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

PDF https://breastfeeding-and-medication.co.uk/wp-content/uploads/2024/06/haemorroids-and-breastfeeding.pdf

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. “

 

this information is reproduced from my book Breastfeeding and Medication

pdf https://breastfeeding-and-medication.co.uk/wp-content/uploads/2024/06/vaccines.pdf

Vaccines have low bio-availability and absorption from breastmilk is unlikely in most circumstances other than with live vaccines. Cessation or interruption of breastfeeding is not normally required but individual regimens should be considered especially with yellow fever (Data taken from LactMed website [2012]; Martindale [2005]; Advisory Committee on Immunization Practices [ACIP]; CDC [Kroger 2006]; Advisory Committee on Immunization Practices [2006]). UK data are available in the Department of Health ‘The Green Book’ available on the internet (Plotkin and Orenstein 2004; Department of Health Green Book).

Although there is a theoretical risk of live vaccine being present in breastmilk, vaccination with common vaccines is not contra-indicated for women who are breastfeeding when there is significant risk of exposure to disease. There is no evidence of risk from vaccinating women who are breastfeeding, with inactivated viral or bacterial vaccines or toxoids (BNF).

References

•             Advisory Committee on Immunization Practices, MMWR Recomm Rep, 2006;55(RR15):1–48.

•             Immunisation against infectious disease – Department of Health 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).

However, live vaccines should not be given to immunocompromised mothers or children exposed to biological drugs during pregnancy until after 6 months of age. See https://breastfeeding-and-medication.co.uk/fact-sheet/live-vaccinations-and-immunosuppressant-medication-taken-by-breastfeeding-mothers

               Measles, mumps and rubella     

Rubella vaccine virus can appear in breastmilk and result in infections in some infants (Buimovici-Klein et al. 1977). There is no evidence of mumps and measles vaccine viruses being found in breastmilk. Some breastfed infants acquire passive immunity to rubella after maternal vaccination, as do infants of mothers with natural rubella immunity. However, neither group of infants has a decreased response to rubella vaccine administered directly (Krogh et al. 1989). The CDC (Kroger et al. 2006) state that vaccines given to a nursing mother do not affect the safety of breastfeeding for mothers or infants and that breastfeeding is not a contra-indication to MMR vaccine. Breastfed infants should be vaccinated according to the routine recommended schedules (Plotkin and Orenstein, 2004; Department of Health Green Book).

Compatible with use during breastfeeding.

References

•             Buimovici-Klein E, Hite RL, Byrne T et al. Isolation of rubella virus in milk after pospartum immunization, J Pediatr, 1977;91:939–41.

•             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.

•             Krogh V, Duffy LC, Wong D, Rosenband M, Riddlesberger KR, Ogra PL, Post-partum immunization with rubella virus vaccine and antibody response in breastfeeding infants, J Lab Clin Med, 1989;113(6):695–9.

Diptheria, tetanus and pertussis             

One study of previously vaccinated infants found that at 21 to 40 months of age breastfed infants had higher immunoglobulin G (IgG) levels against diphtheria, higher secretory IgA levels in saliva against diphtheria and tetanus and higher fecal IgM against tetanus than formula-fed infants (Hahn-Zoric et al. 1990).

Pisicane et al. (2010) found that breastfed infants were also less likely to have fever after immunisation than their non-breastfed counterparts. Lopez-Alarcon et al. (2002) found they were also less likely to experience loss of appetite and reduced energy intake after routine childhood immunisation than those who are not breastfed. Although baseline calorie intakes were higher in the formula-fed infants mean intakes fell by 12% in the post-immunisation period.

There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated viral or bacterial vaccines or toxoids (Kroger 2006; Plotkin and Orenstein 2004; Department of Health Green Book).

Compatible with use during breastfeeding.

References

•             Hahn-Zoric M, Fulconis F, Minoli I, Moro G, Carlsson B, Böttiger M, Räihä N, Hanson LA, Antibody responses to parenteral and oral vaccines are impaired by conventional and low protein formulas as compared to breastfeeding, Acta Paediatr Scand; 1990;1979:1137–42.

•             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.

