Steroid injections and Breastfeeding
Steroid injections, are anti-inflammatory medicines used to treat a range of conditions such as joint pain, arthritis, and sciatica. If you’re having an injection to relieve pain, it will usually also contain local anaesthetic. This provides immediate pain relief that lasts up to a few hours.
They can be given in several different ways, including:
- into a joint (an intra-articular injection)
- into a muscle (an intramuscular injection)
- into the spine (an epidural injection)
The injections normally take a few days to start working, although some work in a few hours. The effect usually wears off after a few weeks or months. During this time the steroid is released very slowly and locally. The amount passing into your blood, let alone milk is very small and insignificant to the level that can be given orally. There is no need to interrupt breastfeeding after a local steroid injection.
E.g. Depo-medrone with lidocaine™ (methylprednisolone with lidocaine),
Local anaesthetics and Breastfeeding
Local anaesthetics are quite widely used in society from repairing the damaged perineum in childbirth to tooth fillings and extractions as well as biopsies of the breast.
I find it fascinating that women are still advised to interrupt breastfeeding for a period after the injection. If you think about this from a common sense point of view we know that only the very local area around the injection is numbed. If the dentist injects into your gum, your arm doesn’t become numb? Which supports why there is no need to stop breastfeeding for even a moment because it doesn’t get absorbed from milk.
Having said that one women who contacted me had been told by her dentist that if she continued to feed her baby would damage her nipples as the mouth would be numb!
Local anaesthetics are also included in lozenge and sprays for sore throats https://breastfeeding-and-medication.co.uk/fact-sheet/sore-throat-tonsilitis-and-breastfeeding and these are compatible with breastfeeding.
Some practitioners are concerned that injecting into the breast during a biopsy makes it more likely that the anaesthetic will more likely be absorbed into the milk due to proximity to the milk ducts. There is no evidence for this and the most important pharmacokinetic factor is that the drug is poorly bio-available and generally have a short half life.
Local anaesthetics may also be included with steroids in injections into joints which are also compatible with breastfeeding.
Benzocaine (taken from Hale online access):
temporarily relieves pain associated with minor cuts, minor burns, itching. There are no adequate and well-controlled studies or case reports in breastfeeding women. Due to its poor bioavailability after topical application, concentrations achieved in maternal plasma are probably too low to produce any significant clinical effects in the breastfed infant. Dental procedure benzocaine usage is minimal and should pose no harm to the breastfed infant. Maternal plasma and milk levels do not seem to approach high concentrations and the oral bioavailability in the infant would be quite low (<35%).
Lidocaine
Oral bioavailability <35% https://www.e-lactancia.org/breastfeeding/lidocaine/product/ and compatible with topical application
BNF “Present in milk but amount too small to be harmful.”
Sore throat, tonsilitis and Breastfeeding
Most of us can identify with the pain of a sore throat when having symptoms of a cold, although sore throats can also manifest as tonsilitis which is inflammation of the tonsils, two oval-shaped pads of tissue at the back of the throat — one tonsil on each side. Signs and symptoms of tonsillitis include swollen tonsils, sore throat, difficulty swallowing and tender lymph nodes on the sides of the neck.
Sore throats can be soothed by sucking anything which has a demulcent effect including sipping glycerine, honey and lemon drinks, raisins, cool drinks or ice cream. Sucking over the counter lozenges and using sore throat sprays. sprays e.g. Difflam™, Vick Chloraseptic™, Own Brands and lozenges which may include a local anaesthetic or an anti-inflammatory eg Strepsils™, Dequadin™ and Dequacaine™, Jackson’s lozenge™, glycerine and honey pastilles, Strefen™
The leaflets within packaging may include wording such as “ ask your GP or pharmacist before using this product if you are breastfeeding”. This is due to licence application rather than risk.
The main symptoms of tonsilitis in children and adults are: https://www.nhs.uk/conditions/tonsillitis/
- a sore throat
- problems swallowing
- a high temperature
- coughing
- a headache
- feeling and being sick
- earache
- feeling tired
Sometimes the symptoms can be more severe and include:
- swollen, painful glands in your neck
- pus-filled spots or white patches on your tonsils
- bad breath
Tonsilitis can least a few days. Treatment To help treat the symptoms include getting plenty of rest (not always easy with children around) and the over the counter remedies listed above. If you continue to have a raised temperature you can consult a local pharmacist via the walk in scheme https://www.england.nhs.uk/primary-care/pharmacy/pharmacy-services/pharmacy-first/ rather than waiting to see a GP.
