Tirzepatide is a long-acting GIP (glucose-dependent insulinotropic polypeptide) receptor and GLP-1 (glucagon-like peptide-1) receptor agonist that increases insulin sensitivity and secretion, suppresses glucagon secretion, and slows gastric emptying.

Tirzepatide is used to treat Type 2 diabetes mellitus as monotherapy (if metformin is inappropriate), or in combination with other antidiabetic drugs (including insulin) if existing treatment fails to achieve adequate glycaemic control. It is also used in the treatment of obesity by weekly subcutaneous administration.

No information is available on the clinical use of tirzepatide during breastfeeding. Because tirzepatide is a large peptide molecule with a molecular weight of 4814 Da, the amount in milk is likely to be low and absorption is unlikely because it is probably partially destroyed in the infant’s gastrointestinal tract. Until more data become available, tirzepatide should be used with caution during breastfeeding, especially while nursing a newborn or preterm infant. (LactMed).

Due to its protein nature, it is inactivated in the gastrointestinal tract and is not absorbed (oral bioavailability is practically nil), which makes it difficult or impossible for it to pass into the infant’s plasma from ingested breast milk, except in premature infants and in the immediate neonatal period, where there may be greater intestinal permeability. (E-lactancia).

While caution is still necessary without confirmatory data, it is unlikely to be present in large quantities in the milk compartment (Hale )

See also https://www.infantrisk.com/content/weight-loss-lactation

Hale and Krutsch (Infantrisk pharmacists express concern on the use of weight loss medications and breastfeeding due to inadequate consumption of nutrients.

“Concerns have been expressed about how the pharmacodynamics of GLP-1 agonists such as tirzepatide or semaglutide could impact the nutritional constituents of milk. These drugs are analogs of natural GLP-1 with small modifications to slow their degradation by the DPP-4 enzyme. However, lactation, in general, is expected to occur during a catabolic physiological state – GLP-1 agonists catalyze the catabolism to encourage weight loss. As long as the mother has sufficient weight to lose, the nutrient profile of milk would likely be similar if compared to a diet producing equivalent weight loss. If a mother is reducing caloric intake for any reason, we recommend a postnatal vitamin and attention to consuming enough calories to meet the elevated nutrient needs required during lactation”.

Other sources of information

NICE  TA 1026 Tirzepatide for managing overweight and obesity . https://www.nice.org.uk/guidance/ta1026

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

Liraglutide and Breastfeeding https://breastfeeding-and-medication.co.uk/fact-sheet/liraglutide-saxenda-and-breastfeeding

I have shared the chapter on ADHD from my book Breastfeeding and Chronic Medical Conditions multiple times this week. Many mothers seem to be diagnosed in later life and are concerned about breastfeeding. Hope this is a useful link.

More information

ADHD and Breastfeeding Factsheet

If this is useful maybe you need the book available on Amazon. I published on Kindle to try to make this more affordable and available to mothers and breastfeeding supporters as well as professionals

https://infantrisk.com/content/adhd-medications-and-breastfeeding

I came off my medication to conceive and my baby is now 6 months old. I am really struggling to think straight now and getting really overwhelmed by the smallest of things.

Description

ADHD is a disorder that includes symptoms such as inattentiveness, hyperactivity, and impulsiveness. It is normally diagnosed in childhood, but some parents have found themselves being diagnosed when seeking a diagnosis for their children. The cause is unknown, but it seems to at least in part, genetic. It has been suggested that being born prematurely (before the 37th week of pregnancy), having a low birth weight or maternal smoking or alcohol or drug abuse during pregnancy may be linked. Attention deficit hyperactivity disorder (ADHD) is thought to affect about 1 in 20 children in the UK with incidence being three times higher in boys.

