throw away comment. As mothers we know that stopping may not be as simple as it sounds. Our babies are reliant on breastfeeding not just for nutrition but also for comfort, for relief when they feel unwell, just because it feels good. To take that away suddenly is hard. It may be that your treatment will not take place for a little while and you can wean your baby from the breast slowly. However, for some it may need to be sudden and rapid. I have heard from mothers who want to continue to feed as normal until the very last moment, others who want to feel well enough to comfort their child during the period. Everyone has their own approach. There are medications to dry up the milk but they can have nasty side effects for some people although not all. Cabergoline is the best option. If weaning slowly the herb sage may be useful https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-lowering-stopping-milk-supply. Support from an experienced breastfeeding person can be invaluable so that you avoid symptoms of engorgement or mastitis. In the team supporting you there may be someone able to provide information, Lactation Consultants may be able to help or any of the voluntary breastfeeding charities will be knowledgeable in support.

Mummy’s Star supports women and their families with a diagnosis of during pregnancy or the postnatal period. https://www.mummysstar.org/  or on Facebook https://www.facebook.com/MummysStar

Depending on the age of your baby when you are diagnosed the Hearts Milk Bank may be able to provide donor breastmilk for a period (depending on availability) https://heartsmilkbank.org/ or on Facebook https://www.facebook.com/heartsmilkbank

Treatment Options

Your treatment plan will be individual to you but may involve surgery, chemotherapy, radiotherapy or a mixture of these.

As part of all of these interventions you may feel nauseous. Two of the drugs frequently prescribed are anti-emetic drugs which stimulate milk supply! These are domperidone and metoclopramide (this can also precipitate depression). Make sure that your team are aware of the potential difficulties of taking these drugs when you are trying to reduce your supply or dump what you are producing. There are alternatives such as ondansetron. Many anaesthetists, oncologists and GPs seem unaware of the potential to increase prolactin as they focus on treating you.

There are many chemotherapy agents and I do not intend to try to provide information on all of them in this sheet. If you want to email me wendy@breastfeeding-and-medication.co.uk I will be happy to discuss your regime with you and supply full information to your oncology team.

Email me wendy@breastfeeding-and-medication.co.uk or message me through the Facebook Page Breastfeeding and Medication

Multiple Sclerosis and Breastfeeding

This is one of the chapters of the new book about breastfeeding with a chronic condition https://tinyurl.com/mbbebe8x .

Please not there have been changes to the data from the book – update to book on the way

So many people told not to breastfeed or to stop for medication. Hope this changes some of those concepts. Any queries please feel free to email wendy@breastfeeding-and-medication.co.uk

pdf of factsheet available here

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2022/11/multiple-sclerosis-and-breastfeeding.pdf

I have multiple sclerosis and I receive 1 monthly infusions of Tysabri. I chose to come of the infusions while pregnant and a month after I had my little boy so I could breast feed a little. I received information but I chose not to continue breastfeeding because I felt nobody actually knew the risks of the drug, I take on breast milk. I felt the sample of people taking Tysabri and breast feeding was too little, and I did not want to risk the health of my beautiful little boy. It wasn’t an easy choice to resume my medication and I have had a few emotional moments where I have felt terrible, I couldn’t give my boy the breast milk he deserves.

I have been on various self-injecting disease modifying drugs until 2015 when I had two very serious flare ups. I went to see the MS team and the neurologist was horrified and apologized for letting me get so bad, he said I should have been in better drugs to control my flare ups. I shuffled and had little movement in my legs, my right being worse. It was the first time I had ever had to use a stick. On other occasions my stubbornness would not let me use a stick but this occasion I had no choice, I was extremely bad. I was then but on Tysabri.

I found out I was pregnant mid-June of last year and phoned neurology to say I would not be getting my next treatment and did not want treatment while I was pregnant. The MS nurse said that women during pregnancy don’t tend to have flare ups, they think mainly because of the pregnancy hormones. I know this was the case for my sister. I received conflicting information about the use of amitriptyline while pregnant from neurologists and the obstetricians. During pregnancy I felt fine. Just the usual tiredness (plus my MS aching which meant I couldn’t always sleep) in the first couple of months and then again at the end. I managed to work full time at beamish museum (I’m a project officer helping with the new 1950’s town) until two weeks before my due date.I spoke to the MS nurse while pregnant and she said as soon as I wanted to return to my treatment I was just to ring. I did this after a month of breast feeding. The neurologist believed I would be ok to continuing breast feeding for 6 months but he wasn’t 100 per cent sure. Based on this information I continued breast feeding for another two weeks after a month of breastfeeding, I was going to go longer. After my first infusion but George (my little boy) got a temperature and was out of sorts, quite grumpy, etc. I was perhaps a little paranoid but thought my milk was affected by the

medication. You just want the best for your child, and I was worried I was giving him something awful through my milk.

My next infusion, I had a bad reaction, my body went into shock, my temperature was high, my heart rate and blood pressure went up, but I was shivering and my extremities were freezing. The consultant on call said he’d not seen a reaction like it before but after they gave me something, I’m not sure what and draped me in blankets, I was a got better. I guess my reaction made me feel I kind of did the right choice not continuing breast feeding. The cases studying so far are few and everyone reacts differently to medication. My body might have released the drug into my breast milk more or George’s body might not have been able to take a small amount of the drug.