•             López-Alarcón M, Garza C, Habicht JP, Martínez L, Pegueros V, Villalpando S, Breastfeeding attenuates reductions in energy intake induced by a mild immunologic stimulus represented by DPTH immunization: possible roles of interleukin-1beta, tumor necrosis factor-alpha and leptin, J Nutr, 2002;132:1293–8.

•             Pisacane A, Continisio P, Palma O, Cataldo S, De Michele F, Vairo U, Breastfeeding and risk for fever after immunization, Pediatrics, 2010;125:e1448–52.

               Meningococcal vaccination         

Immunisation of pregnant or lactating women with meningococcal vaccine increased the specific secretory IgA content of milk ( Shahid et al. 2002). There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated virus or bacterial vaccines or toxoids (Granoff et al. 2004, Department of Health Green Book).

Compatible with use during breastfeeding.

References

•             Granoff DM, Feavers IM, Borrow R, Meningococcal vaccines. In: Plotkin SA, Orenstein WA, Vaccines 4th edition, Philadelphia: WB Saunders, 2004 (cited in Department of Health Green Book, 959–88).

•             Shahid NS, Steinhoff MC, Roy E, Begum T, Thompson CM, Siber GR, Placental and breast transfer of antibodies after maternal immunization with polysaccharide meningiococcal vaccine: a randomized, controlled evaluation, Vaccine, 2002;20:2404–9.

Typhoid vaccination        ☺

Recommended as compatible with breastfeeding by the CDC and the American Academy of Pediatrics (AAP). There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated viral or bacterial vaccines or toxoids (Kroger 2006; Plotkin and Orenstein 2004; Department of Health Green Book).

Compatible with use during breastfeeding.

References

•             Immunisation against infectious disease – Department of Health 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.

Influenza vaccination    

Use of live, attenuated or inactivated vaccine is recommended as compatible with breastfeeding by the CDC and the AAP. There is no evidence of risk from vaccinating pregnant women, or those who are feeding, with inactivated viral or bacterial vaccines or toxoids (Plotkin and Orenstein 2004). Where possible, pregnant women should receive a thiomersal-free influenza vaccine (Department of Health Green Book ).

Compatible with use during breastfeeding.

References

•             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.

BCG vaccination             

BCG vaccination against tuberculosis is recommended as compatible with breastfeeding by CDC and the AAP (Kroger 2006). Although no harmful effects on the foetus have been observed from BCG during pregnancy, it is wise to avoid vaccination, particularly in the first trimester, and wherever possible to delay until after delivery. Breastfeeding is not a contraindication to BCG (Plotkin and Orenstein 2004; Department of Health Green Book).

Compatible with use during breastfeeding.

References

•             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.

Pneumococcal vaccines

Some evidence of decreased pneumococcal disease has been found among breastfed infants of vaccinated mothers (Lehmann et al. 2003). Pneumococcal-containing vaccines may be given to pregnant women when the need for protection is required without delay. There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated viral or bacterial vaccines or toxoids (Kroger 2006; Plotkin and Orenstein 2004; Department of Health Green Book).

Compatible with use during breastfeeding.

References

•             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.

•             Lehmann D, Pomat WS, Riley ID, Alpers MP, Studies of maternal immunisation with pneumococcal polysaccharide vaccine in Papua New Guinea, Vaccine, 2003;21:3446–50.

Varicella vaccine            

Recommended as compatible with breastfeeding by the CDC and the AAP (Kroger 2006). Women who are pregnant should not receive varicella vaccine and pregnancy should be avoided for 3 months following the last dose. Studies have shown that the vaccine virus is not transferred to the infant through breastmilk (Bohlke et al. 2003) and therefore breastfeeding women can be vaccinated if indicated (Plotkin and Orenstein 2004; Department of Health Green Book ).

Compatible with use during breastfeeding.

References

•             Bohlke K, Galil K, Jackson LA, Schmid DS, Starkovich P, Loparev VN, Seward JF, Vaccine Safety Data link Team. Post-partum varicella vaccination: is the vaccine virus excreted in breastmilk?, Obstet Gynecol, 2003;102 (5 Pt 1):970–7.