The normal antibiotic for a non penicillin allergic mother is penicillin V tablets which are compatible with breastfeeding. Other antibiotics are available for penicillin allergic people. https://breastfeeding-and-medication.co.uk/fact-sheet/antibiotics-and-breastfeeding
Cystitis and Breastfeeding
PDF https://breastfeeding-and-medication.co.uk/wp-content/uploads/2024/06/cystitis-and-breastfeeding.pdf
Cystitis is defined as a urinary tract infection (UTI) that affects the bladder. It’s common, particularly in women. It often gets better by itself, but may sometimes be treated with antibiotics. Some people get cystitis frequently and may need regular or long-term treatment.
Early symptoms of cystitis can be treated by drinking lots of watery liquids and the use of over the counter remedies containing sodium citrate (Effercitrate, . This does not pass into breastmilk but just makes the urine more alkaline and less attractive to the bacteria causing the infection. Sodium citrate is added to formula milk.
Symptoms of cystitis include:
- pain, burning or stinging when you pass urine
- needing to wee more often and urgently than usual
- urine that’s dark, cloudy or strong smelling
- pain low down in your abdomen
Treatment of cystitis
- Drink lots of watery drinks until your urine becomes pale in colour although the instinct is not to drink as much to avoid having to wee and the associated pain which can be enough to make you want to cry.
- Try over the counter remedies which alter the pH of the urine to discourage the growth of the bacteria.
- If symptoms don’t improve or the pain moves up to your kidney area with the passing of blood seek medical attention as soon as possible. Most pharmacies now offer a walk in service.
Medication for cystitis
- Over the counter remedies usually contain sodium or potassium citrate e.g. Cystopurin, Effercitrate, CanesOasis, Own Brands. These are all compatible with breastfeeding https://www.e-lactancia.org/breastfeeding/sodium-citrate/product/
- Prescribed medication may depend on the results of the results of your urine sample to identify which anti-biotic the bacteria would be sensitive to and indeed whether an infection is present or absent. These include Trimethoprim, Amoxycillin, Nitrofurantoin, These are all compatible with breastfeeding https://breastfeeding-and-medication.co.uk/fact-sheet/antibiotics-and-breastfeeding
- Repeated UTI may need long term antibiotic but are often related to vaginal dryness due to perimenopause and sexual intercourse. https://www.nhs.uk/conditions/cystitis/
- Some women find that cranberry juice is useful and is compatible with breastfeeding although the evidence base of efficacy is poor
- A frequently asked question is about the use of D-mannose as a supplement. There is no research on the amount passing into milk. The risk appears low according to https://www.e-lactancia.org/breastfeeding/mannose-d-mannose/product/
Anti-diarrhoea medication and Breastfeeding
This information is largely taken from my book Breastfeeding and Medication (Routledge 2017)
Diarrhoea is defined as passing looser, watery or more frequent poo (stools) than is normal for you. It affects most people from time to time and is usually nothing to worry about. It can be distressing and unpleasant. It normally clears up in a few days to a week. It is often caused by bacteria in addition to vomiting but can occur alone. It may be part of another chronic condition e.g. inflammatory bowel disease.
Diarrhoea can lead to dehydration, involving excess water and electrolyte loss. Optimal treatment is oral rehydration. Acute diarrhoea is generally self-limiting and may be seen as the body’s attempt to rid itself of the infection. However, many people are unwilling to put up with the inconvenience of frequent, watery stools for more than a short period. Breastfeeding mothers may be concerned that their milk will dry up if their own symptoms of diarrhoea are not treated quickly. Mothers should be encouraged to drink according to thirst and to take rehydrating solutions in addition to anti-motility agents if there is excess fluid loss. Careful hygiene is important but there is no reason to stop breastfeeding if the mother has diarrhoea as she will pass on antibodies to the infection to her baby via the entero-mammary pathway.
Rehydration products are suitable for artificially fed infants in addition to formula milk during episodes of diarrhoea. Breastfeeding should be continued freely and should not be replaced by rehydration fluids. Exclusively breastfed babies have a very low risk of diarrhoea.
Rehydration therapy (Dioralyte®, Electrolade® Own Brands)
Rehydration solution sachets contain balanced levels of sugar and salts to correct the electrolyte and fluid balance. They would not affect breastfed babies as no significant levels would be passed into breastmilk. They may prevent dehydration of the mother with severe diarrhoea.