Although I think I made the right choice it wasn’t an easy choice to stop breast feeding and I have agonized about the choice to resume treatment. I had a few emotional moments, specifically while eating dinner I broke down and my partner had to comfort me (post pregnancy hormones)! I had looked for a local breast milk bank. But there are none, to my knowledge, around here. However, a colleague, who donates to a bank, has recently offered some of her milk which I’ll gladly accept. I agree breast milk is best. I eat really healthy and wish my son could benefit from my healthy diet.

I was undiagnosed and had my first symptoms appear after my first who was breastfed. I still wasn’t diagnosed until after my second child and a second relapse. I was breastfeeding exclusively and after losing my sight amongst other things, I was encouraged to stop breastfeeding, take steroids and start a disease modifying drug asap. Putting my own health second to breastfeeding was one of the most difficult decisions I have had to make. It effected my relationship with my partner as well, but I am thankful I chose to continue. I chose not to and fed until my son was 18 months and then decided to stop after another MRI with contrast showed I was still highly active. I was offered Mavenclad (immunosuppressant chemo drug) and started that. Although I have a wonderful team there was not much confidence in terms of drugs and breastfeeding

I was being investigated for MS pre-birth of my first child, following birth, my symptoms got a lot worse which I just put down to being a new mum, which I have now realised was MS related and is no surprise to me that I was diagnosed soon after giving birth.  I had my baby during a heatwave, which my MS is particularly sensitive to. I can only describe the impact as having the life sucked out of me, like I am not the same person. This impact to my state of mind was huge, but was so breastfeeding, a natural aid that I unknowingly, desperately needed at that time. It was such a balancer for me, gave me purpose and was a huge achievement to know I was sustaining the beautiful life that I had grown, it made me so proud.MS diagnosed after my second child in 2013. Had baby number three in 2019. Came off all disease modifying drugs in order to conceive and stayed off for ten months afterwards to breastfeed. I was determined to exclusively breastfeed for three months minimum due to research suggesting it

reduces relapse risk after birth. I managed to exclusive breastfeeding until I started weaning. My (female) neurologist supportive and helped me work out a strategy to breastfeed even discussing potential relapse treatment that could be taken whilst breastfeeding. My experience of feeding though was difficult. My milk came in late (day 5) and I had a lot of shooting pains in the breast after feeding. I wondered if the spinal cord damage I had from MS was having an impact here. When I tried to research it there was zero information on experience of breastfeeding for women with MS and whether spinal cord damage has an impact. This surprised me as MS overwhelmingly affects young women of childbearing age.

Description

Multiple sclerosis (MS) is a condition that can affect the brain and spinal cord, causing a wide range of potential symptoms, including problems with vision, arm or leg movement, sensation or balance.

It’s a lifelong condition but its effects vary widely between individuals. A variety of medication is used to control symptoms. It’s most commonly diagnosed in people in their 20s and 30s, although it can develop at any age. It’s about 2 to 3 times more common in women than men.

The main symptoms may be progressive or include times of remission. They include:

  • fatigue
  • difficulty walking
  • vision problems,
  • problems controlling the bladder
  • numbness or tingling in different parts of the body
  • muscle stiffness and spasms
  • problems with balance and co-ordination

Nelson (1988) studied 191 pregnant women in a non-progressive phase of multiple sclerosis. During pregnancy they noted an exacerbation rate of 10%. Over the nine months after birth the rate increased to 34% but in the first three months it was 68%. Of the women studied, 96 breastfed for an average duration of 6.3 months. The rate of exacerbation was not significantly influenced by breastfeeding with a relapse rate of 37.5% compared with 31.5% in those who didn’t feed. However, Langer-Gould (2013) claimed that exclusively breastfeeding for more than two months produces a five-fold benefit in risk to relapse in the first year.

Pisicane (1994) reported that patients with multiple sclerosis were less likely to have been breastfed for a prolonged period with rates of 55% compared with 76.4% of women in a control group (healthy) who were breastfed for longer than seven months.

Multiple sclerosis patients should be told that if they breastfeed it should be exclusive, because this is more likely to be associated with decreased multiple sclerosis disease activity (Coyle 2016). Some studies suggest that breastfeeding, particularly when prolonged (at least four months), reduces risk for multiple sclerosis in the child (Conradi 2013).

Langer-Gould et al (2017) recruited 397 women with newly diagnosed MS and 433 matched controls. Total ovulatory years and the remaining factors that determine it, including gravidity, parity, episodes of amenorrhea, and hormonal contraceptive use, as well as age at first birth, showed no significant association with the risk of MS. However, among women who had live births, a cumulative duration of breastfeeding for ≥15 months was associated with a reduced risk of MS.

Krysko et al (2019)  carried out a systematic review and meta-analysis of 24 studies that include 2974 women with multiple sclerosis. She found a 43% reduced rate of postpartum multiple sclerosis relapses in women who were breastfeeding compared with those who were not breastfeeding, with a stronger benefit of exclusive rather than nonexclusive breastfeeding.

