Following the recommendation by NICE (March 2023) I looked at the evidence on semaglutide and breastfeeding. There are no current published reports, only theory from pharmacokietics.

It seems that there are no supplies just now either as I understand.

I have found the ZOE podcast interesting (no financial involvement) https://link.chtbl.com/s9cwxMzY

And Margaret MCartnetny view in the BMJ https://www.bmj.com/content/380/bmj.p624.full

Pdf of factsheet :

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/03/semaglutide-and-breastfeeding-.pdf

Semaglutide binds to, and activates, the GLP-1 (glucagon-like peptide-1) receptor to increase insulin secretion, suppress glucagon secretion, and slow gastric emptying.

Semaglutide is used to treat Type 2 diabetes mellitus as monotherapy (if metformin inappropriate), or in combination with other antidiabetic drugs (including insulin) if existing treatment fails to achieve adequate glycaemic control. In March 2023 it was recommended for the treatment of obesity in specific circumstances.

Use in obesity.

Semaglutide (Wegovy™) was recommended by the National Institute for Health and Care Excellence (NICE) to treat thousands of people with obesity in England (March 2023). Semaglutide will be allowed to be prescribed to help people lose weight as part of their treatment in an NHS specialist weight management service. The drug works by suppressing appetite by mimicking the hormone glucagon-like peptide-1 (GLP-1), which is released after eating. It is injected once a week by patients. NICE first recommended the drug in draft guidance 2022, after a clinical trial of just under 2000 volunteers found that people lost on average 12% more weight with semaglutide alongside supervised weight loss coaching (BMJ 2023;380:556).

Guidelines for use in obesity

Semaglutide is recommended as an option for weight management, including weight loss and weight maintenance, alongside a reduced-calorie diet and increased physical activity in adults, only if:

• it is used for a maximum of 2 years, and within a specialist weight management service providing multidisciplinary management of overweight or obesity (including but not limited to tiers 3 and 4), and
• they have at least 1 weight-related comorbidity and:
• a body mass index (BMI) of at least 35.0 kg/m2, or a BMI of 30.0 kg/m2 to 34.9 kg/m2 and meet the criteria for referral to specialist weight management services in NICE’s guideline on obesity: identification, assessment and management.

Consideration should be made to stop semaglutide if less than 5% of the initial weight has been lost after 6 months of treatment. (https://www.nice.org.uk/guidance/TA875/chapter/1-Recommendations)

Currently Wegovy is not commercially available. Ozempic is available but is not licensed for weight management but only treatment of diabetes.

Dose

By subcutaneous injection( Ozempic™ ): Initially 0.25 mg once weekly for 4 weeks, then increased to 0.5 mg once weekly for at least 4 weeks, then increased if necessary to 1 mg once weekly.

By mouth (Rybelsus™): Initially 3 mg once daily for 1 month, then increased to 7 mg once daily for at least 1 month, then increased if necessary to 14 mg once daily, dose to be taken on an empty stomach, one 14 mg tablet should be used to achieve a 14 mg dose; use of two 7 mg tablets to achieve a 14 mg dose has not been studied and is therefore not recommended; maximum 14 mg per day.

By subcutaneous injection (Wegovy™): initially 0.25 mg once a week and increased every 4 weeks until the full dose of 2.4 mg is reached.