Compatible with use during breastfeeding as they only restore normal electrolyte balance.
Loperamide (Imodium®, Imodium Plus® (with simeticone), Own Brands)
Loperamide provides symptomatic relief of diarrhoea by inhibiting gut motility. Only small amounts are found in breastmilk as it is poorly absorbed (Nikodem and Hofmeyr 1992) making this a suitable drug to be taken by a breastfeeding mother. It is licensed to be given to children over the age of 4 years in syrup formulation at a dose of 1 mg three or four times daily for a maximum of 3 days.
For babies and children continued breastfeeding if applicable, and rehydration is generally recommended unless symptoms continue, as loperamide has been associated with toxicity and paralytic ileus.
Relative infant dose is quoted as 0.03% (Hale online access). The BNF states that amount secreted into breastmilk is probably too small to be harmful.
Compatible with breastfeeding as poorly absorbed from the gut.
References
Nikodem VC, Hofmeyr GJ, Secretion of the antidiarrhoeal agent loperamide oxide in breastmilk , Eur J Clin Pharmacol, 1992;42:695–6.
Codeine phosphate
The BNF states that the amount secreted into breastmilk is usually too small to be harmful; however, mothers vary considerably in their capacity to metabolise codeine and there is a risk of morphine overdose in infants (Koren et al. 2006). One death of an infant has been reported where the mother was an ultra-rapid metabolizer.
A study of two mothers found very low levels of free codeine and its metabolite morphine, in the plasma of breastfed infants whose mothers had taken a 60 mg dose of codeine. It was considered that such levels were sub-therapeutic and unlikely to cause respiratory depression (Naumburg et al. 1987). However concerns raised by Koren are important to take into consideration.
Relative infant dose quoted as 0.6% – 8.1% (Hale 2017 online access). Other preparations such as loperamide may be considered more suitable for a breastfeeding mother (see concern over codeine use under analgesics section).
Use loperamide as alternative if possible to control diarrhoea during breastfeeding as codeine may accumulate in baby and cause respiratory depression.
References
Koren G, Cairns J, Chitayat D, Gaedigk A, Leeder SJ, Pharmacogenetics of morphine poisoning in a breastfed neonate of a codeine-prescribed mother, Lancet, 2006;368(9536):704.
Naumburg EG, Meny RG, Findlay Brill JL and Alger LS. Codeine and morphine levels in breastmilk and neonatal plasma, Pediatr Res, 1987;21(4, pt 2):240A. Abstract.
Lomotil® Co-phenotrope (diphenoxylate plus atropine)
Co-phenotrope is a synthetic derivative of pethidine but has no analgesic effects. It reduces intestinal motility and is particularly useful in the control of faecal consistency after colostomy or ileostomy. It is rarely used purely as an anti-diarrhoeal drug any more. There is little information on its transfer into breastmilk and its use in lactation is not recommended. Unless there are compelling reasons to use co-phenotrope, loperamide is a safer option.
The BNF states that it may be present in milk.
Use loperamide as alternative if possible to control diarrhoea during breastfeeding as limited information on amount passing into breastmilk.
Orlistat for Weight Loss and Breastfeeding
orlistat and breastfeeding (2018)
See also https://breastfeeding-and-medication.co.uk/fact-sheet/semaglutide-and-breastfeeding
Orlistat Brand name: Xenical®, Alli®
Orlistat is a lipase inhibitor and reduces the absorption of dietary fat. It is used in conjunction with a hypocalorific diet with a low-fat level. Orlistat may reduce the absorption of fat-soluble vitamins. There is no information on its use in lactation although it is reported to be minimally absorbed after oral doses (Martindale 2017). In the absence of safety data, lifestyle advice and support may be preferable.
Hale (2017 online access) comments that ‘With high protein binding, moderately high molecular weight, and poor oral absorption, it is unlikely that orlistat would enter breastmilk in clinically relevant amounts, or affect a breastfeeding infant’. In the presence of fats orlistat can produce explosive diarrhoea. As breastmilk is high in fat there may be a concern that the baby may produce similar bowel motions, although these have not been reported in any publication.
The BNF states that “No information is available and it should be avoided”.