Treatment

Options include:

  • Acute courses of prednisolone, usually 5 days of prednisolone 40mg a day
  • Interferon beta 1 a (Avonex ™ – I/M injection once a week, Rebif ™ sub cutaneous 3 times a week) – molecule too large to pass into milk and zero oral bioavailability
  • Interferon beta 1 b (Betaferon ™ sub cutaneous injection every other day)- molecule too large to pass into milk and zero oral bioavailabilityPeginterferon (Plegidry™ sub cutaneous injection every 2 weeks)-– molecule too large to pass into milk and zero oral bioavailability
  • Glatiramer (Copaxone™)– sub cutaneous injection once a day or three times a week) useful if no response to interferons. It is degraded to amino acids and cannot be measure in plasma. Very low oral bioavailability. New data presented in 2021 has confirmed that it is compatible with breastfeeding https://www.tevapharm.com/news-and-media/latest-news/new-safety-data-on-treatment-with-copaxone-glatiramer-acetate-of-breastfeeding-mothers-who-live-with-r/
  • Natalizumab (Tysabri™) – an infusion every 4 weeks – molecular weight 149,000 and oral bioavailability zero. In the Piano study of women with inflammatory bowel disease in pregnancy 8 women received natalizumab while breastfeeding their infants. Among those who received natalizumab or another biologic agent while breastfeeding, infant growth, development or infection rate was no different from infants whose mothers received no treatment (Matro 2018).
  • Dimethyl fumarate (Tecfidera™) – a tablet taken twice a day. Ciplea studied 2 mothers and noted limited transfer into milk (RID 0.01% – 0.03%), the amount being too small to be harmful. Monitor breastfed infants for flushing, vomiting, diarrhoea, adequate weight gain, and developmental milestones.
  • Ocrelizumab (Ocrevus™) – an infusion every 6 months. No research in breastfeeding but while no levels in milk have been published, it is likely they are low, and that present, is probably not orally bioavailable (Hale 2020).
  • Cladribine (Mavenclad™) is for highly relapsing MS. The tablet is taken in two courses. Each treatment course consists of two treatment weeks, one at the beginning of the first month and one at the beginning of the second month. This is then repeated a year later. Normally this doesn’t need to be repeated. Cladribine is not recommended for use in lactation, withhold breastfeeding for a minimum period of 48 hours after the last dose of medication (Hale 2020).
  • Teriflunomide (Aubagio™) tablet taken once a day). No studies in breastfeeding and should be avoided.
  • high dose methylprednisolone for exacerbations. Cooper (2015) studied a lactating mother receiving intravenous (1000 mg) doses of methylprednisolone on three consecutive days. Whilst the infant was not breastfed, the measured levels in milk were too low to affect a breastfeeding infant. An interruption of 12 hours following IV therapy would virtually eliminate any risk to the baby. So, the mother could breastfeed overnight and dump milk during the day.
  • Rituximab ™, ™ ) a monoclonal antibody given by infusion. It has zero oral bio-availability and cant be absorbed by the baby from breastmilk. In a 2019 study (Kryso) the absolute infant dose over 24 hours was 0.0094 mg/kg/day. No adverse effects were reported in the infants up to one year later. References
  • Almas S, Vance J, Baker T et al. Management of multiple sclerosis in the breastfeeding mother. Mult Scler Int. 2016; 2016:6527458.
  • Ciplea AI, Datta P, Rewers-Felkins K, Baker T, Gold R, Hale TW, Hellwig K. Dimethyl fumarate transfer into human milk. Ther Adv Neurol Disord. 2020 Oct 31;13:1756286420968414. doi: 10.1177/1756286420968414. PMID: 33193814; PMCID: PMC7607748.
  • Conradi S, Malzahn U, Friedemann P, Quill S, Harms L, Bergh F, et al., Breastfeeding is associated with lower risk for multiple sclerosis, MSJ, 2013;19:553–8.
  • Cooper SD, Felkins K, Baker TE, Hale TW, Transfer of methylprednisolone into breast milk in a mother with multiple sclerosis, J Hum Lact, 2015May;31(2):237–9.
  • Hale TW Medications and Mothers Milk online access
  • Krysko KM, LaHue SC, Anderson A, Rutatangwa A, Rowles W, Schubert RD, Marcus J, Riley CS, Bevan C, Hale TW, Bove R. Minimal breast milk transfer of rituximab, a monoclonal antibody used in neurological conditions. Neurol Neuroimmunol Neuroinflamm. 2019 Nov 12;7(1):e637.
  • Krysko KM, Rutatangwa A, Graves J, Lazar A, Waubant E. Association Between Breastfeeding and Postpartum Multiple Sclerosis Relapses: A Systematic Review and Meta-analysis. JAMA Neurol. 2020;77(3):327–338.
  • Langer-Gould A, Beaber BE, Effects of pregnancy and breastfeeding on the multiple sclerosis disease course, Clin Immunol, 2013Nov;149(2):244–50.
  • Langer-Gould A, Smith JB, Hellwig K, Gonzales E, Haraszti S, Koebnick C,  Xiang A. Breastfeeding, ovulatory years, and risk of multiple sclerosis. Neurology (2017); 89 (6): 563-569
  • Matro R, Martin CF, Wolf D et al. Exposure concentrations of infants breastfed by women receiving biologic therapies for inflammatory bowel diseases and effects of breastfeeding on infections and development. Gastroenterology. 2018; 155:696-704.
  • Nelson LM, Franklin GM, Jones MC, Risk of multiple sclerosis exacerbation during pregnancy and breast-feeding, JAMA, 1988;259(23):3441–3.
  • Pisacane A, Impagliazzo N, Russo M, Valiani R, Mandarini A, Florio C, et al., Breast feeding and multiple sclerosis, BMJ, 1994;308:1411–12.

