as written for Maternity and Midwifery Forum Vaccinations in pregnancy and breastfeeding – Maternity & Midwifery Forum

The long-term impact of the use of thalidomide for nausea in the 1960’s continues to be in the minds of many pregnant women and their families. They fear exposing their growing baby to anything from foods to medicines to passive smoking. The anti-vax campaign after COVID-19 still lurks when we discuss the benefits of vaccination in pregnancy. Women should not be dismissed but their fears acknowledged, and evidence-based information provided.

We can share with them that vaccination is recommended for Flu and COVID-19 as their own immunity is supressed in pregnancy making them more prone to infections which can be more severe than normal. In addition, no vaccination would be added to the schedule without significant consultation on risks and benefits by the UK Teratology Information Service. The vaccines are also given to protect the vulnerable newborn from infections and possible hospitalisation.

Active listening

As part of my training as a volunteer breastfeeding supporter I learned about active listening and how that can help someone clarify their fears, doubts and intentions. I have continued to use these in all areas of my professional practice and within the family!

These skills include:

• making eye contact, if possible (many of us, as healthcare professionals, are busy filling in forms and records as we talk!),
• picking up the non-verbal clues (how are they sitting, sounding?),
• not interrupting or phrasing the question with an implied agreement. For example, “so you are going to have the vaccine, aren’t you?” But maybe “at this stage in pregnancy we normally offer vaccine x, how do you feel about that? Do you have any questions?”
• unconditional respect for that decision, we are not in a position to judge. You could offer further information for the family to look at and discuss. Written information is powerful. Think how many people believe everything they find on google searches! Ensure that you are providing appropriate evidence-based information.
• show that you are listening by nodding and don’t pass on your opinions.
• paraphrase back to the family the concerns that they might have expressed. “So, I’m hearing that you have seen some experiences and opinions on social media that are concerning you. Is that correct?”
• ask open questions rather than anything to which the expected reply is yes or no.

We cannot force vaccinations onto pregnant women without addressing their concerns, if they have them. Otherwise, they may worry for the rest of the pregnancy that they have damaged this precious baby which may not have been conceived simply and on who great hopes are placed. NICE has particularly emphasised that all healthcare professionals should be facilitating shared patient choses in all aspects of their care. The vaccinations recommended in pregnancy are currently Flu, COVID-19, Whooping Cough, Respiratory syncytial virus (RSV) vaccine.

Flu vaccine

Flu vaccination is recommended in pregnancy to protect the woman from complications of flu and to help prevent the baby from catching flu in the first few weeks after delivery. Pregnant women are more likely to suffer complications such as chest infections and pneumonia.    https://www.medicinesinpregnancy.org/leaflets-a-z/flu-vaccine/

Whooping Cough vaccine

The whooping cough vaccine is given sometime after 16 weeks but normally around 20 weeks. Some immunity passes across the placenta protecting the neonate until it can have its own vaccination. There has been an increase in cases of whooping cough reported over the past year and the youngest babies are at greater risk of severe illness and hospitalisation. There are sadly even reports of infant death. https://www.medicinesinpregnancy.org/leaflets-a-z/whooping-cough-vaccine/

Respiratory syncytial virus (RSV) vaccine

The new RSV vaccine given to the mother (available from 1.9.24) protects the baby for the first 6 months after birth from severe lung infections which may make it difficult for babies to breathe and necessitate hospital admission. The vaccine is normally offered around 28 weeks of pregnancy. RSV is a common virus that causes coughs and colds but can lead to bronchiolitis in babies making it difficult for them to breathe and feed. https://www.gov.uk/government/publications/respiratory-syncytial-virus-rsv-maternal-vaccination/a-guide-to-rsv-vaccination-for-pregnant-women

COVID-19 vaccine

The COVID-19 vaccine can be given at any stage in pregnancy. It protects both mother and baby. Pregnant mothers who develop COVID-19 can become seriously ill. If the mother contracts it late in pregnancy the baby may become seriously unwell and need to be admitted to special care. https://www.medicinesinpregnancy.org/leaflets-a-z/covid-19-vaccine/

Live virus vaccines

Vaccines to be avoided in pregnancy include all those which contain live virus. These include MMR, BCG and Oral typhoid, polio and yellow fever

Vaccination during breastfeeding

Breastfeeding mothers can have all routine vaccinations which they may have missed, and which are injected e.g. MMR, Flu, COVID-19.