Symptoms fall into 2 categories:

inattentiveness main symptoms of which are:

• having a short attention span and being easily distracted
• making careless mistakes
• appearing forgetful or losing things
• being unable to stick to tasks that are tedious
• appearing to be unable to listen to or carry out instructions
• constantly changing activity or task
• having difficulty organising tasks

hyperactivity and impulsiveness main symptoms of which are:

• being unable to sit still and constantly fidgeting
• being unable to concentrate on tasks
• excessive physical movement
• excessive talking
• being unable to wait turn
• acting without thinking
• interrupting conversations
• little or no sense of danger
• ADHD may be linked with anxiety, autism, and several other conditions. By the age of 25, an estimated 15% of people diagnosed with ADHD as children still have a full range of symptoms, and 65% still have some symptoms that affect their daily lives. ( https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/symptoms/)

Treatment

•        Methylphenidate (Ritalin ™, Concerta ™); works by increasing the amount of a dopamine in the parts of the brain responsible for self-control and attention. It is usually the first line treatment. There are side effects of loss of appetite and difficulty sleeping and mood swings. Limited evidence indicates that methylphenidate levels in milk are very low and not detectable in infant serum. The effects of methylphenidate in milk on the neurological development of the infant have not been well studied. Monitor the baby for agitation, irritability, poor sleeping patterns, changes in feeding and poor weight gain.
•         Atomexatine is a selective noradrenaline reuptake inhibitor (SNRI), increasing levels of noradrenaline rather than dopamine. It can aid concentration and help control impulses. Side effects include rise in blood pressure and heart rate, nausea and vomiting, gastric pain, difficulty sleeping, dizziness, headaches, and irritability. More importantly it has been associated with suicidal thoughts and liver damage. There is no published experience with atomoxetine during breastfeeding, although reports from the manufacturer found no serious adverse effects in two breastfed infants (Besag 2014).
•         Dexamphetamine. Side effects include decreased appetite, mood swings, agitation and aggression, dizziness, headaches, nausea, vomiting and diarrhoea. Only used if lisdexamphetamine is helpful but not tolerated. In dosages prescribed for medical indications, some evidence indicates that dextroamphetamine might not affect nursing infants adversely. The effect of dextroamphetamine in milk on the neurological development of the infant has not been well studied. It is possible that large dosages of dextroamphetamine might interfere with milk production.  Infant Monitoring for agitation, hyperactivity, insomnia, decreased appetite, weight gain, and tremor.
•         Lisdexamphetamine (Vyvance ™) may be offered as first line treatment in adults. Side effects include decreased appetite, aggression or drowsiness, dizziness, headaches, nausea, vomiting and diarrhoea. Lisdexamfetamine is a prodrug of dextroamphetamine. In medicinal dosages, some evidence (5 mothers studied) indicates that dextroamphetamine might not affect nursing infants adversely. The effect of dextroamphetamine in milk on the neurological development of the infant has not been well studied. Infant Monitoring should be for agitation, irritability, poor sleeping patterns and poor weight gain.
• The NHS website suggests that for adults with ADHD if you find it hard to stay organised, then make lists, keep diaries, stick up reminders and set aside some time to plan what you need to do
• let off steam by exercising regularly
• find ways to help you relax, such as listening to music or learning relaxation techniques
• if you have a job, speak to your employer about your condition, and discuss anything they can do to help you work better
• talk to your doctor about your suitability to drive, as you will need to tell the Driver and Vehicle Licensing Agency (DVLA) if your ADHD affects your driving
• contact or join a local or national support group – these organisations can put you in touch with other people in a similar situation, and can be a good source of support, information, and advice

References

• Attention deficit hyperactivity disorder: diagnosis and management; NICE guideline (March 2018, updated September 2019)
• Attention deficit hyperactivity disorder; NICE CKS, May 2018
• Besag FM. ADHD treatment and pregnancy. Drug Saf. 2014; 37:397-40
• NHS ADHD https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/living-with/
• Further Information
• AADUK https://aadduk.org/

Can women with ADHD stay on medication while they breastfeed?

Anecdotally there are many mothers who take medication for ADHD during their breastfeeding journey despite a lack of published studies on the effect of the level of medication passing through breastmilk to babies. It is a topic regularly raised on social media discussions from which many parents take their information. Since the pandemic the increase in diagnoses of adults has driven the discussions too.