Further information

Breastfeeding and Chronic Medical Conditions, Wendy Jones

Anaesthesia and breastfeeding

I had the pleasure of working with a small team of anaesthetists for some time to develop guidelines so that breastfeeding mothers can have surgery, pain relief etc and continue to breastfeed as normal. The guideline also recommends support for the mother in terms of pumps, information and her baby nearby – not necessarily in that order.

In World Breastfeeding Week 2020 I was proud to share this guideline and infographic but sadly old habits seem to be coming back in with mothers advised incorrectly not to breastfeed for 24 hours after surgery. Policies seem to still need to be updated and training particularly of some pre-op nurses although many are up to date and well informed.

Guideline on anaesthesia and sedation in breastfeeding mothers is available in full at

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15179

Summary

Breastfeeding has many health benefits for the mother and infant. Women who are breastfeeding may require anaesthesia or sedation. Concerns regarding the passage of drugs into breast milk may lead to inconsistent advice from professionals. This can sometimes result in the interruption of feeding for 24 hours or longer after anaesthesia, or expressing and discarding (‘pumping and dumping’) breast milk; this may contribute to early cessation of breastfeeding. However, there are data regarding the transfer of most anaesthetic drugs into breast milk. We advise that breastfeeding is acceptable to continue after anaesthesia and should be supported as soon as the woman is alert and able to feed, without the need to discard breast milk. We provide evidence-based information on the pharmacokinetics of drugs commonly used during anaesthesia so that professionals can undertake a risk-benefit discussion with the woman. We advise the development of local policies that aid logistical planning and guide staff to facilitate breastfeeding during the woman’s hospital stay.

Recommendations

  1. Women should be encouraged to breastfeed as normal following surgery.
  2. There is no need to express and discard breast milk after anaesthesia.
  3. Anaesthetic and non-opioid analgesic drugs are transferred to breast milk in only very small amounts. For almost all drugs used peri-operatively, there is no evidence of effects on the breastfed infant.
  4. Drugs such as opioids and benzodiazepines should be used with caution, especially after multiple doses and in babies up to 6 weeks old (corrected for gestational age). In this situation, the infant should be observed for signs of abnormal drowsiness and respiratory depression, especially if the woman is also showing signs of sedation.
  5. Codeine should not be used by breastfeeding women following concerns of excessive sedation in some infants, related to differences in metabolism.
  6. Any women with an infant < 2 years should routinely be asked if they are breastfeeding during their pre-operative assessment.
  7. Opioid-sparing techniques are preferable for the breastfeeding woman. Local and regional anaesthesia have benefits in this regard, and also have the least interference with the woman’s ability to care for her infant.
  8. Where possible, day surgery is preferable to avoid disrupting normal routines. A woman having day surgery should have a responsible adult stay with her for the first 24 h. She should be cautious with co-sleeping, or sleeping while feeding the infant in a chair, as she may not be as responsive as normal.
  9. Breastfeeding support should be accessible for lactating women undergoing surgical and medical procedures.
  10. Patient information leaflets and additional resources should be available containing information on the compatibility of anaesthetic agents and analgesics during breastfeeding, and guidance on breastfeeding support in the peri-operative period.

Infographic guideline on anaesthesia and sedation in breastfeeding women

Citalopram and breastfeeding

Especially since the pandemic many more mothers have been asking about the compatibility of citalopram during breastfeeding. It has been a hard time for everyone with the incidence of anxiety and depression continuing to rise. As access to IAPT ( https://www.england.nhs.uk/mental-health/adults/iapt/) may be more difficult the prescription of medication is inevitable. Alternative CBT access may be available on line via and IESO (https://www.iesohealth.com/en-gb)

Citalopram is widely used and we have a high level of experience with it over many years. It is the drug of choice if it has been used by the mother in the past.

Unfortunately many doctors are, in my experience, still recommending that mothers should stop breastfeeding in order to take antidepressants. This may be that they think life would be easier if someone else could help with care of the baby or that the mother may get more sleep. Sadly, this doesnt always happen and the loss of oxytocin may also lower mood further.

There is often an assumption that pressure to breastfeed can lead to depression but in my experience pressure to stop breastfeeding in order to take medication may increase depression and may also stop mothers accessing professional help to avoid having that discussion.

This link to the RCGP perinatal mental health toolkit may be useful for professionals and parents

RCGP perinatal mental health toolkit

https://elearning.rcgp.org.uk/mod/book/view.php?id=13115

This factsheet contains information from my book Breastfeeding and Medication. Please message me for references used or with any questions.

See also https://breastfeeding-and-medication.co.uk/fact-sheet/depression-and-breastfeeding-2

https://www.breastfeedingnetwork.org.uk/factsheet/anxiety/

https://bnf.nice.org.uk/drugs/citalopram/#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.”

https://www.ncbi.nlm.nih.gov/books/NBK501185/

https://www.e-lactancia.org/breastfeeding/citalopram/product/

citalopram and breastfeeding factsheet pdf

Citalopram  is widely used by breastfeeding mothers.