•             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.

Yellow fever vaccine     

Until 2009 no adverse effects to yellow fever vaccine had been reported in infants exposed via breastfeeding. In 2009, the first case of meningoencephalitis caused by the yellow fever vaccine virus transmitted via breastmilk was confirmed.

Traiber et al. reported on a 38-day-old infant who was exclusively breastfed by a mother who had received yellow fever vaccination, the baby was discharged when convulsions resolved.

Kuhn et al. reported a case study of a previously healthy 5-week-old baby admitted to hospital with a 2-day history of fever and irritability, he subsequently fitted in the emergency department. When the baby was 10 days of age his mother was given travel vaccinations including yellow fever for a holiday to Venezuela. Hospital tests showed symptoms consistent with encephalitis. His symptoms resolved following a 21-day course of aciclovir.

The CDC (Kroger 2006) recommend against vaccinating nursing mothers with yellow fever vaccine before the baby is 6 months of age. However, if travel by the nursing mother to a high-risk yellow fever endemic area cannot be avoided or postponed, the mother may be vaccinated. Exposure to yellow fever vaccine via breastmilk would not increase the risk to an infant who receives the vaccination after the age of 6 months (Plotkin and Orenstein 2004, Department of Health Green Book ).

Compatible with use during breastfeeding. Avoid in first 6 months unless essential.

References

•             Centers for Disease Control and Prevention (CDC), Transmission of yellow fever vaccine virus through breastfeeding – Brazil, 2009, MMWR Morb Mortal Wkly Rep, 2010;59:130–32.

•             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.

•             Kuhn S, Twele-Montecinos L, MacDonald J, Webster P, Law B,Case report: probable transmission of vaccine strain of yellow fever virus to an infant via breastmilk, CMAJ, 2011;183(4):E243–5.

•             Staples JE, Gershman M, Fischer M, Centers for Disease Control and Prevention (CDC). Yellow fever vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR, 2010;59 (RR-7):1–27.

•             Traiber C, Amaral PC, Ritter VR, Winge A, Infant meningoencephalitis probably caused by yellow fever vaccine virus transmitted via breastmilk, J Pediatr (Rio J), 2011;87:269–72.

Hepatitis B vaccine        

Recommended as compatible with breastfeeding by the CDC and the AAP (Kroger 2006). Breastfed infants of hepatitis B surface antigen positive mothers have a different response in the development of Ig subtypes after vaccination with hepatitis B vaccine than do formula-fed infants. However, breastfeeding does not interfere with the infant’s antibody response to hepatitis B vaccine (Azarri et al. 1990; Wang et al. 2003). There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated viral or bacterial vaccines or toxoids (Plotkin and Orenstein 2004; Department of Health Green Book ).

Compatible with use during breastfeeding.

References

•             Azzari C, Resti M, Rossi ME et al. Modulation by human milk of IgG subclass response to hepatitis B vaccine in infants, J Pediatr Gastroenterol Nutr, 1990;10:310–15.

•             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.

•             Wang JS, Zhu QR, Wang XH, Breastfeeding does not pose any additional risk of immunoprophylaxis failure on infants of HBV carrier mothers, Int J Clin Pract, 2003;57(2):100–102.

Hepatitis A vaccine        

Recommended as compatible with breastfeeding by the CDC and the AAP (Kroger 2006). There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated viral or bacterial vaccines or toxoids (Plotkin and Orenstein 2004; Department of Health Green Book )

Compatible with use during breastfeeding.

References

•             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.

Cholera vaccine

Use of oral cholera vaccine to the mother decreased the risk of cholera in their breastfed infants by 47% in one study (Clemens et al. 1990). The authors hypothesised that vaccination of the mothers reduced their transmission of cholera to their infants. There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated viral or bacterial vaccines or toxoids (Kroger 2006; Plotkin and Orenstein 2004; Department of Health Green Book ).

Compatible with use during breastfeeding.

