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Pain relief when breastfeeding

It is not acceptable to leave any mother in pain because she is breastfeeding nor to suggest that she could have more effective pain relief if she stopped breastfeeding.

I’m often asked about the safety of opioids during breastfeeding so this is a really interesting study

Despite opioids being used first line in emergency settings to treat severe acute extremity pain, there is limited evidence available to inform this practice.

In a study in JAMA (7 November 2017), researchers randomly assigned 416 patients in the emergency department with moderate-to-severe acute extremity pain to one of the following groups: 400mg ibuprofen/1000mg paracetamol; 5mg oxycodone/325mg paracetamol; 5mg hydrocodone/300mg paracetamol; or 30mg codeine/300mg paracetamol[1].

https://jamanetwork.com/journals/jama/article-abstract/2661581?redirect=true

I have written this powerpoint presentation which I hope explains the analgesic ladder and helps professionals to understand the compatibility of analgesics and breastfeeding

  • Paracetamol or NSAID
  • Paracetamol + NSAID
  • Paracetamol+NSAID+Opioid (at the lowest possible dose for the shortest possible time co prescribed with a laxative)

Non steroidal anti inflammatory drugs

Opioids 

https://breastfeeding-and-medication.co.uk/thoughts/breastfeeding-and-codeine 

https://breastfeeding-and-medication.co.uk/fact-sheet/accidental-dose-of-codeine-when-breastfeeding

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://breastfeeding-and-medication.co.uk/fact-sheet/constipation-laxatives-and-breastfeeding

Analgesics and breastfeeding Powerpoint 

see also https://www.breastfeedingnetwork.org.uk/factsheet/analgesics/

https://breastfeeding-and-medication.co.uk/fact-sheet/dihydrocodeine-and-breastfeeding

https://breastfeeding-and-medication.co.uk/thoughts/breastfeeding-and-codeine

https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-neuropathic-pain-gabapentin-and-pregabalin

https://breastfeeding-and-medication.co.uk/fact-sheet/migraine-treatment-and-breastfeeding

https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-pain-relief-for-acute-back-injury

Rivaroxaban and other anticoagulants and breastfeeding

For many years the standard anti coagulants to treat and prevent deep vein thrombosis (DVT) have been heparin and low molecular weight heparionoids e.g Enoxaparin (Clexane®)  or alternately but generally less frequently Tinzaparin (Innohep®), Dalteparin (Fragmin®, Fondaparinux (Arixtra®). Alternatively warfarin may be given as a tablet but generally takes too long to stabilise the clotting mechanism. All of these drugs are compatible with breastfeeding. The sub cutaneous injections are too large molecules which cannot be absorbed from breastmilk (are not orally bio-available). Because of the very low milk levels with warfarin doses less than 12 mg daily, amounts ingested by the infant are small. No adverse reactions in breastfed infants have been reported from maternal warfarin use during lactation, even with a dose of 25 mg daily for 7 days. There is a consensus that maternal warfarin therapy during breastfeeding poses little risk to the breastfed infant. No special precautions are necessary. (Lactmed https://www.ncbi.nlm.nih.gov/books/NBK501137/).

See also Using heparins during breastfeeding Jan 2024 https://www.sps.nhs.uk/articles/using-heparins-during-breastfeeding/

Although these drugs are not absorbed from milk, caution is recommended where there is donation to a milk bank of surplus breastmilk. Should any small amount reach a pre-term baby it may result in a bleed with catastrophic results. There are no studies to confirm this but the recommendation is made to protect these most vulnerable babies.

Deep vein thrombosis

Whilst DVTs are uncommon they are 5 times more common in pregnancy and in the first 6 weeks after delivery than in women who are not pregnant.