It has a lower plasma protein binding than sertraline – less than 80% and the metabolite enters breastmilk in low levels. The manufacturer anecdotally reported cases of excessive somnolence, decreased feeding and weight loss in breastfed infants (Hale). However, more recent research suggests that symptoms are minimal and may not be associated with the use of this drug in lactation

There is one report of an infant exhibiting ‘uneasy’ sleep patterns on a maternal dose of 40 mg per day (Schmidt et al. 2000) that resolved when the mother’s dose was reduced and partial substitution with artificial formula undertaken.

Spigsett et al. (1997) studied two patients and estimated the absolute dose to the infant during steady-state conditions would be 0.7–5.9% of the weight-adjusted maternal dose.

Berle’s study (2004) of 25 women taking SSRI antidreprssants (nine taking citalopram) reported that  no adverse effects on the babies were noted. The infant serum levels of citalopram were undetectable in four infants and low in the remaining six.

Lee et al. (2004) conducted a prospective, observational study of 31 mothers suffering from depression and taking citalopram with 12 mothers with depression but not taking citalopram and 31 healthy control women and babies. Mothers were taking up to 60 mg citalopram daily. There were numerically more reports of adverse events in the trial group 3 per 31 (depressed and taking citalopram group) compared with 1 per 31 (control group) and 0 per 12 (depressed but not taking citalopram group) but this was not a statistically significant difference. Infants of the mothers in the group exposed to citalopram reported colic, decreased feeding and irritability.

Heikkinen et al. (2002) studied 11 mother and baby pairs with matched controls, for up to 2 months after delivery. The neurodevelopment of the children was monitored for up to 1 year. The levels in infant plasma were very low or undetectable. The delivery outcomes and development were normal. Relative infant dose quoted as 3.6% (Hale).

References

  • Berle JØ, Steen VM, Aamo TO, Breilid H, Zahlsen K, Spigset O, Breastfeeding during maternal anti-depressant treatment with serotonin reuptake inhibitors: infant exposure, clinical symptoms, and cytochrome P450 genotypes, J Clin Psychiatry, 2004;65:122834.
  • Heikkinen T, Ekblad U, Kero P, Ekblad S, Laine K, Citalopram in pregnancy and lactation, Clin Pharmacol Ther, 2002;72: 184–91
  • Lee A, Woo J, Ito S, Frequency of infant adverse events that are associated with citalopram use during breastfeeding, Am J Obstet Gynecol, 2004;190(1):21821.
  • Schmidt K, Oleson OV, Jensen PN, Citalopram and breastfeeding: serum concentration and side effects in the infant, Biol Psychiatry, 2000;47:1645.
  • Spigset O, Carieborg L, Ohman R, Norstrom A, Excretion of citalopram in breastmilk, Br J Clin Pharmacol, 1997;44(3):2958.

My book “Breastfeeding and chronic medical conditions” contains chapters on anxiety and depression

wendy@breastfeeding-and-medication.co.uk

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

Lowering / stopping milk supply and Breastfeeding

Sometimes mothers want to reduce their breastmilk supply. I’ve provided some information and links on herbs and medications – some things have evidence of effectiveness, many do not.

pdf lowering or stopping breastmilk supply

Sometimes mothers experience problems with excessive milk supply especially when weaning. Others may need or wish to stop their milk supply suddenly for a variety of reasons. Several options have been suggested;

Herbal products

  • Sage can be used as the herb, as a tea or as drops which are consumed can lower supply https://kellymom.com/bf/can-i-breastfeed/herbs/herbs-oversupply/
  • Jasmine flowers. In a 1998 study the use of topical application of jasmine flowers was compared to bromocriptine to suppress lactation immediately after birth. ( 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.)

Abstract (https://www.ncbi.nlm.nih.gov/pubmed/3214386?dopt=Abstract)

“The efficacy of jasmine flowers (Jasminum Sambac) applied to the breasts to suppress puerperal lactation was compared 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 2 modes of therapy to be equally effective. The failure rates of the 2 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  Peppermint, Spearmint, Parsley,

  • Chickweed, Black Walnut, stinging nettles Yarrow, Herb Robert Lemon Balm, Oregano, Periwinkle Herb, Sorrel.

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

Lowered milk supply as a side effect of 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.

Medication to stop milk supply

Two drugs have been marketed to stop milk production. These are bromicriptine (Parlodel ®) and cabergoline (Dostinex®). In the past they have been commonly used to dry up the milk of mothers of babies born sleeping or those who die soon after birth. In this situation the mother’s body will initiate milk production as normal.

These drugs have very severe side-effects, including vomiting, postural hypotension, fatigue, dizziness and dry mouth. Also, particularly with high doses, women may suffer confusion, psychomotor excitation, hallucinations; rarely diarrhoea, gastro-intestinal bleeding, gastric ulcer, abdominal pain, tachycardia, bradycardia, arrhythmia, insomnia, psychosis, visual disturbances, and tinnitus. 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.

The BNF contains a warning on the use of bromocriptine:

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. If a dopamine-receptor agonist is required, cabergoline is preferred.

The FDA approved indication for the use of bromocriptine for lactation suppression has been withdrawn, and it is no longer approved for this purpose due to numerous maternal deaths. In 2015, the French pharmacovigilance program 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 (reported in Hale online, accessed August 2016).

For the suppression of established lactation, cabergoline 0.25mg is taken every 12 hours for two days for a total of 1mg. However, this drug also has significant side effects, including headache, dizziness, fatigue or insomnia, orthostatic hypotension (feeling faint when you stand up), oedema, nose bleed, dry mouth, inhibition of lactation, nausea, constipation, anorexia and weakness. There may of course also be interactions with the drugs prescribed that have caused the cessation of breastfeeding.