As with many drugs we rely on the pharmacokinetics of the products: that is the way that the drugs are handled by the body. Drugs used to treat ADHD are not recommended during breastfeeding as the manufacturers are not required to take responsibility as they cannot ethically conduct clinical trials during the development of the medication. This is true of virtually all products used by breastfeeding women – they are used outside of the product licence and prescribed with the professionals being required to take responsibility.

For example methylphenidate (Concerta™ and Ritalin™) was studied in 3 women taking between 35 and 80mg daily. The average milk levels measured were very low.  The infants had no drug-related adverse reactions and were developing normally for their ages which averaged 4.4 months. No adverse events have been identified according to specialist sources although it would be wise to monitor changes in sleep patters and feeding including weight gain.

What ones are safest?

It is difficult to say which one is “safest” as this is a relative term. No drug is absolutely safe, but all of the drugs used to treat ADHD are recognised as compatible with breastfeeding by expert, specialist sources. The drug which would generally be chosen is the one that has proven to be most effective for the mother. Methylphenidate could perhaps be said to have the best evidence but as has already been discussed, the data published is limited. The decision to prescribe should be agreed between the mother and her professionals with full, accessible information so that she can make an informed choice in the risks and benefits for her and her nursling. Ongoing breastfeeding has many health advantages but if the mother has concerns about exposing her child to the medication (in however low a level) that may influence her choice as to whether to take the drug and continue to breastfeed, breastfeed but delay the drug or take the medication and choose to formula feed. We all have individual feelings as to the risks and benefits of each choice.

Is there a risk to the baby at all?

In the first 6 weeks after birth a baby has immature kidney and liver function and is at greater risk of not being able to metabolise the levels of drug passing through breastmilk. This in turn makes it more likely that side effects such as changes in sleep and feeding patters may occur but are difficult to identify from normal neonatal behaviour.

Individual reactions are always possible although reporting in specialist expert sources suggest these are limited.

Is it advised to stay on rather than coping without it?

That is very much an individual decision depending on how well the mother is coping with her symptoms alongside the complexity of life with a newborn which will all be associated with loss of routine and long periods sitting to breastfeed. Most mothers stop medication during pregnancy and may be desperate to re start. A fully informed discussion with appropriate, accessible data puts the decision with the mother on what she feels comfortable with.

Specialist sources of information

https://www.ncbi.nlm.nih.gov/books/NBK501922

https://www.e-lactancia.org

https://www.infantrisk.com/content/adhd-medications-and-breastfeeding#:~:text=It%20is%20rare%20that%20a,breastfeeding%20to%20take%20a%20medication.&text=Multiple%20studies%20have%20demonstrated%20that,her%20ADHD%20medication%20as%20prescribed.

https://www.sps.nhs.uk/articles/safety-in-lactation-drugs-for-adhd

Helicobacter pylori (H. pylori) infection is one of the most common causes of peptic ulcer disease, with 95% of duodenal and 70–80% of gastric ulcers associated with it.

Treatment aims to eradicate H. pylori with a relatively short course of 2 high dose antibiotics together with a proton pump inhibitor (PPI) drug such as such as esomeprazole, lansoprazole, omeprazole, pantoprazole, or rabeprazole sodium.  Combinations of drugs may vary.

These are the options given in the British National Formulary (BNF).

No penicillin allergy

Oral first line for 7 days:

• A proton pump inhibitor, plus amoxicillin, and either clarithromycin or metronidazole (treatment choice should take into account previous treatment with clarithromycin or metronidazole).

If this fails to resolve the infection other treatments are available.

Penicillin allergy

Oral first line for 7 days:

• A proton pump inhibitor, plus clarithromycin, and metronidazole.

If this fails to resolve the infection other treatments are available.

Safety in breastfeeding.

PPI:  esomeprazole, lansoprazole, omeprazole, pantoprazole, or rabeprazole sodium are largely destroyed in the mother’s stomach. Several of them have enteric coated pellets within capsules to protect them before appropriate release.