Compatibility with breastfeeding

• It is currently not known if semaglutide is excreted in human milk.  The molecular weight of this medication  means that it would have great difficulty entering breast milk. It is described as having oral bioavailability < 1% although an oral preparation exists. In consequence very little of this medication would be absorbed by the infant orally even  if found in breast milk. The risk of this in a breastfed infant would be expected to be very low (Hale and Krutsch).
• Manufacturer advises avoid stating that it is present in milk in animal studies. so its use in a lactating mother would be outside of the product licence (BNF)
• No information is available on the clinical use of semaglutide during breastfeeding. Because semaglutide is a peptide molecule with a molecular weight of 4113 daltons and is over 99% protein bound, the amount in milk is likely to be very low. Absorption by the infant is unlikely because the drug is probably destroyed in the infant’s gastrointestinal tract. Until more data become available, semaglutide should be used with caution during breastfeeding, especially while nursing a new-born or preterm infant. (https://www.ncbi.nlm.nih.gov/books/NBK500980/)
• Elactancia cites semaglutide as of very low risk in lactation (https://www.e-lactancia.org/breastfeeding/semaglutide/product/ ).  Its high molecular weight and high fixation to plasma proteins make it very unlikely to pass into mothers’ milk in a clinically significant quantity. (Serrano 2015). In addition, due to its protein nature it is inactivated in the gastrointestinal tract, not being absorbed (practically null oral bioavailability), which hinders or prevents the passage into plasma of the infant from ingested breast milk (Serrano 2015), except in premature infants and during the immediate neonatal period, in which there may be greater intestinal permeability.

Common or very common side effects

Appetite decreased; burping; cholelithiasis; constipation; diarrhoea; dizziness; fatigue; gastrointestinal discomfort; gastrointestinal disorders; hypoglycaemia (in combination with insulin or sulfonylurea); nausea; vomiting; weight decreased (BNF).

There are recent reports of eye problems following use of semaglutide, https://www.aao.org/newsroom/news-releases/detail/weight-loss-drug-and-eye-health

Semaglutide linked to sight-threatening eye condition, study results suggest

Monitoring of nursling for side effects

Although adverse effects have not been noted the baby should be monitored for decreased appetite, abdominal distension, GERD, constipation, diarrhoea. (Hale and Krutsch)

Can my GP prescribe Wegovy™  in the UK for weight loss?

Semaglutide can only be prescribed as part of a specialist (tertiary) weight management service with multidisciplinary input and for a maximum of two years. https://www.nice.org.uk/guidance/ta875/chapter/1-Recommendations

Conception and contraception

Manufacturer advises women of childbearing potential should use effective contraception during and for at least two months after stopping treatment.

References

Drugs and Lactation Database (LactMed) https://www.ncbi.nlm.nih.gov/books/NBK501922/

Hale TW and Krutsch K Hale’s Medications & Mothers’ Milk™ 2023: A Manual of Lactational Pharmacology (online access HalesMeds.com January 2023)

Joint Formulary Committee (2022) British National Formulary. [Online]. London: British Medical Association and  Royal Pharmaceutical Society of Great Britain. Available at: Medicines Complete Database, [Accessed January 2023].

 Elactancia Is it compatible with breastfeeding? https://www.e-lactancia.org/

Serrano Aguayo P, García de Quirós Muñoz JM, Bretón Lesmes I, Cózar León MV. Tratamiento de enfermedades endocrinológicas durante la lactancia. [Endocrinologic diseases management during breastfeeding.] Med Clin (Barc). 2015 Jan 20;144(2):73-9.

I have recently written an article for ELACTA on a subject that causes so many problems. Just this week I received this question ” I have a 30 week prem baby, I didnt want to braestfeed so they gave me a single dose of cabergoline and the baby is having donor breastmilk. I’ve changed my mind and I would love to feed her. Can I give her the milk I have expressed today?” It is such a difficult question as we have so little data on the passage of cabergoline into braestmilk, the baby is very premature so has poor kidney and liver function and expressing to get a full supply is going to be a long hard journey. On the day of delivering such a tiny precious bundle, it is so hard to take in the implications of taking the drug

ELACTA is a European Journal for European Lactation Consultants. “Lactation & Breastfeeding” is also available in the UK as an electronic version for €8 per issue ( 4 annual editions) if you are not a member of ELACTA. Single Issues (elacta-magazine.eu)

PDF of the article can be downloaded

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/01/Pharmacological-methods-of-weaning-versus-conservative-weaning.pdf