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. https://goo.gl/fxA8Xi

“In 1975, 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. There were a lot of them in those years before HIV/AIDS became an issue. I would have LOVED donating Marisa’s milk. -Chantal”

“A counselor at the hospital instructed her in techniques to dry up her milk.”

“It’s funny,” Weidner said. “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.”

Natural reduction of milk supply

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.

Pharmacological methods of weaning versus conservative weaning

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.

Text Box: There are several  UK organisations which support bereaved mothers to donate breastmilk. There may be other European organisations. https://oursam.org.uk/memory-milk-lactation-milk-donation-after-loss/https://www.milkbankatchester.org.uk/donationafterloss/https://www.nhsggc.scot/hospitals-services/services-a-to-z/milk-bank-scotland/memory-milk-gift-donation-after-loss/https://humanmilkfoundation.org/hearts-milk-bank/donating-after-bereavement/ “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

Pain relief for acute back injury and Breastfeeding

So many mums seem to injure their backs – maybe we need antenatal classes on how to lift your baby (and equipment!) or more assessment of post-natal damage. When pain has not resolved with simple painkillers (paracetamol and ibuprofen (taken regularly and at full dose) sometimes further treatment is necessary from professionals. This may help the mother access physiotherapy or other mobility treatment.

Information here on how to treat the pain of acute back injury and relieve the spasm. I hope that it aids mothers and professionals.

Breastfeeding and pain relief for acute back injury

Non- steroidal analgesia

Normally mothers have taken ibuprofen along with paracetamol and may have found the pain has not resolved. I would suggest changing ibuprofen to naproxen or diclofenac to see if that helps. Both are compatible with breastfeeding. They should be taken with food and may be co-prescribed with omeprazole to protect the mother’s stomach from gastric bleed. The omeprazole is largely destroyed in the maternal gut and does not impact on breastfeeding. See https://www.sps.nhs.uk/articles/using-nsaids-during-breastfeeding

Muscle spasm

Muscle spasm relief can be achieved by the use of cold packs or heat packs. Topical rubs containing NSAIDS (Volatrol ®, Ibuleve®, PhorPain ®, Fenbid® etc) can be used with paracetamol. Ribs which produce warming or cooling can also provide relief along with massage to the area (Deep Heat ®, Tiger Balm®, Algesal® etc)

Up to a maximum of three days of diazepam 2mg 2-3 times a day to relive the spasm is also regularly used. It doesn’t seem to cause any problems used short term like this despite the long half-life. This is normally long enough to access some physio or other exercise regime. The evidence for this is largely anecdotal and based on my professional experience over the past 20 years. (Hale TW Medications and Mother’s Milk “Some reports of lethargy, sedation, and poor suckling have been found. The acute use such as in surgical procedures is not likely to lead to significant accumulation.”

Opiate pain relief

If greater pain relief is required, tramadol, Oramorph or dihydrocodeine are all breastfeeding compatible options.

  • Dihydrocodeine or co dydramol is widely used post c section and is now the opiate analgesic of choice due to the fact that it has a cleaner metabolism.
  • Morphine has extensive first pass metabolism so actually reaches low levels in milk. Oramorph is widely used
  • Tramadol reaches low levels in babies but can make mum very sleepy. Watch the baby for signs of drowsiness too.

Constipation

If you take co-dydramol or oramorph or any opioid you will need a laxative like lactulose, bisacodyl or dioctyl all of which you can buy from a pharmacy, See https://breastfeeding-and-medication.co.uk/fact-sheet/constipation-laxatives-and-breastfeeding

The following data is extracted from my book Breastfeeding and Medication 2018

Co-dydramol – paracetamol 500 mg and dihydrocodeine 10 mg.

Preferred compound analgesic due to cleaner metabolism than codeine. Use for as short a time as possible. Observe baby for drowsiness. If baby becomes drowsy stop drug immediately and seek medical advice.

Tramadol

Tramadol is an opiate analgesic used for moderate to severe pain. Its use would appear to have increased as a result of concern over codeine preparations. It is subject to first-pass metabolism. It has an elimination half-life of six hours. Tramadol inhibits the reuptake of noradrenaline and serotonin and may potentiate the action of other drugs with similar action, e.g. SSRI anti-depressants.

Ilett et al. (2008) studied 75 breastfeeding mothers who were given 100 mg tramadol post-caesarean section on days two–four. They collected milk and plasma samples of four or more doses to reflect steady state. Additionally, he observed the infants together with matched controls not exposed to tramadol. He determined a relative infant dose quoted as 2.24% for tramadol and 0.64% for its metabolite. No difference was noted in the behaviours of the infants exposed compared with the controls and the authors therefore concluded that short-term maternal use of tramadol is compatible with breastfeeding.

In 2015 the FDA recommended that tramadol is not used in breastfeeding mothers. When tramadol is taken, it is changed in the liver to O-desmethyltramadol (known as M1). Both tramadol and M1 relieve pain and are responsible for side effects that some people may experience, but M1 has stronger opioid effects than the tramadol. Tramadol is metabolised in the liver by enzyme cytochrome P450 isoenzyme 2D6 (CYP2D6). Some people have a variation of this enzyme that changes codeine to morphine and tramadol to M1 faster and to a greater extent than in other people. These individuals are called CYP2D6 ultra-rapid metabolisers. Just as in codeine, this can produce an accumulation of the drug in breastmilk. This genotype is present in up to 10% of the white population in Europe and North America, but only 4% of black African Americans (FDA 2015).