The risk of developing DVT during pregnancy is even greater if :

  • there is a history or family history of DVT
  • age over 35
  • obese BMI >30
  • a severe infection or recent serious injury, which restrict exercise
  • thrombophilia
  • multiple birth
  • after fertility treatment
  • after a caesarean section
  • currently smoke
  • have severe varicose veins
  • dehydration

https://www.nhs.uk/pregnancy/related-conditions/complications/deep-vein-thrombosis/

If the clot breaks off into the bloodstream, it can block a blood vessel in the lungs. This is called a pulmonary embolism (PE) and needs emergency treatment. It may be investigated by a VQ or CT scan (preferably the latter as it involves no interruption of breastfeeding . See https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-after-vq-scans

The newer treatments to prevent clots are called Direct Oral Anticoagulant Medications (DOAC) which have advantages in that they are oral medications and need less frequent blood tests to confirm the INR.

UKDILAS have produced an excellent summary https://www.sps.nhs.uk/articles/using-oral-anticoagulants-in-breastfeeding-women/

Rivaroxaban  (Xarelto®): compatible with breastfeeding

Dabigatran (Pradaxa ®) compatible with breastfeeding

  • There are no studies on the transfer of dabigatran to breast milk. The molecular weight is large (628 Daltons) and the oral bioavailability is low (6.5%); therefore, clinically relevant levels are not expected to occur in a breastfed infant. (Hale).
  • In adults, less than 7% of dabigatran is absorbed orally in its prodrug form of dabigatran etexilate mesylate; dabigatran itself is not absorbed orally. Preliminary data from 2 individuals indicate that dabigatran is poorly excreted into breastmilk and unlikely to affect the breastfed infant. If the mother requires dabigatran, it is not a reason to discontinue breastfeeding. Because data are limited, monitor preterm or newborn infants for signs of bleeding. (Lactmed https://www.ncbi.nlm.nih.gov/books/NBK500744/
  • Its low oral bioavailability (EMA 2018, Blech 2008) hinders transfer to infant plasma via breastmilk, except in premature infants and the immediate neonatal period when there may be increased intestinal permeability.It is the oral anticoagulant with the lowest excretion in breast milk (Daei 2021). https://www.e-lactancia.org/breastfeeding/dabigatran-etexilate/product/
  • This is one of the preferred choice DOACs. Milk levels are likely to be low. Dabigatran etexilate is one of the largest of the DOAC molecules and has a large volume of distribution, therefore it would be expected to pass into breast milk in low amounts. Milk levels were tested from two breastfeeding women who took dabigatran etexilate 220mg as a single dose. The relative infant dose was calculated to be between 0.01 and 0.07%. The infants did not receive any breast milk during this time. Infant absorption is likely to be low. Dabigatran etexilate also has very low oral bioavailability, so the infant is unlikely to absorb clinically significant amounts from the breast milk. It is therefore very unlikely that the infant would get any side-effects.https://www.sps.nhs.uk/articles/using-oral-anticoagulants-during-breastfeeding/

Apixaban(Eliquis®) and Edoxaban (Lixiana®) due to limited research should not be prescribed during breastfeeding.

Glucosamine and chondroitin supplements during breastfeeding

More breastfeeding mums seem to have taken up running again or for the first time. We have all needed to take exercise in this strange world the past few years.

This is the information on glucosamine and chondroitin during breastfeeding – enjoy your running. Yes it is safe in breastfeeding :

https://kellymom.com/bf/can-i-breastfeed/lifestyle/mom-exercise/

Glucosamine

Glucosamine is either derived from shellfish or synthetically produced. The shellfish derived product should be avoided by anyone with a shellfish allergy.

It is most commonly used to treat osteoarthritis and joint pain or to prevent joint damage. A glucosamine derivative, N-acetylglucosamine, is a normal component of human breastmilk. Glucosamine occasionally causes stomach discomfort in adults  but is generally well tolerated. There are no studies on levels in breastmilk but it is poorly absorbed and metabolised in the liver so levels absorbed by the breastfed baby are likely to be very low.

Chondroitin

Chondroitin is a  mixture of large glycosaminoglycans and disaccharide polymers, usually derived from shark or bovine cartilage. It is most commonly used to treat osteoarthritis because it acts as a flexible connecting material between the protein filaments in cartilage.