References

•             Clemens JD, Sack DA, Chakraborty J, Rao MR, Ahmed F, Harris JR, van Loon F, Khan MR, Yunis M, Huda S, Field trial of oral cholera vaccines in Bangladesh: evaluation of anti-bacterial and anti-toxic breastmilk immunity in response to ingestion of the vaccines, Vaccine, 1990;8:469–72.

•             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.

Polio vaccine    

Two types of poliomyelitis vaccine are available: inactivated poliomyelitis vaccine (for injection in combination with diphtheria vaccine) and live (oral) poliomyelitis vaccine.

Administration of oral poliovirus vaccine to nursing infants is less effective if it is given the neonatal period, due to maternal antibodies in colostrum and breastmilk (WHO 1995; Zaman et al. 1991). However, breastfeeding does not interfere with the infant’s response to oral polio vaccine, when given at the normal scheduled times (Kim-Farley et al. 1982; John et al. 1976). There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated viral or bacterial vaccines or toxoids according to the CDC and the AAP (Kroger et al. 2006) and the Department of Health Green Book (Plotkin and Orenstein 2004; Department of Health Green Book  )

Compatible with use during breastfeeding.

References

•             John TJ, Devarajan LV, Luther L, Vijayarathnam P, Effect of breastfeeding on seroresponse of infants to oral poliovirus vaccination, Pediatrics, 1976;57:47–53.

•             Kim-Farley R, Brink E, Orenstein W, Bart K, Vaccination and breastfeeding, JAMA, 1982;248:2451–2. Letter.

•             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.

•             World Health Organization Collaborative Study Group on Oral Poliovirus Vaccine, Factors affecting the immunogenicity of oral poliovirus vaccine: a prospective evaluation in Brazil and the Gambia, J Infect Dis, 1995;171:1097–1106.

•             Zaman S, Carlsson B, Jalil F, Jeansson S, Mellander L, Hanson LA, Specific antibodies to poliovirus type I in breastmilk of unvaccinated mothers before and seven years after start of community-wide vaccination of theirinfants with live, oral poliovirus vaccine, Acta Paediatr Scand, 1991;80:1174–82.

Japanese encephalitis vaccine  

Recommended as compatible with breastfeeding by the CDC and the AAP (Kroger 2006) and the Department of Health Green Book (2013). There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated viral or bacterial vaccines or toxoids (Plotkin and Orenstein 2004).

Compatible with use during breastfeeding.

References

•             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.

The development of anaesthetic data was prompted at least in part by the questions from mothers are diagnosis, treatment and surgery for gallstones whilst pregnant. Women are more likely than men to have gallstones and they are more common after the birth of several children so unsurprisingly this frequently covers breastfeeding mothers.

So here are my thoughts and a fact sheet on the topic

gallstones and breastfeeding fact sheet

Gallstones are present in at least 10% of the population. They vary in size and shape and consist primarily of cholesterol or the bile pigment bilirubin. They occur twice as frequently in women as men. Risk factors include high cholesterol intake, obesity, having had several children and the use of oral contraceptives (Gould 2006).

Symptoms of gallstones

Gallstones frequently cause no symptoms but larger calculi (stones) can obstruct a duct causing sudden severe waves of pain in the upper right-hand side of the abdomen (just under the ribs) often radiating to the back and right shoulder.  Feeling sick or vomiting, with a high temperature, shivering and sweating are also common.

Severe pain (biliary colic) may be precipitated by eating a fatty meal. Chronic symptoms may include intolerance to fatty foods, belching, bloating and mild epigastric pain.

Treatment is usually necessary if gallstones are causing symptoms – such as abdominal pain or complications – such as jaundice or acute pancreatitis

In these cases, keyhole surgery to remove the gallbladder may be recommended. This procedure, known as a laparoscopic cholecystectomy, is relatively simple to perform and has a low risk of complications. It is possible to lead a perfectly normal life without a gallbladder. The liver will still produce bile to digest food, but the bile will just drip continuously into the small intestine, rather than build up in the gallbladder (NHS www.nhs.uk/conditions/gallstones/#treating-gallstones)

Diagnosis of gallstones

Apart from acute symptoms often requiring emergency admission, diagnosis is by Ultrasound, MRI and CT scans all of which can be undertaken without interruption to breastfeeding together with blood tests. https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-after-ct-and-mri-scans

Treatment of gallstone

Simple over the counter painkillers (paracetamol and ibuprofen) may be sufficient. Anti spasmodic drugs may also be prescribed e.g. Hyoscine (Buscopan®). Anti nauseants e.g. cyclizine or ondansetron may be required. All can be used with continued breastfeeding (Jones 2018)

Ursodeoxycholic acid has been used for the management of gallstone disease, there is no evidence to support its use.