As with other opiates, exposure of premature infants should be undertaken with caution because of the risk of apnoea and sedation. Amount probably too small to be harmful, but manufacturer advises avoidance (BNF).

Avoid if possible although the amount in breastmilk is probably too small to be harmful. Use for as short a time as possible. Observe baby for drowsiness. If baby becomes drowsy stop drug immediately and seek medical advice.

  • FDA, Use of Codeine and Tramadol Products in Breastfeeding Women, FDA, 2015.
  • Ilett KF, Paech MJ, Page-Sharp M, Sy SK, Kristensen JH, Goy R, Chua S, Christmas T, Scott KL, Use of a sparse sampling study design to assess transfer of tramadol and its o-desmethyl metabolite into transitional breastmilk, Br J Clin Pharmacol, 2008;65(5):661–6.

Morphine

Therapeutic doses of morphine in the breastfeeding mother are unlikely to be harmful to baby in the short term, e.g. post-operatively. Infants under 4 weeks of age have a prolonged elimination half-life and clearance does not approach adult levels until 2 months of age. Respiratory difficulties may be important to be aware of with premature babies or others at risk of apnoea. The oral absorption of morphine is very poor and first-pass metabolism is high. It is therefore frequently used post-caesarean section as Oramorph solution.

Robieux et al. (1990) reported a single case of an infant who was breastfed while his mother was receiving low doses of morphine. Morphine concentration in his serum was in the analgesic range (4 ng per millilitre), while concentrations in the milk varied substantially from 10–100 ng per millilitre. The authors calculated that the baby had received 0.8–12% of the maternal dose. Oberlander et al. (2000) studied one baby born to a mother who received morphine intrathecally during and after pregnancy. Minimal levels were determined in breastmilk over seven weeks and the infant’s development and feeding up to seven months were normal. Baka et al. (2002) also studied women receiving patient-controlled analgesia post-caesarean section and noted that the concentrations of morphine in breastmilk were very small (<1 to 274 ng per millilitre) with a m/p ratio <1. Relative infant dose is quoted as 9.1% (Hale 2017 online access). Therapeutic doses unlikely to affect infant (BNF).

Compatible with use short term during breastfeeding. Observe baby for sedation and poor feeding.

References

  • Baka NE, Bayoumeu F, Boutroy MJ, Lexenaire MC, Colostrum morphine concentrations during postcesarean intravenous patient-controlled analgesia, Anesth Analog, 2002;94:184–7.
  • Ilett KF, Paech MJ, Page-Sharp M, Sy SK, Kristensen JH, Goy R, Chua S, Christmas T, Scott KL, Colostrum morphine concentrations during postcesarean intravenous patient-controlled analgesia, Anesth Analg, 2002;94:184–7.
  • Oberlander TF, Robeson P, Ward V, Huckin RS, Kamani A, Harpur A, McDonald W, Prenatal and breastmilk morphine exposure following maternal intrathecal morphine treatment, J Hum Lact, 2000;16:137–42.
  • Robieux I, Koren G, Vandenbergh H, Schneiderman J, Morphine excretion in breastmilk and resultant exposure of a nursing infant, J Toxicol Clin Toxicol, 1990;28:365–70.
  • Naproxen  
  • Naproxen is more than 99% bound to plasma proteins. Davies and Anderson (1997) reported that although naproxen is excreted into breastmilk, the amount of drug transferred comprises only a small fraction of the maternal exposure. In Jamali and Stevens’ study (1983) only 0.26% of the mother’s dose was recovered from the infant and adverse effect reports are low. However, this drug has a longer half-life than other NSAIDs, normally being taken only twice a day. The BNF considers that the amount of naproxen distributed into breastmilk is too small to be harmful to a breastfed infant; however, some manufacturers recommend that breastfeeding should be avoided during naproxen therapy, due to licencing considerations rather than potential risk. Relative infant dose is quoted as 3.3% (Hale 2017 online access). The BNF states that the amount in breastmilk is too small to be harmful but that the manufacturer advises use should be avoided.
  • Compatible with use during breastfeeding due to limited transfer into breastmilk.
  • References
  • Davies NM, Anderson KE, Clinical pharmacokinetics of naproxen, Clin Pharmacokinet, 1997;32:268–93.
  • Jamali F, Stevens DRS, Naproxen excretion in milk and its uptake by the infant, Drug Intell Clin Pharm, 1983;17:910–11.
  • Diclofenac  
  • Research studies are not widely documented as it is used less frequently in the USA than in the UK. However, the lack of reports of adverse effects suggests that there is little cause for concern. It has been one of the most widely used drugs in the immediate postpartum period in the UK but is now being replaced by naproxen because of the risk of cardio-vascular effects.
  • Oral diclofenac is almost completely absorbed but it is subject to first-pass metabolism so less reached the systemic circulation. Its high plasma protein binding (in excess of 99%) limits its passage into breastmilk. It is widely used on post-natal wards. Relative infant dose is quoted as 1% (Hale 2017 online access). The BNF states that the amount present in breastmilk is too small to be harmful.