Chondroitin is poorly absorbed orally with a bioavailability of about 10%. Its molecular weight averages 50,000 Daltons so is unlikely to be absorbed by breastfed babies at all.

 It is well tolerated in mothers with occasional gastrointestinal upset reported. Although no studies exist on the use of chondroitin sulphate supplements during breastfeeding, small amounts occur naturally in breastmilk. Mothers of preterm infants excrete greater amounts of chondroitin into breastmilk than mothers of fullterm infants.The use of chondroitin by a nursing mother is unlikely to adversely affect the breastfed infant.

References

Coppa GV, Gabrielli O, Zampini L et al. Glycosaminoglycan content in term and preterm milk during the first month of lactation. Neonatology. 2011;101:74-76. https://pubmed.ncbi.nlm.nih.gov/21934331/

Hale TW Medications and Mothers Milk

LactMed https://www.ncbi.nlm.nih.gov/books/NBK501922/

Detox products and Breastfeeding

I am often asked about products, usually herbal, to detox and about breastfeeding afterwards. In general these products contain a combination of herbal laxatives and at least one diuretic . Basically the result is to make you pass more urine and develop diarrhoea to “cleanse” the system and usually to lose weight. There is a large risk that in doing so your milk supply will diminish too.

The data on the safety of the herbs in breastfeeding is often poor. I cannot provide data that these products are either safe to use and feed as normal or that they are unsafe – there is just is not enough data that I would be confident in using. Therefore I cannot help with information. The decision has to be your own or on the recommendation of a qualified herbalist who is willing to take professional responsibility.

Collagen and breastfeeding

Collagen seems to be another frequent supplement I get asked about . Collagen is found in connective tissue and can be used during exercise routines but also in the prevention and treatment of wrinkles as well as to strengthen hair I believe.

There are no studies on passage into breastmilk and it would therefore be unethical for me to comment.

Elactancia however, designates it as very low risk:

“A fibrous-protein type which is a component of the mammalian connective tissue forming the attachment fibers of all tissues in the organism (bone, cartilage, tendons, skin, muscles, etc.). It represents one-third of total body’s protein content and is composed by amino acids.

Collagen has a great variety of medical, surgical, nutritional and industrial uses such as grafts, sutures, hemostatic products, subcutaneous implants and fillers, pill and capsule covering, glue and cement manufacturing, parts of musical instrument, cosmetic gels, food, photographic and pharmaceutical industry.

Collagen, because of its fibrous nature, is very difficult to chew and digest. To be used as a food it needs to be boiled and treated with various chemicals that break down the bonds and convert it into the so-called hydrolyzed, denatured collagen or gelatin, which is marketed as powder or tablets for various medicinal or health uses like arthritis, joint pains, weight loosing, anti-aging, strengthening of the hair or nails, improvement of the physical fitness and so on, all of them without any serious scientific basis that would guarantee effectiveness.(MedlinePlus Supplements 2015, Revenga 2015, EFSA 2013, EFSA 2011)

Since the last update we have not found any published data on its excretion in breast milk.

Because of a protein nature it is digested by the gastrointestinal tract and absorbed itself as a form of amino acids as those of any other meat. This prevents both the passage to breast milk as a hypothetical plasma absorption by the nursing infant.

Collagen as a supplement is not necessary at all whenever a healthy and balanced diet is followed. https://juanrevenga.com/2015/09/diga-colage-no-o-la-tonteria-de-los-suplementos-de-este-tipo/”

Caffeine and Breastfeeding

Several questions have come up recently about caffeine intake and breastfeeding. With spending more time indoors we are probably all drinking more caffeinated beverages.

Most of us drink caffeine in one form or another. Women who drink a significant amount of caffeinated drinks who notice that their babies are jittery and restless, may find reduction in caffeine consumption leads to resolution of symptoms. This does not mean that all breastfeeding women need to restrict their consumption of tea and coffee A baby who appears restless may benefit from lowered caffeine intake by the mother but for the average consumption there is little evidence to support restricting intake. From research maternal consumption below 300 milligrammes a day should not cause issues for breastfed babies.