Surgery for gallstones

A laparoscopic cholecystectomy involves only small cuts in the abdomen to pass the instruments. It is normally carried out as a day case enabling return home on the same day or at most after an overnight stay. Full recovery takes around 10 days and mothers may need help with lifting and caring for toddlers.

It is possible to breastfeed as soon as the mother is awake and alert after surgery as the drugs stay in the system a short time. Doses of antibiotics and painkillers may be administered in theatre or in recovery, but these would normally be suitable for breastfeeding.

Analgesia (pain relief) after surgery for gallstones

Response to pain after surgery is very individual. The use of paracetamol plus non- steroidal drugs such as ibuprofen, naproxen and diclofenac may be sufficient for some. Others may need opiate drugs. Oramorph and dihydrocodeine are the preferred drugs during breastfeeding. Codeine should not be prescribed https://breastfeeding-and-medication.co.uk/fact-sheet/pain-relief-when-breastfeeding

It is not acceptable to prescribe a drug which is unsuitable to be taken by breastfeeding mother as there are risks to not continuing normal breastfeeding (risk of engorgement or mastitis, risk baby will not take milk from a bottle, risk of allergy on exposure to artificial formula) but above all prescription should be in accordance with the stated wishes of the mother to continue to feed as normal.

For more information on anaesthetics, anti-nauseants and analgesics see https://breastfeeding-and-medication.co.uk/fact-sheet/anaesthesia-and-breastfeeding and https://breastfeeding-and-medication.co.uk/fact-sheet/pain-relief-when-breastfeeding

References

Gould  B.E. Pathophysiology for the Healthcare professional 3^RD Ed Elsevier 2006

Hale TW Medications and Mothers Milk Springer 18^th Ed  2019

Jones W Breastfeeding and Medication 2^nd Ed Routledge 2018

LactMed actmed.nlm.nih.gov

NHS Choices – Gallstones www.nhs.uk/conditions/gallstones/

NICE Gallstone disease: diagnosis and management CG188 2014

The Breastfeeding Network Fact sheets www.breastfeedingnetwork.org.uk/drugs-factsheets/

Pdf https://breastfeeding-and-medication.co.uk/wp-content/uploads/2024/06/vaginal-thrush-and-bf.pdf

Most women have suffered the intense itching associated with vaginal thrush. It can also cause a white vaginal discharge (often described as like cottage cheese), which does not usually smell. It can also sting when you pass urine or have sex. It is a fungal infection but can occur after antibiotics, during hot weather or after wearing tight jeans regularly. It can also be caught from your partner during intercourse particularly if this has been maybe rapid or over enthusiastic. As an undergraduate I had this described as “honeymoon disease” but that was maybe in a different era!

It is not harmful but can be very uncomfortable. Some people experience symptoms more frequently than others.

Treatment:

Many treatments can be purchased over the counter rather than needing a GP appointment. The leaflets may say “ ask your GP or pharmacist if you are breastfeeding” which relates to licensing application rather than risk

• Vaginal creams and pessaries containing clotrimazole (Canesten™)
• External creams eg clotrimazole (Canesten™), Vagisil™
• Single dose antifungal medication containing fluconazole (Canesten Once™, Diflucan™, Own brands
• Combinations of internal and external creams, oral tablet and cream

Your partner can be treated with clotrimazole cream applied to the penis and extra lubrication during sex may help.