Compatible with use during breastfeeding due to limited transfer into breastmilk.

Omeprazole  

Omeprazole is rapidly destroyed in acid conditions of the stomach below pH 4. It is also given to infants to treat severe gastric reflux. It is 95% bound to plasma proteins. It is not licenced for use in children below 1 year but is used outside of its licence application at a dose of 700 µg per kilogramme per day for reflux compared with an estimated dose through breastmilk of 3 µg per kilogramme per day passing through breastmilk in the study of one mother (Marshall et al. 1998). Hale 2017 (online access) quotes the relative infant dose as 0.02%.

Omeprazole suspension (unlicenced) is the only proton pump inhibitor liquid preparation available for administration to infants. This preparation is a ‘special’ and needs to be ordered by the pharmacy from a specials laboratory. However, it is not licenced for children under 1 year of age. It is metabolised by the cytochrome P450 system so potential interactions are possible. The BNF reports that it is present in milk but that it is not known to be harmful.

Compatible with breastfeeding as destroyed at pH <4. Used directly in children with severe gastro oesophageal reflux disease.

References

  • Marshall JK, Thompson AB, Armstrong D, Omeprazole for refractory gastroesophageal reflux disease during pregnancy and lactation, Can J Gastroenterol, 1998;12:225–7.
  • National Institute for Health and Care Excellence (NICE), Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people (cks.nice.org.uk/gord-in-children).

Pain relief after birth and breastfeeding

I was recently asked for input in a guideline on pain relief for new mothers after birth. I was surprised to see it almost seemed to penalise breastfeeding mothers suggesting that if you are breastfeeding you cant have effective pain relief for more than 3 days even if you have had a c section. I decided to put together this information. It includes pain relief, laxatives, haemorrhoidal treatment and iron supplements

After birth you may need pain relief for stitches, after pains as the womb contracts or if you need a caesarean section.

Standard pain relief which you might find useful to take regularly is paracetamol (2 tablets 4 times a day) and ibuprofen (400mg three times a day).

If this isn’t sufficient you can take:

  • co-dydramol – paracetamol and dihydrocodeine (latter available over the counter as Paramol although it will say don’t take if you are breastfeeding because the manufacturer doesn’t take responsibility). It can also be prescribed in combination or separately
  • naproxen or diclofenac which are stronger than ibuprofen – virtually none gets into breastmilk. These will need to be prescribed. See https://www.sps.nhs.uk/articles/using-nsaids-during-breastfeeding
  • You may be given morphine if you have a caesarean section and can feed as normal
  • oramorph – morphine liquid which will be prescribed in hospital after a c section
  • AVOID codeine as it may make your baby drowsy. Some people concentrate codeine in their milk. Most find that it makes them feel sick or dizzy themselves. See https://breastfeeding-and-medication.co.uk/thoughts/breastfeeding-and-codeine

Constipation

If you take co-dydramol or oramorph you will need a laxative like lactulose, bisacodyl or dioctyl all of which you can buy from a pharmacy, See https://breastfeeding-and-medication.co.uk/fact-sheet/constipation-laxatives-and-breastfeeding

Piles

IF you experience haemorrhoids (piles) after birth you can use suppositories and creams e.g. Anusol, Anusol HC, Preparation H, Germaloids, pharmacy own brands

Anaemia

You can take iron supplements after birth – ferrous sulphate or fumerate or gluconate.

Pain relief after a c section and Breastfeeding

This week I posted a link to a recently published paper which concluded that poor pain relief after a C section affected breastfeeding. https://consultqd.clevelandclinic.org/following-cesarean-delivery-postoperative-pain-affects-likelihood-of-in-hospital-breastfeeding/

I was saddened that we even had to think that pain would not be managed well for any mother, let alone when she was trying to initiate breastfeeding. It isn’t always easy to life a baby from a cot side crib when you have had surgery, let alone try to position a baby to achieve the perfect latch.

copyright Juliet Klottrup

What surprised and horrified me was the mother’s who replied that they hadnt been given good pain relief when in hospital. They mentioned:

  • not being told that more than paracetamol was available
  • being offered only paracetamol and ibuprofen even when they needed more
  • being forgotten on medication rounds,
  • being discharged without sufficient pain relief.

This just isnt good enough and I would hope that everyone to whom this applies contacts the ward directly or through PALS that pain management plans are essential.

Pain relief which should be given to a breastfeeding mum in my opinion:

  • In theatre a non steroidal anti inflammatory eg diclofenac as a suppository
  • On the ward there should be available oramorph (subject to extensive first pass metabolism so little in milk)
  • Discharge packs should include the NSAID offered in hospital plus limited number of dihydrocodeine(usually 5 days supply) and if necessary although rarely oramorph. This may challenge the formulary in the hospital but can be overcome simply with care and thought for the patient.
  • All opioids can cause nausea and dizziness but almost invariably cause constipation so it is wise to commence stool softeners like lactulose and/or docusate both of which are compatible with breastfeeding as they don’t pass into milk.
  • See https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.16008?fbclid=IwAR33__7INyztvFrQqcdMyyjZ0_eAWHis1KOGcsfkfOuixcMW6xZOYurxqQs Breast milk oxycodone concentrations in mothers given oxycodone for post-Caesarean delivery pain management

NO WOMAN SHOULD BE LEFT IN PAIN BECAUSE SHE IS BREASTFEEDING

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