Extract reproduced from Breastfeeding and Medication 2018 by Jones W (Routledge, London)

See also https://www.e-lactancia.org/breastfeeding/caffeine/product/

Moderate coffee consumption does not produce significant levels of caffeine in plasma or urine of infants, and may be undetectable or below therapeutic levels in the neonatal period. (Blanchard 1992, Fulton 1990, Berlin 1984, Hildebrandt 1983, Bailey 1982, Rivera 1977)

Doses greater than 300 – 500 mg of caffeine daily can cause nervousness, irritability and insomnia in the infant (Santos 2012, Martin 2007, Clement 1989, Rustin 1989), as well as decreased iron levels in breast milk and anemia in the infant (Muñoz 1988). Also has been related to the Raynaud’s phenomenon in the nipple of nursing women. (McGuinness 2013)

One study found no problems in infants whose mothers consumed 500 mg of caffeine daily for 5 days. (Ryu 1985)

There is insufficient evidence on the recommended amount of caffeine during lactation. (McCreedy 2018)

Breastfeeding during baby immunisation

As a new mum I remember how hard I found it holding my babies whilst they had their immunisations and hearing them cry. I always breastfed them as soon as I could to comfort them. I recalled a paper which mentioned using sucrose to relieve the pain during painful procedures. I recall it being in the BMJ but have it may not have been but may have been Abad (1996).

No one ever suggested that I could breastfeed during the immunisation because my babies were born back in the 1980s when breastfeeding was far from the norm after 6 weeks.

However, this paper has looked data from 10 trials, with results for 1,066 babies, mostly between one and six months old, following their normal immunisation schedule. They found that babies who were breastfed before and during routine childhood immunisations cried on average for 38 seconds less and had lower pain scores compared to babies not breastfed. Thirty-eight seconds may not sound a lot but to a mum witnessing her baby’s distress it definitely matters.

The authors noted “There is good evidence that breastfeeding during blood tests reduces pain in new-born babies (up to 28 days old), but the evidence was unclear for older babies. There were no evidence reviews looking at whether breastfeeding might help during painful procedures in babies aged one month to one year” which made me sad. It suggests that we still don’t consider breastfeeding is the norm and is about so much more than nutrition.

They mention that The good practice in postoperative and procedural pain management guideline from the Association of Paediatric Anaesthetists of Great Britain and Ireland, published in 2012, recommends that breastfeeding (along with swaddling, pacifiers, and sugar) should be considered for babies being vaccinated.

None of the included studies reported any adverse effects such as choking, gagging, spitting or coughing. No studies reported on the acceptability of breastfeeding, from the mothers’ or healthcare professionals’ perspective. The studies didn’t report on the practicalities of breastfeeding in the immunisation clinics but surely this isnt impossible to arrange?

So next time your baby needs an immunisation or you as a professional need to immunise a baby maybe this is something to think about?

References

Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. Sucrose for analgesia in new-born infants undergoing painful procedures. Cochrane Database Syst Rev. 2016 Jul 16;7(7):CD001069. doi: 10.1002/14651858.CD001069.pub5. PMID: 27420164; PMCID: PMC6457867. https://pubmed.ncbi.nlm.nih.gov/27420164/

Abad F, Díaz NM, Domenech E, Robayna M, Rico J. Oral sweet solution reduces pain-related behaviour in preterm infants. Acta Paediatr. 1996 Jul;85(7):854-8. doi: 10.1111/j.1651-2227.1996.tb14167.x. PMID: 8819554.

The good practice in postoperative and procedural pain management guideline from the Association of Paediatric Anaesthetists of Great Britain and Ireland

https://www.apagbi.org.uk/news/considerations-acute-and-chronic-pain-management-children-paediatric-anaesthesia-tutorial

Harrison D, Reszel J, Bueno M, et al. Breastfeeding for procedural pain in infants beyond the neonatal period. Cochrane Database Syst Rev. 2016;10:CD011248.