• Omeprazole (20-40mg) is only 30-40% orally bioavailable and has RID 1.1%. Preferred PPI
• Esomeprazole (20mg) is 90% orally bioavailable and has RID 2.06%. After 8 hours levels in breastmilk below level of detection
• Lansoprazole (30mg) 80%  orally bioavailable (enteric coated) and is very unstable in gastric acid
• Pantoprazole (40mg) is 77% orally bioavailable (enteric coated) and RID 1% with milk levels undetectable after 5 hours
• Rabeprazole (20mg) is 52% orally bioavailable (enteric coated) and unstable in gastric acid

Antibiotics ( see https://breastfeeding-and-medication.co.uk/fact-sheet/antibiotics-and-breastfeeding)

• Amoxycillin: licensed for paediatric use. Dose 1g twice daily
• Clarithromycin: licensed for paediatric use 250mg or 500mg twice daily
• Metronidazole: 400mg twice daily. Studies show no untoward effects at this dose although there are some dated reports that it affects taste of the milk. Most babies do not react and it is widely used for anaerobic infections in the perinatal period and for dental infections.

H. Pylori infection treatment as above is compatible with continued breastfeeding. For any variations please contact me wendy@breastfeeding-and-medication.co.uk

Morphine is an opioid analgesic (painkiller) prescribed when paracetamol and ibuprofen provide inadequate pain relief. Other opioid painkillers include codeine (not recommended in breastfeeding but see https://breastfeeding-and-medication.co.uk/fact-sheet/accidental-dose-of-codeine-when-breastfeeding ), dihydrocodeine ( see https://breastfeeding-and-medication.co.uk/fact-sheet/dihydrocodeine-and-breastfeeding) , oxycodone ( see  https://breastfeeding-and-medication.co.uk/fact-sheet/oxycodone-and-breastfeeding) and Tramadol (see https://breastfeeding-and-medication.co.uk/fact-sheet/tramadol-and-breastfeeding) See also  https://breastfeeding-and-medication.co.uk/fact-sheet/pain-relief-when-breastfeeding. All of these drugs can cause constipation so should be prescribed with a suitable laxative ( https://breastfeeding-and-medication.co.uk/fact-sheet/constipation-laxatives-and-breastfeeding) .

Therapeutic doses of morphine in the breastfeeding mother are unlikely to be harmful to baby in short term e.g. post-operatively because morphine is subject to extensive first pass metabolism. Respiratory difficulties may be important to be aware of with premature babies or others at risk of apnoea. The oral absorption of morphine is very poor and first pass metabolism is high. It is therefore frequently used post caesarean section as Oramorph solution.

Robieux et al. (1990) reported a single case of an infant who was breastfed while his mother was receiving low doses of morphine. Morphine concentration in his serum was in the analgesic range (4 ng per millilitre), while concentrations in the milk varied substantially from 10–100 ng per millilitre. The authors calculated that the baby had received 0.8 to 12% of maternal dose. Oberlander et al. (2000) studied one baby born to a mother who received morphine intra-thecally during and after pregnancy. Minimal levels were determined in breastmilk over 7 weeks and the infant’s development and feeding up to 7 months were normal. Baka et al. (2002) also studied women receiving patient controlled analgesia post-caesarian section and noted that the concentrations of morphine in breastmilk were very small (<1 to 274 ng per millilitre) with a m/p ratio <1. Relative infant dose quoted as 9.1% (Hale  online access).

Therapeutic doses unlikely to affect infant (BNF).

Compatible with use short term during breastfeeding. Observe baby for sedation and poor feeding. As with other opiates, exposure of premature infants should be undertaken with caution because of the risk of apnoea and sedation.

The amount in breastmilk is probably too small to be harmful. The dose should be as low as possible for as short a period as possible as with all opioid medication and titrated down to paracetamol and NSAID once pain relief is adequate. Observe baby for drowsiness. If baby becomes drowsy stop drug immediately and seek medical advice.