The vaccines are not transmitted through breastmilk as they are poorly orally bioavailable and so cannot be absorbed from breastmilk. Healthcare workers can receive hepatitis vaccines without interrupting breastfeeding.

Other vaccines which can be used are chickenpox, hepatitis a and c, pneumonia, tetanus, typhoid, BCG, DipPT, whooping cough, injected polio vaccine (but not oral drops).

Children’s vaccines which can affect the mother.

Immunocompromised mothers i.e. those taking drugs such as azathioprine, biological drugs (Infliximab, Humira™ etc) should wear gloves when changing nappies for 2 weeks if their baby is given rotavirus drops as part of their routine immunisation. This is because live viral particles are shed in faeces for two weeks. https://breastfeeding-and-medication.co.uk/fact-sheet/live-vaccinations-and-immunosuppressant-medication-taken-by-breastfeeding-mothers

Immunotherapy drugs given during pregnancy.

If the mother continued biological drugs during pregnancy the baby should not receive the rotavirus drops for at least 6 months (12 months for infliximab). This is because sufficient of the drugs pass the placenta to impact on the baby’s immunity. Other vaccines to avoid are BCG if that is necessary because the baby is at increased risk of contracting tuberculosis. https://www.nhs.uk/vaccinations/bcg-vaccine-for-tuberculosis-tb/

Although MMR vaccine contains a live virus there is little evidence of risk to an immunocompromised mother[JH1] .

The card below was developed by Lorna Orriss-Dib at Healthwatch Essex as a resource for mothers with Inflammatory Bowel Disease to be stuck into the Red Book. Some healthcare professionals were not aware of the risks to women taking medication which caused them to be immunocompromised during pregnancy or when their babies received live vaccines, according to a study undertaken by Lorna. I have also witnessed this on the Facebook group which I administer for breastfeeding mothers with IBD. The card was developed as a simple tool to be ensure everyone was fully informed of the risks and benefits. Healthwatch Essex are keen that it can be widely disseminated to other areas.

The information applies whether the mother is breastfeeding or using infant formula if she is immunocompromised.

In summary:

• For mothers who were taking biological medication in the third trimester of pregnancy, their babies, should not receive live vaccinations before at least 6 months of age
• Mothers who are immunocompromised may be infected by faecal particles shed following the use of rotavirus vaccine to their baby and should take hygiene precautions

Image developed by Lorna Orriss-Dib at Healthwatch Essex Reproduced with consent and can be widely disseminated ).

Further information

Breastfeeding and Medication https://breastfeeding-and-medication.co.uk/fact-sheet/vaccines-and-breastfeeding

Immunisation against infectious disease. The Green Book https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

Kroger AT, Atkinson WL, Marcuse EK, Pickering LK, Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR Recomm Rep, 2006;55(RR-15):1–48.

Plotkin SA, Orenstein WA, Vaccines 4th edition, Philadelphia: WB Saunders, 2004 (cited in Department of Health Green Book chapter 34).

Using vaccines during breastfeeding https://www.nhs.uk/vaccinations/bcg-vaccine-for-tuberculosis-tb/

Vaccines in pregnancy Public Health Scotland https://www.youtube.com/watch?v=yqGN2tivZT4

UK Teratology Information Service. https://uktis.org/

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I’m really saddened that so many mothers are recommended to stop breastfeeding in order to be treated with medication. There is some evidence that breastfeeding in itself protects the mother

Research on Rheumatoid Arthritis

I hope that this factsheet provides some alternatives. The information is taken from Breastfeeding and Chronic Medical Conditions – https://tinyurl.com/mbbebe8x