There are several different reasons why a mother may wish to wean her baby from the breast if we accept that weaning for the purpose of this article means as the  cessation of breastfeeding rather than introduction of appropriate complimentary solid foods:

• Physiological natural weaning because the mother has decided that the time is right for them and their baby to stop breastfeeding and there is a natural reduction of milk supply.
• Unintentional weaning which may include ongoing supplementation or as a side effect of medication
• The prescription of medication to reduce lactation in the puerperium such as following a stillbirth or neonatal death, a baby to be adopted or where the mother has chosen not to breastfeed
• To rapidly cease lactation at a later period because of a medical diagnosis e.g., a diagnosis of cancer,  or more rarely because of initiation of a medication which is incompatible with breastfeeding initiation of long-term methotrexate or lithium
• The use of supplementary or complimentary products to reduce lactation which may include perceived over-supply
• To discourage an older nursling who is reluctant to stop breastfeeding
• To stop lactation following a stillbirth or baby loss

Physiological weaning

For the majority of women weaning from the breast occurs gradually over a period usually after the introduction of appropriate complimentary solid foods  (). As such under the influence of the Feedback Inhibitor of Lactation (FIL) supply diminishes slowly and without symptoms or discomfort or need for medication. As the baby breastfeeds less the feedback inhibitor lowers the production of milk.

Unintentional weaning

However, some 80% of lactations in the UK ceased before the baby was 6 months old and before the mother had planned to stop, usually because of lack of support and perceived low milk supply (McAndrew et al., 2012)  In this case usually breastmilk feeds have been replaced by formula milk feeds so that breastmilk supply has gradually reduced and ceased altogether. This sadly can happen because a mother has misunderstood the way that milk supply is stimulated or that a short-term feeding plan involving top ups of formula milk or replacement of breastfeeds has been continued longer than may have been anticipated by the professionals. Not reaching the goals of breastfeeding  been shown to be associated with feelings of loss and grief (Brown,2019) ⁽.

Suppression of lactation in the puerperium when mother has chosen not to breastfeed

Some mothers of course choose not to breastfeed from birth because of personal wishes or ill health of mother or baby. In the past many of them were prescribed medication to dry up their milk. Oladapo& Fawole ⁾  conducted a review of 46 controlled trials that randomised a total of 5164 mothers to receive the treatment under investigation, no treatment or another treatment (Oladapo & Fawole, 2019). The trials were generally of limited quality, and most were conducted among healthy women who chose not to breastfeed for personal reasons at hospitals in industrialized countries before 1980. Half of the trials involved bromocriptine which is no longer recommended for routine suppression of lactation and has indeed been withdrawn in USA by the FDA due to numerous maternal deaths.

Adoption

In the past many women whose babies were to be placed for adoption were offered medication to suppress lactation presumably to diminish the grief of the separation. In some cases, where limited contact with the baby is being maintained under supervision, mothers may choose to provide some breastmilk which can either be given as expressed breastmilk by the carer or directly by the mother feeding during contact. Anecdotally there have been reports to social services (personal communications to the author) where foster mothers have reported concerns that following maternal breastfeeds the baby appeared to have loose bowel motions and that the mother may be passing unacceptable substances via breastmilk. This exemplifies a misunderstanding of the difference between the bowel motions of breast and formula milk fed babies. There appears to be little research on the subject suggesting that long term expression is rare for babies given up for fostering and adoption. Whilst breastfeeding a baby who is to be adopted seems to be more common (Gribble 2006)

Stillbirth or neonatal death

For some mothers the choice to donate their breastmilk, following loss of their baby is a comfort and seen as a tribute to the baby’s memory (Jones, 2018)  .

“When I gave birth to my stillborn daughter, I was given a dry up shot without them even mentioning donating to milk banks as an option. I would have LOVED donating my milk. ”“It’s funny, no one told me about milk donation. I don’t know how I knew about it. I learned when I was planning the C-section, I knew donor milk was an option, but didn’t know who donated it, never suspected I would become one who would be a milk donor.”