References

• Ilett KF, Paech MJ, Page-Sharp M, Sy SK, Kristensen JH, Goy R, Chua S, Christmas T, Scott KL, Colostrum morphine concentrations during postcesarean intravenous patient-controlled analgesia, Anesth Analg, 2002;94:184–7.
• Oberlander TF, Robeson P, Ward V, Huckin RS, Kamani A, Harpur A, McDonald W, Prenatal and breastmilk morphine exposure following maternal intrathecal morphine treatment, J Hum Lact, 2000;16:137–42.
• Robieux I, Koren G, Vandenbergh H, Schneiderman J, Morphine excretion in breastmilk and resultant exposure of a nursing infant, J Toxicol Clin Toxicol 1990
• Hale T, Krutsch K.  Hale’s Medications & Mothers’ Milk 2025-2026

Tramadol is an opioid analgesic (painkiller) prescribed when paracetamol and ibuprofen provide inadequate pain relief. Other opioid painkillers include codeine (not recommended in breastfeeding but see https://breastfeeding-and-medication.co.uk/fact-sheet/accidental-dose-of-codeine-when-breastfeeding ), dihydrocodeine ( see https://breastfeeding-and-medication.co.uk/fact-sheet/dihydrocodeine-and-breastfeeding) , oxycodone ( see Oxycodone and Breastfeeding – Breastfeeding and Medication)  and morphine  ( https://breastfeeding-and-medication.co.uk/fact-sheet/pain-relief-when-breastfeeding). All of these drugs can cause constipation so should be prescribed with a suitable laxative ( https://breastfeeding-and-medication.co.uk/fact-sheet/constipation-laxatives-and-breastfeeding) .

Brand name: Zydol®, Zamadol®

Tramadol is an opiate analgesic used for moderate to severe pain. It is subject to first pass metabolism which limits passage into milk. It has an elimination half-life of 6 hours. Tramadol inhibits the reuptake of noradrenaline and serotonin and may potentiate the action of other drugs with similar action e.g. SSRI anti-depressants.

Ilett et al. (2008) studied 75 breastfeeding mothers who were given 100 mg tramadol post-caesarian section on days 2 to 4. He collected milk and plasma samples of four or more doses to reflect steady state. Additionally, he observed the infants together with matched controls not exposed to tramadol. He determined a relative infant dose quoted as 2.24% for tramadol and 0.64% for its metabolite. No difference was noted in the behaviours of the infants exposed compared with the controls and the authors therefore concluded that short-term maternal use of tramadol is compatible with breastfeeding.

Tramadol is metabolized in the liver by enzyme cytochrome P450 isoenzyme 2D6 (CYP2D6). Some people have a variation of this enzyme that changes codeine to morphine and tramadol to M1 faster and to a greater extent than in other people. These individuals are called CYP2D6 ultra-rapid metabolizers. Just as in codeine this can produce an accumulation of the drug in breastmilk. This genotype is present in up to 10% of the white population in Europe and North America, but only 4% of black African Americans (FDA 2015).

As with other opiates, exposure of premature infants should be undertaken with caution because of the risk of apnoea and sedation.

The amount in breastmilk is probably too small to be harmful. The dose should be as low as possible for as short a period as possible as with all opioid medication and titrated down to paracetamol and NSAID once pain relief is adequate. Observe baby for drowsiness. If baby becomes drowsy stop drug immediately and seek medical advice.

References

• Ilett KF, Paech MJ, Page-Sharp M, Sy SK, Kristensen JH, Goy R, Chua S, Christmas T, Scott KL, Use of a sparse sampling study design to assess transfer of tramadol and its o-desmethyl metabolite into transitional breastmilk. Br J Clin Pharmacol, 2008;65(5):661–6
• Hale T, Krutsch K.  Hale’s Medications & Mothers’ Milk 2025-2026

Oxycodone is an opioid analgesic (painkiller) prescribed when paracetamol and ibuprofen provide inadequate pain relief. Other opioid painkillers include codeine (not recommended in breastfeeding but see https://breastfeeding-and-medication.co.uk/fact-sheet/accidental-dose-of-codeine-when-breastfeeding ), dihydrocodeine ( see https://breastfeeding-and-medication.co.uk/fact-sheet/dihydrocodeine-and-breastfeeding) , tramadol and morphine  . ( https://breastfeeding-and-medication.co.uk/fact-sheet/pain-relief-when-breastfeeding). All of these drugs can cause constipation so should be prescribed with a suitable laxative ( https://breastfeeding-and-medication.co.uk/fact-sheet/constipation-laxatives-and-breastfeeding) .