RA and Breastfeeding Factsheet

“Recovering from childbirth is horrendous enough (well it was for me), never mind having RA
symptoms on top of it. I met with my consultant 3 weeks after the birth, and straight away she was
urging me to stop breastfeeding and trying to get me to begin courses of strong medication.
Overwhelmed by the pain, the sleepless night, and the huge amount of information she was throwing
at me, I found it very hard to take much of what she said in. I just knew I wanted to do the best for
my baby. Appointments with rheumatology since have been similar, pushing me to stop
breastfeeding, not listening to my reasons for wanting to breastfeed, and pushing the stronger
meds.”
“In autumn 2016 I noticed my left thumb was sore a lot of the time. Thinking I had hurt it in
somehow, I did not do anything more about it. Soon after I noticed the rest of my fingers and hands
starting to ache. There were days in work where I could not do my job properly, because my hands
were so sore, and I could barely stand to wash my hands, the pain was so severe. A few bloods taken
in January 2017 by my GP, revealed that I had developed Rheumatoid Arthritis. There is no history of
it in my family, and I knew very little about it. I waited several months for my first rheumatology
appointment at the hospital. When I eventually got my appointment, several months later, I was
pregnant with our second baby, and was amazed that the pregnancy had almost completely
eliminated my RA pains. The consultant warned me that after my baby arrived the RA would hit me
hard. And wow was she right.”
“I have seropositive erosive rheumatoid arthritis. I was diagnosed in July 2019. I breastfed my toddler
until he was nearly 17 months but stopped due to entering the 2nd trimester of pregnancy, by then
he was ready to stop and so was l. When l was diagnosed my baby was 10months old. It appears l
may have had RA since l was 17 but did not realise. I was told to stop breastfeeding by many nurses,
GPs and rheumatologists. As l had 7 years of infertility and 3 failed IVF l was desperate to not stop
breastfeeding until l thought my son was ready. I thought he would be my only baby. I have anxiety
and suffer from frequent panic attacks, but breastfeeding helped me manage the emotions and
exhaustion of motherhood. Through seeking guidance from you l asked my rheumatologist if l could
be put on Sulfasalazine which is safe for breastfeeding. It was very slow and ineffective to treat my
active inflammation at the start but allowed me to continue my breastfeeding journey. They wanted
to put me on methotrexate which is not suitable for breastfeeding. They gave me 4 massive injections
of steroids to try and get my RA under control over a period of a few months. My inflammation was
still sky high. When l found out l was pregnant in November 2019 l went into remission with the
change in hormones. I was put on Cimzia (biologic) just before Christmas to prevent any further
erosions in my feet. I have had to come off Cimzia a few days ago, due to a high risk of severe
symptoms if l catch Corona Virus as technically, they think my disease activity has only been reduced
due to pregnancy hormones. I am now 26 weeks pregnant. I hope l do not flare in trimester 3 or
when the baby is born because then they may force me to take methotrexate and another immune
suppressing biologic. I desperately hope to breastfeed baby 2 but understand this pandemic may not
be going away any time soon. I want to be safe for my children. Thank you for your advice because
you enabled me to continue to feed my baby for another 9 months more after diagnosis. I feel a lot of
people including many in the medical profession think if you have fed your baby until they are on
solids then it is not necessary to keep on breastfeeding. By understanding what meds are safe for
breastfeeding a lot of women have more choice to decide when it is right for them to give up.”