The side effects of cabergoline, used to stop lactation are not insignificant and it can precipitate depression, already a high risk after baby death in the puerperium.

Some mothers (personal communication to the author) were encouraged to not express their milk after sick, pre-term birth “just in case” their baby didn’t survive. In each of the cases, although limited in number, the mothers expressed regret that they felt that they had been excluded from caring for their baby.

Unintentionally lowering of milk supply due to medication

Drugs known to lower milk production as a side effect of use as medication are the combined contraceptive pill and the decongestant pseudoephedrine. Use to deliberately lower supply is not supported by research and effects vary with individuals. There have been no clinical trials on use for this purpose. Side effects of the drugs may be to raise the blood pressure of the mother and cause restlessness and irritability in the baby.

In one study of eight mothers (Aljazaf et al., 2003) a single dose of 60 mg pseudoephedrine was found to reduce the breastmilk supply by 24%. The reduction appeared to be more pronounced in those with later stage lactation defined as more than 60 weeks. The authors proposed that this may be due to a reduction in the production of prolactin although the reduction did not reach statistical significance with this small study population. Theoretically the reduction is also possible with the more frequently used phenylephrine although this hasn’t been reported in studies (Hale & Krutsch 2022, ) .

Dr Jack Newman has reported that bromocriptine and cabergoline are prescribed to overcome the symptoms of engorgement and mastitis sometimes on a routine basis (Newman, 2014)  without the mother being aware of the potential effect on her long-term chances of successful breastfeeding.

Early post-partum use of the combined oral contraceptive pill has been shown to decrease milk supply in some women due to the oestrogenic activity. However, the reduction seen is not consistent and seems to vary from woman to woman. The studies available are very dated and evidence relies on anecdotal reporting by mothers and lactation specialists.

Other non-prescribed products used to reduce lactation

The herb sage has been reported to lower milk supply although without clinical research. In 2014 Eglash  stated that “Sage is the most common herb used to reduce milk supply. Sage tea or extract made from the leaves is typically recommended, although there are no studies on the use of sage for hypergalactia and very few on its effect on the nursing baby. Sage tea may be prepared by steeping 1–3 g of dried sage leaves in a cup of hot water. The mother should be advised to just use one dose of the extract or 1 cup of tea and to observe the effect on her supply, as well as any behavioural change in the baby, over the next several hours. If she does not notice a difference in supply in 8–12 hours, then she can try another, stronger dose. Once she sees a response, she should just use it as needed. Often women will use one dose every 12 hours for 3 days to keep their supply down. Sage is known to have several side effects in high doses, including nausea, vomiting, and dizziness. It can induce wheezing, lower the blood sugar, and induce seizures, so high doses should be avoided in asthmatics, diabetics, and people prone to seizures. It is considered safe when used as a food.

In a 1998 Shrivastavet al  studied  the use of topical application of jasmine flowers was compared to bromocriptine to suppress lactation immediately after birth⁽. They reported that “The efficacy of jasmine flowers applied to the breasts to suppress puerperal lactation was compared to that of Bromocriptine. Effectiveness of both regimens was monitored by serum prolactin levels, clinical evaluation of the degree of breast engorgement and milk production and the analgesic intake. While both bromocriptine and jasmine flowers brought about a significant reduction in serum prolactin, the decrease was significantly greater with bromocriptine. However, clinical parameters such as breast engorgement, milk production and analgesic intake showed the two modes of therapy to be equally effective. The failure rates of the two regimens to suppress lactation were similar; however, rebound lactation occurred in a small proportion of women treated with bromocriptine. Jasmine flowers seem to be an effective and inexpensive method of suppressing puerperal lactation and can be used as an alternative in situations where cost and nonavailability restrict the use of bromocriptine.”

KellyMom reports that other herbs can be used to decrease supply but no evidence from research is supplied to support the statement. The herbs include Peppermint, Spearmint, Parsley, Chickweed, Black Walnut, stinging nettles, Yarrow, Herb Robert Lemon Balm, Oregano, Periwinkle Herb, Sorrel (KellyMom, 2018).