One natural remedy often recommended is to apply live, natural yoghurt on a tampon to restore natural flora and to eat live yoghurt/ take probiotics. Cotton pants, loose clothing and even going commando helps. Do not try to be over enthusiastic about wiping after going to the loo and try not to scratch as this will further damage the skin. Symptoms should resolve within a week

As a community pharmacist I often saw patients repeatedly ordering their blue inhalers to relieve symptoms of asthma because they were scared that the brown preventer inhalers contained steroid and would make them look like body builders. This is, of course not going to happen using inhalers correctly. Oral thrush can be common if inhaler technique is poor but simple things like rinsing the mouth after use or using a spacer can help. Talk to your specialist asthma nurse if you are struggling with symptoms.

If we add in breastfeeding it is no surprise that mothers are concerned about their medication use to control asthma but without cause. Inhalers and steroids are compatible with breastfeeding. Not only that but breastfeeding helps to minimise the risk of your baby developing asthma in the future according to new research.

The symptoms of asthma being high because of very high pollen counts coupled with the risk of thunderstorms which can be a bad combination.

I hope this factsheet taken largely from Breastfeeding and Chronic Medical Conditions helps

wendy@breastfeeding-and-medication.co.uk

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2022/06/asthma-.pdf

“My asthma actually improves when feeding and I had a big decline when I weaned my 2-year-old twins. The symptoms have gone again now I’m breastfeeding my 3-month-old.”

Description

Breastfeeding protects against asthma in children up to the age of 6. Shorter duration and non-exclusivity of breastfeeding were associated with increased risks of asthma-related symptoms in pre-school children (Mukherjee 2016). Thus, mothers with asthma may be keen to breastfeed exclusively to protect their baby. In a study of 366 pregnancies, symptoms worsened in 36% of women (Schatz 1988).  Further studies by Schatz (1995) and Wendel (1996) in the United States suggest that 11–18% of pregnant women with asthma will have at least one emergency department visit for acute asthma and, of these, 62% will require hospitalisation.

Wilson et al (2022) studied 2021 mother-child dyads. Women reported the duration of any and exclusive breastfeeding and child asthma outcomes during follow-up at child aged 4 to 6 years. Outcomes included current wheeze (previous 12 months), ever asthma, current asthma (having ≥2 of current wheeze, ever asthma, medication use in past 12-24 months), and strict current asthma (ever asthma with either or both current wheeze and medication use in past 12-24 months). They showed that longer duration of exclusive breastfeeding had a protective association with child asthma.

Treatment

Asthma can be controlled during breastfeeding with:

• inhalers (short and long-acting beta 2 agonists to relieve symptoms
•  bronchodilators to prevent symptoms
• compound inhalers, 
• Prednisolone
• Leukotriene receptor antagonists. 

Beta-adrenoreceptor agonists relieve symptoms of asthma attack such as breathlessness: E.g., Salbutamol, Bambuterol , Formoterol, Salmeterol, Terbutaline.The inhalers act locally in the lungs and limited transfer into blood let alone milk –

Oral Corticosteroids : Prednisolone – limited transfer at 40mg/day, higher doses short term. Very high doses or long term wait 4 hours after administration to breastfeed (but rarely necessary in my experience)

Inhaled Corticosteroid Inhalers prevent asthma symptoms and are used when regular use of preventer inhalers is necessary: E.g., Beclometasone, Budesonide, Fluticasone, Mometasone. Inhalers  act locally in lungs and limited transfer into blood let alone milk

Leukotrine Receptor antagonists: Montelukast – relative infant dose 0.68%. Used in children so compatible with breastfeeding. However, in September 2019 the MHRA added a caution to use in children so individual mothers may need to decide for themselves if they wish to take this drug whilst breastfeeding.

“Healthcare professionals are advised to be alert for neuropsychiatric reactions, including speech impairment and obsessive-compulsive symptoms, in adults, adolescents, and children taking montelukast. The risks and benefits of continuing treatment should be evaluated if these reactions occur. Patients should be advised to read the list of neuropsychiatric reactions in the information leaflet and seek immediate medical attention if they occur.”

Theophylline/ Aminophylline – prolonged half-life in neonates (babies < 6 weeks). One reported case of irritability. Avoid if possible, especially with young babies .