“Would I be in a better position if I weren’t breastfeeding? The consultant could not answer that.
Every case is different, and everyone responds differently to the medicine. There is no proof that if I
stopped, I would be in less pain, so I am happy to feed my boys for as long as they keep wanting me
to. I am trying exercise, physio and dietary changes to help reduce pain, instead of relying solely on
medication. I am taking it one day at a time, and I love being a Mummy more than anything.
Breastfeeding is so much more than just giving your child nourishment, it is quality time together, a
special bond between mum and baby, which I will never forget. I will always cherish my years of
breastfeeding, the cuddles, smiles and love we have shared together. Yes, I have rheumatoid
arthritis, but it does not define me. Always remember, never give up on a hard day. Tomorrow is
another beginning.”
Description
Rheumatoid arthritis (RA) is a common chronic inflammatory autoimmune disease. It is associated
with significant pain and disability. Control of the inflammation in the early stages can prevent long
term damage which is why consultants are keen to use disease modifying agents as soon as possible.
The overall occurrence of RA is two to four times greater in women than in men. The peak age of
incidence in the UK for both genders is the 40s, but people of all ages can develop the disease. There
is a genetic influence in developing the condition, but it is also linked with environmental factors,
such as high birth weight, smoking, silica exposure, alcohol abstention, obesity, and diabetes
mellitus.
There is evidence (NICE 2015) that the first 12-week period of the disease represents a unique
opportunity to influence the progress of the disease. The challenge is to recognise early symptoms
see a specialist. Presenting symptoms can be very variable: profound fatigue, influenza-like
symptoms, fever, sweats and weight loss are common. Other organs can be involved. Typically, there
may be periods of exacerbations and remissions, but it may be mild self-limiting condition or a
chronic progressive illness.

Treatment
There is evidence that breastfeeding protects against the risk of developing rheumatoid arthritis
(Chen 2015). No protective effect was noted from simply having children and not breastfeeding, or
from taking oral contraceptives (Pikwer 2008)
Drugs for rheumatoid arthritis which can be taken during breastfeeding:
Non-steroidal anti-inflammatory drugs (NSAIDS)
Ibuprofen: very low levels in breastmilk. Can be used even when baby needs direct
ibuprofen syrup e.g. during teething or fever
diclofenac: has historically been widely used in breastfeeding
naproxen: longer half-life than diclofenac or ibuprofen but levels in breastmilk low
celecoxib: low levels in breastmilk
Mefenamic acid – no studies but BNF states “amount in milk too small to be
harmful”
Ketoprofen: low levels in breastmilk, one centre in France 8/174 incidences of
adverse events including oesophageal ulceration, erosive gastritis, meningeal
haemorrhage, and renal insufficiency.

Meloxicam: Limited oral bioavailability but no studies.

Etoricoxib – no data , celecoxib preferable

Indometacin: One case of seizure reported in neonate exposed through milk. Avoid as safer
alternatives
all of the above with PPI omeprazole to protect the mother’s stomach.
DMARDS such as Hydroxychloroquine (see Lupus) but not methotrexate are acceptable
Biologicals – etanercept, infliximab, adalimumab, rituximab. All have large molecular
weights which produce zero oral bioavailability. Certolizumab pegol has a licence for use by
breastfeeding mothers.
Where opiates are required dihydrocodeine would be the drug of choice as it has a cleaner
metabolism than codeine. Tramadol is also acceptable

References

• Davies NM, Anderson KE, Clinical pharmacokinetics of naproxen, Clin Pharmacokinet,
  1997;32:268–93.
• Eeg-Olofsson O, Malmros I, Elwin CE, Steen B. Convulsions in a breast-fed infant after
  maternal indomethacin. Lancet. 1978;2 (8082):215. Letter Gardiner SJ, Doogue MP, Zhang
  M, Begg EJ, Quantification of infant exposure to celecoxib through breastmilk, Br J Clin
  Pharmacol, 2006;61:101–4.
• Hale TW, McDonald R, Boger J, Transfer of celecoxib into human milk, J Hum Lact,
  2004;20(4):397–403.

• Ito S, Blajchman A, Stephenson M, Prospective follow-up of adverse reactions in breastfed
  infants exposed to maternal medication, Am J Obstet Gynecol, 1993;168:1393–9.
• Jamali F, Stevens DRS, Naproxen excretion in milk and its uptake by the infant, Drug Intell
  Clin Pharm, 1983;17:910–11.
• Knoppert DC, Stempak D, Baruchel S, Koren G, Celecoxib in human milk: a case report,
  Pharmacotherapy, 2003;23(1):97–100.
• NICE CG 79 2015. Rheumatoid arthritis in adults: management
• Soussan C, Gouraud A, Portolan G et al. Drug-induced adverse reactions via breastfeeding: a
  descriptive study in the French Pharmacovigilance Database. Eur J Clin Pharmacol. 2014;
  70:1361-6
• Townsend RJ, Benedetti TJ, Erickson SH, Cengiz C, Gillespie WR, Gschwend J, Albert KS,
  Excretion of ibuprofen into breastmilk, Am J Obstet Gynecol, 1984;149(2):184–6.
• Walter K, Dilger C, Ibuprofen in human milk, Br J Clin Pharmacol, 1997;44:211–12.
• Weibert RT, Townsend RJ, Kaiser DG, Naylor AJ, Lack of ibuprofen secretion into human milk,
  Clin Pharm, 1982;1:457–8.
  .
  Further Information
  National Rheumatoid Arthritis Society https://www.nras.org.uk/