Practical Suggestions
When I worked with patients trying to lose weight, I found that in the period where they had to prove they were determined to lose weight, they lost more than once orlistat was prescribed. In fact, I rarely needed to prescribe it. Biggest hint I found useful, is to use a smaller plate and as with smoking cessation distract yourself when you are hungry by cleaning teeth, washing the kitchen floor or drinking a whole tumbler of water. Also have an event or photo which you want lose weight for on the fridge / biscuit tin!
The commercial slimming companies like Slimming World® and Weight Watchers® have programmes for breastfeeding mums.
Tips for a low fat, high fibre diet
https://patient.info/health/obesity-overweight/features/orlistat-healthy-eating-guide
- Change from butter or regular spreads to a low-fat spread such as Flora Light®, Bertolli Light® or supermarket versions.
- Choose lean cuts of meat and trim visible fat. Avoid skin on chicken and crackling on pork.
- Avoid added fat/oil when cooking, (or use a spray oil) – grill, poach, bake or microwave instead.
- Choose low-fat dairy foods such as semi-skimmed or skimmed milk, low-calorie yoghurts, reduced-fat cheeses and low-fat spreads.
- Choose lower-fat cook-in sauces with less than 5 g fat per 100 g sauce.
Fibre, fruit and vegetables
Fibre is needed in the diet to help maintain a healthy digestive system, fill you up and it can also help to reduce raised cholesterol levels.
Look carefully at portion sizes
Hale (2024) “Orlistat, is used in the management of obesity. It is a reversible inhibitor of gastric and pancreatic lipases, thus it inhibits absorption of dietary fats by 30%.[1] No studies have been performed on the transmission of orlistat to the breast milk. With high protein binding, moderately high molecular weight, and poor oral absorption, it is unlikely that orlistat would enter breast milk in clinically relevant amounts, or affect a breastfeeding infant. However, due to orlistat’s effect on the absorption of fat soluble vitamins and other fats, nutritional status of a breastfeeding mother should be closely monitored.”
References
- Jones W Breastfeeding and Medication 2018
- Hale TW Medication and Mother’s Milk 2018
Weight Loss and Breastfeeding
I used to run a weight loss clinic in my earlier role as a prescribing pharmacist. Losing weight is hard let alone when you are breastfeeding and sleep deprived.
See https://breastfeeding-and-medication.co.uk/fact-sheet/semaglutide-and-breastfeeding
I’m sharing the brilliant information developed by Dr Hale and Dr Krutsch which I couldnt possibly improve on. It includes a weight loss calorie calculator if that interests you
https://www.infantrisk.com/content/weight-loss-lactation
https://www.infantrisk.com/weight-loss-while-breastfeeding-calculator
Eye preparations and Breastfeeding
This is largely based on information from my book Breastfeeding and Medication (Routledge). For any queries please email wendy@breastfeeding-and-medication.co.uk
To minimise the absorption of any drug into the blood stream naso-lachrymal occlusion (pressing over the tear duct to close it off) as the drops are instilled can be applied.
Absorption of eye drops into breastmilk is unlikely in the majority of conditions:
- Local anaesthetic drops e.g. lignocaine;
- Antibacterial eye drops e.g. chloramphenicol, fusidic acid (Fucithalmic );
- Antiviral eye drops e.g. aciclovir (Zovirax®);
- Corticosteroid eye drops e.g. betamethasone (Betnesol®), prednisolone (Predsol®);
- Ocular lubricants e.g. hypromellose, carbomers.
- Anti-histamine eye drops for hayfever/allergy e.g. Sodium cromoglycate®
Compatible with use during breastfeeding due to poor bio-availability.
Eye Infections
Conjunctivitis treatment is one of the most commonly asked questions. Chloramphenicol drops can be sold over the counter by a pharmacist but in most cases this is outside of the product licence during breastfeeding. This does not imply risk only that the manufacturer has not conducted trials and accepts no responsibility. There is one reported case of bone toxicity but this was when the breastfeeding mother was taking the drug orally rather than using eye drops where absorption is lower. (https://www.ncbi.nlm.nih.gov/books/NBK501494/). Fucidic acid drops (Fucithalmic ®) are preferred where possible but currently this requires a prescription.
Beta blocker eye drops
There is concern over the systemic absorption of beta blockers to treat glaucoma and consideration should be given if the baby suffers from asthma or heart disease and the mother alerted to the possibility, even if remote, of adverse reactions.