There are many options of inhalers and asthma specialist should be able to make symptoms changing life a rare rather than common event. Many athletes have asthma and are able to control symptoms with the right balance of medication. For some symptoms are worse with respiratory infections, for others season affects are greater e.g., moulds, pollen from different plant affecting different times of the year.

References

• Mukherjee M, Stoddart A, Gupta RP, Nwaru BI, Farr A, Heaven M, Fitzsimmons D, Bandyopadhyay A, Aftab C, Simpson CR, Lyons RA, Fischbacher C, Dibben C, Shields MD, Phillips CJ, Strachan DP, Davies GA, McKinstry B, Sheikh A, The epidemiology, healthcare and societal burden and costs of asthma in the UK and its member nations: analyses of standalone and linked national databases, BMC Medicine, 2016;14:113–128.
• Schatz M, Harden K, Forsythe A, Chilingar L, Hoffman C, Sperling W, Zeiger RS, The course of asthma during pregnancy, post-partum, and with successive pregnancies: a prospective analysis, J Allergy Clin Immunol, 1988;81:509–17.
• Schatz M, Zeiger RS, Hoffman CP, Harden K, Forsythe A, Chilingar L, Saunders B, Porreco R, Sperling W, Kagnoff M, Perinatal outcomes in the pregnancies of asthmatic women: a prospective controlled analysis, Am J Respir Crit Care Med, 1995;151:1170–4.
• Wendel PJ, Ramin SM, Barnett-Hamm C, Rowe TF, Cunningham FG, Asthma treatment in pregnancy: a randomized controlled study, Am J Obstet Gynecol, 1996;175:150–4.
• Wilson K, Gebretsadik T, Adgent MA, et al. The association between duration of breastfeeding and childhood asthma outcomes. Annals of Allergy, Asthma & Immunology. (https://www.annallergy.org/article/S1081-1206(22)00400-8/fulltext)
• https://www.sps.nhs.uk/articles/using-inhaled-or-topical-corticosteroids-during-breastfeeding/

Further information: 

Asthma UK https://www.asthma.org.uk/

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

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

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

Risk of breast cancer BNF June 2024 https://bnf.nice.org.uk/treatment-summaries/sex-hormones/

All types of systemic (oral or transdermal) HRT treatment increase the risk of breast cancer after 1 year of use. This risk is higher for combined oestrogen-progestogen HRT (particularly for continuous HRT preparations where both oestrogen and progestogen are taken throughout each month) than for oestrogen-only HRT, but is irrespective of the type of oestrogen or progestogen. Longer duration of HRT use (but not the age at which HRT is started) further increases risk.

Although the risk of breast cancer is lower after stopping HRT than it is during current use, the excess risk persists for more than 10 years after stopping compared with women who have never used HRT. Vaginal preparations containing low doses of oestrogen to treat local symptoms are not thought to be associated with an effect on breast cancer risk.

The MHRA advises discussing the updated information on the risk of breast cancer with women who use or are considering starting HRT, at their next routine appointment. 

There are also risks of endometrial cancer, ovarian cancer, thromboembolism, stroke and coronary vascular disease.

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

PDF of factsheet available:

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

The Menopause And Breastfeeding

There remains no conclusive research on the passage of HRT medication into breastmilk. It appears anecdotally that there is less impact on milk supply from using transdermal preparations than oral medication. There remains the possibility of reduction in lactation due to the oestrogen contact inhibiting prolactin. Anecdotally HRT at standard dose of less than 2mg has been used by breastfeeding women without impact on the nursling or supply. There is no research on higher doses or use outside of licence application.

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

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

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

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

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

Premature ovarian insufficiency (POI)

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

Perimenopause

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

Menopause

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

Typical menopausal symptoms, include:

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

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

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

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

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

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

Post menopause

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

HRT and Breastfeeding

HRT contains oestrogen and sometimes a progesterone e.g., norethisterone, not that dissimilar to that in the combined oral contraceptive which can be used in breastfeeding. The ethinylestradiol content of COCs range from 20–40 micrograms whilst that in HRT products contain 1 – 2 milligrams of estradiol (there are 1000 micrograms in a milligram).

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

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

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

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

Pharmacokinetics of HRT (Taken from Hale)

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

References

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