Normal consumption of the herbs as foodstuffs or drinking peppermint tea would not be likely to decrease supply.

Medication to reduce lactation

Bromocriptine

In 2015, the French pharmacovigilance program( Bernard) published a review of the adverse events associated with bromocriptine use to cease lactation. This group reported 105 serious adverse reactions including cardiovascular (70.5%), neurological (14.4%) and psychiatric (8.6%) events. There were also two fatalities: one 32-year-old female had a myocardial infarction with an arrhythmia, and a 21-year-old female had an ischemic stroke. (Hale & Kutsch 2022)⁽⁸⁾

Cabergoline

If a dopamine-receptor agonist is required to suppress lactation, cabergoline is preferred at a dose one mg, to be taken as a single dose on the first day postpartum. For the suppression of established lactation, a dose of 0.25mg is taken every 12 hours for two days for a total of 1mg (BNF 2022). However, this drug also has significant side effects, including headache, dizziness, fatigue or insomnia, orthostatic hypotension, oedema, nosebleed, dry mouth, inhibition of lactation, nausea, constipation, anorexia and weakness.

The manufacturer’s summary of product characteristics (Electronics Medicines Compendium SPC) ⁽ states that:

“As with other ergot derivatives, cabergoline should not be used in women with pregnancy-induced hypertension, for example, preeclampsia or post-partum hypertension, unless the potential benefit is judged to outweigh the possible risk.

Serious adverse events including hypertension, myocardial infarction, seizures, stroke or psychiatric disorders have been reported in postpartum women treated with cabergoline for inhibition of lactation. In some patients the development of seizures or stroke was preceded by severe headache and/or transient visual disturbances. Blood pressure should be carefully monitored after the treatment. If hypertension, suggestive chest pain, severe, progressive, or unremitting headache (with or without visual disturbances), or evidence of central nervous system toxicity develop, cabergoline should be discontinued and the patient should be evaluated promptly.

In post-partum studies with cabergoline, blood pressure decreases were mostly asymptomatic and were frequently observed on a single occasion 2 to 4 days after treatment. Since decreases in blood pressure are frequently noted during the puerperium, independently of drug therapy, it is likely that many of the observed decreases in blood pressure after cabergoline administration were not drug-induced. However, periodic monitoring of blood pressure, particularly during the first few days after cabergoline administration, is advised”.

Cabergoline can also cause depression. They should be avoided if the mother has experienced pre-eclampsia. Both drugs can produce sudden onset sleep or excessive daytime drowsiness and driving should be avoided.

Although bromocriptine and cabergoline are licensed to suppress lactation, they are not recommended for routine suppression when women have decided not to breastfeed, or for the relief of symptoms of postpartum pain and engorgement that can be adequately treated with simple analgesics and breast support. Should the mother decide that she wants to continue to breastfeed after taking cabergoline caution is recommended as there are no studies on the effects on babies of the dose used to suppress lactation (Hale and Krutsh 2022). Elactancia suggests that “No untoward effects have been reported in breastfed infants of mothers who were treated (or erroneously had received medication) and decided to resume breastfeeding” whilst recommending waiting 3-7 half lives. The half life of cabergoline is 63-69 hours.

Weaning the reluctant nursling

Social media posts often have posts from mothers who are experiencing aversion to breastfeeding, sometimes around the time of menstruation, or because their babies are “nipple twiddling”. They report that they are desperate to stop breastfeeding whilst their nursling remains bonded and even reliant on breastfeeding. Discussions that they have felt unable to convince their little ones that milk has dried up are undermined when the nursling latches on and finds there is milk. They often question whether taking a medication to suppress lactation would be an option as a strategy of last resort!

