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.
Agnus Castus and Breastfeeding
I am not going to pretend that I am an expert on complimentary medicine but I am frequently asked about Agnus Castus for fertility and menstrual issues so am including this information based on the LactMed entry
Agnus Castus and Breastfeeding Fact Sheet
Other information may be found in :
- Herbs and Breastfeeding: References. https://kellymom.com/bf/can-ibreastfeed/herbs/herbal-ref/
- Herbal safety for nursing moms. https://kellymom.com/bf/can-ibreastfeed/herbs/herbal_safety/
- The Nursing Mother’s Herbal 2003 by Shelia Humphrey. Available from Amazon £9.99
Agnus-castus (Chasteberry) is from the berries of the chaste tree. The berries contain essential oils Chasteberry is often used for irregularities of the menstrual cycle, infertility, premenstrual complaints, and cyclical breast pain. [Dennehy 2006]
In low doses, chasteberry increases serum prolactin and it is a purported to increase milk supply (a galactogogue). [Javan 2017] however, no scientifically valid clinical trials support this use. Galactogogues should never replace evaluation and counselling on modifiable factors that affect milk production. [ Brodribb 2017, ACOG 2021] Some evidence indicates that high doses of chasteberry decrease serum prolactin and might decrease lactation. [ Eglash 2014 ] It has been used to decrease breastmilk oversupply in Persian traditional medicine.[Kabiri 2017]
In general, chasteberry is well tolerated. The most frequent adverse events are nausea, headache, gastrointestinal disturbances, menstrual disorders, acne, pruritus, and erythematous rash; however, all are mild and reversible. Among 352 nursing mothers given chasteberry tincture, 15 cases of pruritus, exanthema, urticaria, and some cases of early menstrual period occurred. Because of concerning safety data and possible lactation suppression, chasteberry should be avoided during lactation. [Daniele 2005]
See also https://www.e-lactancia.org/breastfeeding/vitex-agnus-castus/writing/
References
- Dennehy CE. The use of herbs and dietary supplements in gynaecology: an evidence-based review. J Midwifery Womens Health. 2006; 51:402–9. https://pubmed.ncbi.nlm.nih.gov/17081929/
- Javan R, Javadi B, Feyzabadi Z. Breastfeeding: A review of its physiology and galactogogue plants in view of traditional Persian medicine. Breastfeed Med. 2017; 12:401–9. https://pubmed.ncbi.nlm.nih.gov/28714737/
- Brodribb W. ABM Clinical Protocol #9. Use of galactogogues in initiating or augmenting maternal milk production, second revision 2018. Breastfeed Med. 2018; 13:307–14. https://pubmed.ncbi.nlm.nih.gov/29902083/
- Breastfeeding challenges: ACOG Committee Opinion, Number 820. Obstet Gynecol. 2021;137: e42–e53. https://pubmed.ncbi.nlm.nih.gov/33481531/
- Eglash A. Treatment of maternal hypergalactia. Breastfeed Med. 2014; 9:423–5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216483/
- Kabiri M, Kamalinejad M, Sohrabvand F, et al. Management of breast milk oversupply in traditional Persian medicine. J Evid Based Complementary Altern Med. 2017; 22:1044–50 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871304/
- Daniele C, Thompson Coon J, Pittler MH, et al. Vitex agnus castus: A systematic review of adverse events. Drug Saf. 2005; 28:319–32. https://pubmed.ncbi.nlm.nih.gov/15783241/
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.
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)
- Regular use of an NSAID – ibuprofen, diclofenac or naproxen (low levels in milk) plus paracetamol See https://www.sps.nhs.uk/articles/using-nsaids-during-breastfeeding
- Codeine is no longer recommended but dihydrocodeine can be offered https://breastfeeding-and-medication.co.uk/thoughts/breastfeeding-and-codeine
- (https://breastfeeding-and-medication.co.uk/thoughts/dihydrocodeine-and-breastfeeding)
- 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.
- Breast milk oxycodone concentrations in mothers given oxycodone for post-Caesarean delivery pain management. https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.16008
NO WOMAN SHOULD BE LEFT IN PAIN BECAUSE SHE IS BREASTFEEDING