Brand name: OxyContin, OxyNorm

Oxycodone is an opiate used for severe pain often post operatively. It is suggested that it is associated with more sedation than other opiates. Timm (2013) reported on a 4-day-old breastfed infant who was taken to the emergency department with symptoms indicating opioid intoxication resulting from his mother’s use of oxycodone after caesarean delivery. The infant was hypothermic, lethargic, and had pinpoint pupils. A dose of naloxone reversed the symptoms and the baby fed. The mother discontinued oxycodone and the baby was discharged without further pathology.

Seaton (2007) studied fifty breast-feeding mothers taking oxycodone following caesarean section. Blood and breast milk samples were analysed and forty-one neonates had blood samples taken at 48 hours. Oxycodone was detected in the milk of mothers who had taken any dose in the previous 24 hours. The authors concluded that Oxycodone is concentrated in human breast milk up to 72 hours after delivery and that infants may receive > 10% of a therapeutic infant dose. However, maternal oxycodone intake up to 72-h post section poses only minimal risk to the breast-feeding infant as low volumes of breast milk are ingested during this period.

Whilst it may be suitable as an analgesic short-term post operatively a breastfed infant should be monitored carefully for sedation and breathing difficulties. Studies appear to relate largely to use in the immediate post-partum period at a dose of 5-10mg as necessary to a maximum of 40mg in 24 hours. The dose should be as low as possible for as short a period as possible as with all opioid medication. and titrated down to paracetamol and NSAID once pain relief is adequate.

Hale reports a half-life of 2-4 hours so normally the drug would be assumed to have left the body after 20 hours. The milk plasma level exceeds 1 (3.4) but the oral bioavailability is 60-87% which explains the relative infant dose of 1.01% – 8%

Observe baby for sedation and poor feeding.

References

• Seaton S, Reeves M, McLean S. Oxycodone as a component of multimodal analgesia for lactating mothers after Caesarean section: Relationships between maternal plasma, breast milk and neonatal plasma levels. Aust N Z J Obstet Gynaecol. 2007;47:181-5.
• Timm NL. Maternal use of oxycodone resulting in opioid intoxication in her breastfed neonate. J Pediatr. 2013;162:421-2.
• Hale T, Krutsch K.  Hale’s Medications & Mothers’ Milk 2025-2026

Text taken from Breastfeeding and Medication 2nd ed 2017 Jones W (Routledge)

Folic acid is a water-soluble vitamin of the B group. It is found naturally in green vegetables, legumes and citric fruits. It is actively secreted in breast milk with concentration higher in mature milk compared to colostrum (Cooperman JM, Dweck HS, Newman LJ, Garbarino C, Lopez R. The folate in human milk. Am J Clin Nutr. 1982;36(4):576-580).

Folic acid 400 micrograms per day is recommended in the first 12 weeks of pregnancy to prevent neural tube defects. If the mother is on anti-epileptic medication, is obese (BMI >30), has a history of neural tube defects in a previous pregnancy, has coeliac disease, diabetes, sickle cell anaemia, thalassaemia, she or her partner have spinal cord defects, the dose should be increased to 5 mg daily.

If the mother is continuing to breastfeed an older baby, she can take the dose of folic acid to protect the unborn baby. No harmful effects have been observed by taking folic acid during lactation (https://e-lactancia.org/breastfeeding/folic-acid/product/). Excess of folic acid is eliminated by the kidneys every day.

Mass media campaigns have been successful in increasing folate awareness but in no study has the post-campaign rate of folic acid use exceeded 50%. It has been recommended that all women of childbearing age should take folic acid regularly on the assumption that they might become pregnant (NICE PH11). Currently neural tube defect affected pregnancies arise in 0.8 per 1000 pregnancies, which translates to 800 pregnancies each year in the UK.

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