Doxylamine/pyridoxine (Xonvea™, Cariban™)

This is the only licensed drug treatment for nausea and vomiting of pregnancy. It contains a combination of the antihistamine doxylamine and the vitamin pyridoxine. It became available in England in 2018. It has been widely used for pregnancy sickness in the US and Canada and studies have shown no link with birth defects in the baby. The antihistamine doxylamine might be more likely to cause drowsiness in nursling. https://www.ncbi.nlm.nih.gov/books/NBK500620/  and https://www.e-lactancia.org/breastfeeding/doxylamine-succinate/product/. The 10mg of pyridoxine is unlikely to cause any disruption to breastfeed.

See also Vomiting in pregnancy whilst still breastfeeding – Breastfeeding and Medication

pdf https://breastfeeding-and-medication.co.uk/wp-content/uploads/2024/11/eczema-dermatitis-and-breastfeeding.pdf

We have known for many years that many women give up breastfeeding in the first 6 weeks with unresolved nipple pain and damage.

There is currently discussion about the treatment of thrush during breastfeeding and that many cases may be wrongly diagnosed and be caused by dermatitis (eczema).

CKS How should I diagnose the cause of nipple pain? 2022 mentions that:

• Eczema, psoriasis and contact dermatitis of the areola and nipple may cause itching of the skin.
• Eczema typically causes a bilateral red, dry, scaly rash which may have lichenified (thickened) areas, which tend to spare the base of the nipple.
• Psoriasis typically causes red plaques with clearly demarcated borders, which may have a fine overlying scale.
• Irritant dermatitis may occur due to soaps, nipple creams and other substances in direct contact with the breast.

In 2021 Amir et al (including myself) published a paper “Identifying the cause of breast and nipple pain during lactation” https://www.bmj.com/content/374/bmj.n1628

How can we treat nipple pain?

• In babies under 6 weeks assume, until proven otherwise by a breastfeeding expert, that it is due to less than perfect latch/attachment to the breast.
• If there is a white tip to the nipple after feeds optimise the attachment as this is likely to be vasospasm (temporary loss of blood supply to the nipple)
• Check for tongue tie by an expert trained to assess and treat appropriately. A tongue tie can result in the baby having a white tongue as milk does not reach the back of the tongue as it should.
• If the nipple is itchy after breastfeeds optimise attachment but if the nipple skin is dry and sore treat as a dermatitis with suitable moisturiser (does not need to be a specific product labelled to treat and prevent cracked nipples) and apply a smear of hydrocortisone 1% cream (or other low potency steroid) after feeds
• Frequent application of products sold to prevent and treat cracked nipples may contain lanolin and even highly purified forms can cause allergic reactions which increase itchy sensation.
• A mother may be allergic to anything which is in contact with her breasts during lactation as the environment around the nipple is more moist than usual – breast pads, washing powder, creams, soaps. These may produce a red circular area around the nipple.
• If nipple pain begins when the baby is teething, try to optimise latch and re-attach the baby/toddler if pain continues then apply a smear of hydrocortisone cream 1% after feeds to soothe inflammation and chaffing.
• If the mother has a history of poor circulation (usually Raynaud’s phenomenon) the use of nifedipine 10-20mg three times a day is effective. It is associated with side effects of headaches and/or hot flushes for the mother. If it has produced no improvement within 7 days discontinue and reconsider cause of pain. Research suggests that some mothers can stop treatment but still see resolution of symptoms. See https://breastfeeding-and-medication.co.uk/blog/february-is-raynaud-s-awareness-month-www-sruk-co-uk
• Look at other causes of pain by observing the mother and baby as a dyad and watching a complete feed from approach to the nipple to the baby coming off the breast unprompted. Does the baby have an asymmetrical latch? Does it suck the nipple into the mouth rather than having a wide gape? Does the mother take the nipple to the baby by leaning forward rather than lying back? Is the baby supported in the mother’s elbow?
• Is the pain in both breasts and is it the same after every feed?
• Is there a sloughy discharge in the crack suggesting a bacterial infection?
• Only after all these factors have been considered should a diagnosis of thrush be brought into the discussion. I believe thrush on the nipple is rare although it can occur. It should NEVER in my opinion, be the first treatment for sore nipples. A white tongue is not diagnostic of oral thrush nor is pain on one side.
• Paget’s disease can never be discounted as it presents as steadily progressing eczema.