NHR Evidence Breastfeeding reduces crying during baby immunisation https://evidence.nihr.ac.uk/alert/breastfeeding-reduces-crying-during-baby-immunisation/

Bowel cleansing before colonoscopy and breastfeeding

Just recently I have been contacted by several mothers who were told that they cant breastfeeding during the 24 hour period of bowel prep prior to a colonoscopy or for 24 hours following the procedure under sedation. This is not supported by research and understanding of the pharmacokinetics of the drugs used. It is also a potential risk in that the mother may develop blocked ducts or mastitis necessitating antibiotics if she is unable to express her milk, or in many cases hasn’t been advised to! Not all babies will drink from a bottle so may become dehydrated. Some babies are allergic to cow’s milk protein and may be compromised by 3 days of artificial formula. Hence this fact sheet on the bowel preparations generally used.

It is acceptable to breastfeed as normal during bowel prep. The mother should drink freely of the allowed clear fluids. Someone may be needed to look after the baby during rapid need to evacuate bowels – unless you have taken these products you cant begin to understand the urgency!

PDF of information available

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/08/Moviprep-and-breastfeeding-1.pdf

An increasing number of breastfeeding mothers are having colonoscopies to investigate gut problems. The first stage of a colonoscopy is the use of a strong laxative and 24 hours of a fluid only diet to clear out the gut so that the professionals can see the gut in its entirety completely.

Many mothers worry that not eating for 24 hours will reduce their milk supply. Fasting does drop the supply a small amount for some women but frequent feeds seem to overcome problems. It is important to keep drinking the clear fluids which are allowed in order not to dehydrate.

From experience you may find that you need someone else in the house to take the baby urgently when you have to rush to the toilet – there is no waiting! You may find otherwise that you end up feeding whilst on the loo for practical reasons. The bowel washouts produce considerable urgency

Movicol®

One of the most commonly used laxative agents to clear the gut is Movicol ® otherwise known as polyethylene glycol- electrolyte solution. It is a saline laxative which is not absorbed from the gut but pulls water into the bowel to wash the contents out. Because it is not absorbed from the gut it cannot get into breastmilk and would not affect the baby.

MoviPrep®

This dual sachet product contains macrogol and electrolytes in 2 different sachets, Because it is not absorbed from the gut it cannot get into breastmilk and would not affect the baby.

Plenvu ®

This powder contains macrogol and electrolytes in sachets, Because it is not absorbed from the gut it cannot get into breastmilk and would not affect the baby.

Picolax®

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

KleanPrep ®

KleanPrep contains  macrogol 3350 , an osmotic laxative with a high molecular weigh and zero oral bioavailabilty. Like Moviprep it  accumulates water into the GI tract, where it acts as a laxative. It would be very unlikely to enter the plasma of the mother, or milk.

Citramag®

The ingredients magnesium carbonate and citric acid will form an osmotic laxative by pulling water into the bowel and stimulating the bowel to evacuate. Poor oral absorption of magnesium make it unlikely that any will be absorbed from milk to affect the breastfed baby.

Senna

Senna is a stimulant laxative. Its key ingredient (anthraquinone), is believed to increase bowel activity due to secretion into the colon. It may produce abdominal cramps. In one study of 23 women who received Senokot none was detectable in their milk.[1] Of 15 mothers reporting loose stools, two infants had loose stools (Werthmann 1973). However, in a randomized, double-blind trial comparing Senokot tablets to placebo, of the women in the study, 126 breastfed their infants and took senna while 155 control mothers breastfed their infants. There was no difference in the percentages of infants in the active and control groups with loose stools or diarrhoea (Shelton 1980). In this study 8 doses were taken. In bowel preparation a single dose only is used.

Werthmann MW Jr, Krees SV. Quantitative excretion of Senokot in human breast milk. Med Ann Dist Columbia. 1973;42:4-5.