“So, unless I can come up with a better plan, I need to dry my milk up. I bedshare with my 23-month-old (no other options), am a solo parent, and night nurse all night long (her choice, not mine). I planned to keep breastfeeding for as long as she wanted but I can’t nurse her at night anymore. I have no clue how to night wean her because I’m literally lying next to her all night long. So, I figured the easiest thing to do would be to dry my milk up with drug. “

Conclusion

In an ideal world it is better to allow the breastmilk supply to dwindle slowly, by dropping one feed at a time or expressing/feeding only when the breasts become uncomfortably full. It may however be necessary to speed up this process up, but it is still important to avoid blocked ducts and mastitis. It is possible to treat the breasts as in the early days of engorgement, using simple analgesics and cold savoy cabbage leaves in a firm but well-fitting bra. Or the mother can express just enough milk to remain comfortable, frequently changing breast pads, which may become soaked as milk leaks from the breasts. Restricting the fluids which the mother is drinking will not help the milk to dry up; nor will the use of laxatives to remove water from the body.

Whose choice should it be?

The choice should ultimately be that of the lactating mother having been provided with full information about the side effects of the drug, alternative methods of reducing supply and that this should be a final decision. So many times, mothers say that they have taken cabergoline but regret the decision and wish to return to breastfeeding, for example that formula isn’t suiting their baby. As with so many aspects of parenthood it isn’t always as easy a professionals might suggest.

References

• Aljazaf K, Hale TW, Ilett KF, et al. (2003) Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin Pharmacol. 56(1):18-24  
• Bernard N, Jantzem H, Pecriaux C, et al. Severe adverse effects of bromocriptine in lactation inhibition: a pharmacovigilance survey. BJOG. 2015;122:1244-1251.
• Brown A, Why Breastfeeding Grief and Trauma Matter Pinter and Martin 2019
• Dr Jack Newman Facebook social media https://www.facebook.com/DrJackNewman/posts/the-use-of-cabergoline-dostinex-and-bromocriptine-parlodel-in-breastfeeding-wome/311003792384007/
• Eglash A.  (2014)Treatment of maternal hypergalactia. Breastfeed Med. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216483/pdf/bfm.2014.0133.pdf
• Elactancia online database https://www.halesmeds.com/monographs/60947?q=cabergoline
• Electronics Medicines Compendium SPC  bromocriptine https://www.medicines.org.uk/emc/product/1202
• Cabergoline https://www.medicines.org.uk/emc/product/1691/smpc (accessed December 2022)
• Gribble, K.D.  (2006) Mental health, attachment and breastfeeding: implications for adopted children and their mothers. Int Breastfeed J 1: 5
• Hale TW and Krutsch K Medications and Mothers Milk online access December 2022).
• Joint Formulary Committee. (2022). British national formulary. Accessed  December 2022, fromhttps://www.medicinescomplete.com/#/browse/bnf
• Jones W Breastfeeding and Medication website lowering or stopping breastmilk supply https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-lowering-stopping-milk-supply
• KellyMom Herbs that may decrease milk supply https://kellymom.com/bf/got-milk/herbs_to_avoid/ Accessed December 2022
• McAndrew F, Thompson J, Fellows L, Large A, Speed M, Renfrew MJ (2012) Infant Feeding Survey 2010, Health and Social Care Information Centre
• Oladapo, O.T.; Fawole, B. (2009) Treatments for suppression of lactation. Cochrane Database of Systematic Reviews
• Shrivastav P, George K, Balasubramaniam N, Jasper MP, Thomas M, Kanagasabhapathy AS. Suppression of puerperal lactation using jasmine flowers (Jasminum sambac). Aust N Z J Obstet Gynaecol. 1988 Feb;28(1):68-71

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

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),

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

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.”

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

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

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/

PDF https://breastfeeding-and-medication.co.uk/wp-content/uploads/2024/06/anti-diarrhoea-meds-and-breatsfeeding.pdf

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 and breastfeeding (2018)

See also https://breastfeeding-and-medication.co.uk/fact-sheet/semaglutide-and-breastfeeding

Weight Loss 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