Symptoms of nipple eczema(dermatitis)

Nipple eczema is characterised by redness, crusting, oozing, scales, fissure, blisters, excoriations or lichenification eczema (Core Curriculum for |Lactation Consultant Practice). It is often described by the mother as itching and is usually treated with topical steroids.

In Breastfeeding a Guide for the Medical Profession dermatitis is described as tender, burning, red fissures without exudate or itching, oozing with well-defined plaques. It has a recommendation by Alison Stuebe to culture for aerobic   bacteria and yeast. It differentiates between irritant and contact dermatitis.

Breastfeeding Management for the Clinician describes eczema as including erythema, papules, vesicles, oozing, lichenification, skin erosion, fissures, excoriations and scaling associated with itching which differentiates it to candidal infection. It cites Amir 1993 as recommending removal of the irritant and application of topical steroid (beclometasone 0.05%) with awareness that high colony Staph. Aureus may also be present and necessitate use of a topical antibiotic for example Mupirocin (Bactroban ™).

Barrett suggests that the application of topical steroids is the mainstay of treatment for eczema on the nipple and recommends a low or medium strength steroid applied twice a day for 2 weeks with anything residual being wiped off before a feed (not washed as it may further dry the skin of the nipple.

Barankin and Gross suggest that symptoms may appear after the introduction of some solids to the infant’s weaning diet. This can be ameliorated by rinsing the nipple with water or expressed breastmilk after feeds.

Anecdotally I have found that using a solution of 1 teaspoonful of bicarbonate of soda in a pint of water also helps assuming that it alters the pH of the skin transiently before application of the steroid. Please note that there is no published evidence for this, it is merely my experience of supporting breastfeeding mothers.

References

Amir L. Eczema of the Nipple and Breast: A Case Report. Journal of Human Lactation. 1993;9(3):173-175.

Barankin B, Gross MS. Nipple and Areolar Eczema in the Breastfeeding Woman. Journal of Cutaneous Medicine and Surgery. 2004;8(2):126-130.

Barrett ME, Heller MM, Fullerton Stone H, Murase JE. Dermatoses of the breast in lactation. Dermatol Ther. 2013 Jul-Aug;26(4):331-6. 

Core Curriculum for Lactation Consultant Practice International Lactation Consultant Association Eds Manuel R, Martens PJ, Walker M.  Jones and Bartlett

Douglas P. Re-thinking lactation-related nipple pain and damage. Womens Health (Lond). 2022 Jan-Dec; 18:17455057221087865.

Lawrence RA MD and Lawrence RM Breastfeeding a Guide for the Medical Profession. Elsevier.

Walker M Breastfeeding Management for the Clinician. Jones and Bartlett

Wambach K and Spencer B. Breastfeeding and Human Lactation. Jones and Bartlett

See also.

Thrush and Breastfeeding https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-thrush

What do mothers want healthcare professionals to know about breast and nipple pain in lactation https://breastfeeding-and-medication.co.uk/fact-sheet/what-do-mothers-want-healthcare-professionals-to-know-about-breast-and-nipple-pain-in-lactation