In a case report of a single mother (Lustgarten and Podos 1983) who used one drop of 0.5% timolol maleate, the authors estimated that use of 0.5% timolol drops in one eye twice daily gave the infant 0.63% of a cardiac dose . No side effects were reported.
Johnson et al. (2001) reported on one mother who used eye drops of timolol, dipivifrin, dorzolamide and brimonidine as well as oral acetazolamide. No apnoea or bradycardia was observed in the infant.
Compatible with use during breastfeeding, according to the results of limited studies.
References
- Johnson SM, Martinez M, Freedman S, Management of glaucoma in pregnancy and lactation, Surv Ophthalmol, 2001;45:449–54.
- Lustgarten JS, Podos SM, Topical timolol and the nursing mother, Arch Ophthalmol, 1983;101:1381–2.
Fluorescein ophthalmic solution
A 2% solution may be used to detect corneal abrasions, to fit contact lenses by direct application to the eye. It may also be used intravenously for fluorescein angiography. Maquire 1988 studied the breastmilk of a 29 year old mother who had an angiograph soon after delivering premature twins. She herself had lost central vision acutely soon after she gave birth. The fluorescein was detectable up to 76 hours after the procedure (half life 62 hours) . The peak concentration measured at 6 hours was 372 µg/L. This represents a milk/plasma ratio would be about 0.018 (Hale 2017) representing a small risk to the breastfed infant.
Compatible with use during breastfeeding, according to the results of limited studies.
Maquire AM, Bennett J. Fluorescein elimination in human breast milk. Arch Ophthalmol 1988; 106(6):718-719.
Anal fissures and breastfeeding
Anal fissures are very painful. They may initially be treated as piles but simple treatment does not heal them
Anal fissures are small tears in the inside in the lining of the large intestine near the anus. Sometimes they do not heal and produce severe pain. This may be treated with glyceryl trinitrate ointment (Rectogesic™) 0.2% or 0.4%. The ingredients may cause a headache and/or hot flush for the mother but there are no reports of adverse effects in babies whose mothers have applied it.
Use during breastfeeding is unlicensed. It is assumed that diltiazem cream would similarly not affect the baby, but no research has been identified.
Both glyceryl trinitrate ointment and diltiazem cream are compatible with breastfeeding
References
• Taylor T, Kennedy D. Safety of topical glyceryl trinitrate in the treatment of anal fissure in breastfeeding women. Birth Defects Research Part a-Clinical and Molecular Teratology. 2008; 82:411.
• NICE 2% Topical diltiazem hydrochloride for chronic 2013: anal fissurehttps://www.nice.org.uk/advice/esuom3/resources/2-topical-diltiazem-hydrochloride-for-chronic-anal-fissure-pdf-17548582597
Haemorrhoids (piles ) and Breastfeeding
The pain and discomfort of piles after birth can make breastfeeding difficult. You do not need to avoid the over the counter products which do not pass significantly into breastmilk
Haemorrhoids (piles) are common after birth, especially after an extended second stage of pushing. They can be incredibly painful or cause intense itching. They may also bleed. They can make breastfeeding difficult as it becomes too painful to sit for prolonged periods. They can also occur because of constipation due to taking strong opioid painkillers.
Symptoms according to the NHS https://www.nhs.uk/conditions/piles-haemorrhoids/
- bright red blood after you poo
- an itchy anus
- feeling like you still need to poo after going to the toilet
- mucus in your underwear or on toilet paper after wiping your bottom
- lumps around your anus
- pain around your anus
Simple measure that you can take include:
- drink lots of fluid and eat plenty of fibre or use bulk forming laxatives to keep your poo soft https://breastfeeding-and-medication.co.uk/fact-sheet/constipation-laxatives-and-breastfeeding
- using soft wipes specially designed for wiping your bottom
- take paracetamol and ibuprofen
- take a warm bath to ease itching and pain
- use an ice pack wrapped in a towel to ease discomfort, some people recommend using frozen peas in a bag which can mould into your bottom
The over the counter remedies of creams, ointments and suppositories are all acceptable during breastfeeding despite what the manufacturer leaflet may suggest. Examples include Anusol™, Anusol HC ™, Preparation H ™, Germaloids™, Scheriproct™, Xyloproct™
Anusol has recently launched a product aimed at breastfeeding mothers but it is considerably more expensive, ” Anusol™ Natural Cream is a non-medicated formula that is safe to use during pregnancy and breastfeeding. “