Shelton MG. Standardized senna in the management of constipation in the puerperium. A clinical trial. S Afr Med J. 1980;57:78-80.

Phosphate enema (Fleet®)

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

Bisacodyl (Dulcolax ®)

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

For information on sedatives  (midazolam, fentanyl, pethidine) used in colonoscopies see separate fact sheet . These also do not preclude normal breastfeeding as soon as the mother is awake and alert.

Bismuth subsalicylate (Pepto Bismol®) and Breastfeeding

Another of the frequently asked questions is the use of Pepto Bismol™ for indigestion or nausea

Pepto Bismol™ is marketed to relieve symptoms of upset stomach and diarrhoea. It’s active ingredient is bismuth subsalicylate, so it is related to aspirin which we avoid during breastfeeding at painkilling doses.

We are unsure if bismuth subsalicylate passes into a mother’s breast milk. Although bismuth salts are poorly absorbed from the maternal GI tract, significant levels of salicylate could be absorbed in theory. There are currently no reports of Reye’s syndrome in babies exposed to bismuth subsalicylate and it is normally only used very short term for stomach upset.

Breastfeeding mothers would be well advised to use alternative products to treat acute diarrhoea E.g. loperamide (Imodium®) if possible. However, In my experience of queries Pepto Bismol may be the only product available late at night and at weekends. The risk of short term use is probably low although this cannot be proved. The decision remains with the mother as to whether she wants to take it. Continuing to breastfeed during a stomach upset transfers antibodies to the baby to offer protection from the bacterial or viral condition.

It is also advertised to treat heartburn and indigestion for which there are many alternative remedies which are safe in breastfeeding, containing aluminium, calcium and magnesium carbonate.

See also https://www.e-lactancia.org/breastfeeding/bismuth-sub-oxysalicylate-2/synonym/

A very small amount of bismuth is absorbed from the gut: ≈ 0.1% (Tora 2020, Chen 2010, Boertz 2009, Dresow 1992, Nwokolo 1990: Bismuth is not absorbed into the systemic circulation of the mother, so it cannot be excreted in breast milk.

Salicylate is well absorbed (Nwokolo 1990), but is excreted in breast milk in negligible amounts, and the infant receives a relative dose of 1% (see Aspirin) and no cases of Reye’s syndrome have been reported after taking bismuth salicylate or other non-acetylated salicylate compounds.

Due to the otherwise minimum risk of Reye’s syndrome and the indiscriminate use of bismuth subsalicylate for treatment of gastroenteritis cannot be justifiable since most of gastroenteritis do not require medication instead a simply adequate hydration, a safer alternative should be desirable while breastfeeding. (Chen 2010, Nice 2000) 

Betahistine and Breastfeeding

Betahistine (Serc ) is prescribed for dizzines and vestibular problems. There is little research available on it, because it isnt marketed in USA where most of the research studies are conducted. Anecdotally it is quite widely used without apparent problems. Observe the nursing baby for signs of drowsiness/ poor feeding in case

This is the entry I made for Breastfeeding and Medication 2018

“Betahistine is prescribed for vertigo, tinnitus and hearing loss associated with Ménière’s disease. There is no data on the amount that passes into breastmilk . It is an analogue of histamine and is believed to work by improving the microcirculationn of the labarynth. Side effects are reported to include gastro-intestinal disturbances, headache,  pruritus and rashes. Prochlorperazine or cinnarazine would be the preferred to drug to treat dizziness. If betahistine use is perceived as essential the baby should be observed for drowsiness, GI disturbance and rash. There are no animal studies on use during lactation. Plasma levels of betahistine are very low. Plasma protein binding <5% (manufacturer SPC) Anecdotally it has been used without problems in breastfed babies “

See also https://www.e-lactancia.org/breastfeeding/betahistine/product/

Because of pharmacokinetic data it is likely excretion into breast milk, but though from very low plasma levels, usually below the detection threshold (100 pg/mL), so it is unlikely that the amount that could reach breast milk is significant.

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