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Live vaccinations and Immunosuppressant medication taken by breastfeeding mothers

To finish the posts on immunosuppresant medications the final most frequently asked question is about the administration of live vaccinations to the baby. This is particularly a problem with the rotavirus vaccine.

In August 2022 the summary of product characteristics for Infliximab was changed to state that live vaccines should not be administered to the babies of mothers on Infliximab in pregnacy or breastfeeding, before 12 months of age. https://breastfeeding-and-medication.co.uk/wp-content/uploads/2022/10/Infliximab-exposure-in-pregnancy-and-breastfeeding-Aug-2022-update.pdf

The Torento consensus statement recommended that live vaccinations are not recommended within the first 6 months of life in the offspring of women who were on anti-TNF therapy during pregnancy. The babies of mothers taking immunosupressant drugs eg azathioprine and infliximab have not been shown to be immunocompromised because of the limited passage of medication through breastmilk.

However, if live vaccinations, particularly rotavirus are used then the mother with IBD should use precautions like wearing gloves when changing the baby’s nappy for 2 weeks after the vaccination to avoid picking up the particles of live virus shed in faeces.

The Rotavirus Vaccination Programme Public Health England

” There is a potential for transmission of the live attenuated virus in Rotarix vaccine from the infant to severely immunocompromised contacts through faecal material for at least 14 days. However, vaccination of the infant will offer protection to household contacts from wild-type rotavirus disease and outweigh any risk from transmission of vaccine virus to any immunocompromised close contacts. Those in close contact with recently immunised infants should, as always, observe good personal hygiene which should include handwashing after changing the infant’s nappy”

” Rotavirus vaccine should not be given to infants of mothers that used immunosuppressive biological therapy during their pregnancy because of the potential that these will have a postnatal influence on the infants’ immune status. It is recommended that immunisation with live vaccines should be delayed for 6 months in children born to mothers who were on immunosuppressive biological therapy (TNFα antagonists and other biological medicines such as Infliximab) during pregnancy. As Rotarix vaccine is contraindicated in infants presenting for the first dose after 15
weeks of age (beyond 14 weeks and 6 days), infants whose mothers received such treatment during pregnancy will therefore not be eligible to receive Rotarix vaccine, but they should benefit from herd (indirect) protection.”

” Infants born to mothers who received non-biological immunosuppressive therapy such as steroids, cyclosporine, tacrolimus or azathioprine at any time during their pregnancy can safely have the rotavirus vaccine at the appropriate age. https://www.gov.uk/government/publications/rotavirus-qas-for-healthcare-practitioners/rotavirus-vaccination-programme-information-for-healthcare-professionals


A recent review of the literature concluded that it is safe for mothers to breastfeed while on immune suppression that includes steroids, cyclosporine, tacrolimus or azathioprine. Breastfed infants of mothers taking immunosuppressive therapy can receive rotavirus vaccine at the appropriate age. Rotarix vaccine should not be administered to breastfeeding infants whose mothers are using biological medicines such as Infliximab.”

https://www.medicines.org.uk/emc/dhpc/2511/Document

  • Sameh M, Mohsen EK, Jon JK, Halawa A, Sharma Al. Safety of Breastfeeding by Mothers on Immunosuppressive
    Medication for Renal Transplantation: Obsession, Myth and Truth. JOJ Uro & Nephron. 2017; 3(3): 555612. Available at
    www.juniperpublishers.com/jojun/pdf/JOJUN.MS.ID.555612.pdf
  • Public Health England. Immunisation against infectious disease. Contraindications and Special Considerations. Chapter 6.
    www.gov.uk/government/publications/contraindications-and-special-considerations-the-green-book-chapter-6

ADHD 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/

Medication in pregnancy

As my youngest daughter nears the end of her pregnancy, I thought it was a good time to upload this information that I have been looking at for a while. I wrote the basis for a charity but it doesnt seem to have been used, so updating it and posting here. I dont have the same resources on drugs in pregnancy as I do in breastfeeding so please check UKTIS factsheets https://www.medicinesinpregnancy.org/Medicine–pregnancy/

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2022/08/medicines-in-pregnancy-1.pdf

Medications are only prescribed in pregnancy after careful consideration of the risks  and benefits to mother and baby. Thanks to a world-wide organisation The Organisation of  Teratology Information (OTIS https://mothertobaby.org/about-otis/) who has a service in the  UK (UKTIS http://www.uktis.org/), we have much more information on studies of medicine  use in pregnancy and outcomes for mother and baby than we have ever had before.

This birth information page is not intended to provide advice on certain medication in pregnancy  but to provide sources of information.

What medication should you take in pregnancy?

All pregnant women should take folic acid when trying to conceive and until 12 weeks of pregnancy. 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.

There has been an unexpected increase over the past 15 years in the number of babies found to be suffering from rickets or symptoms of decreased bone mass which demonstrate poor levels of vitamin D (NICE PH11). Vitamin D deficiency is unusual in babies born at term to mothers with adequate vitamin D status. Some women enter pregnancy with low vitamin D levels. This may be due to:

•             lack of exposure to sunlight due to wearing concealing clothing for cultural reasons.

•             inadequate consumption of foods containing vitamin D e.g., oily fish.

•             Inadequate consumption of dairy (prevalent particularly in adolescent girls)

•             BMI greater than 30.

•             Women who spend a lot of time indoors or use sun creams limiting the absorption of ultraviolet (UV) light.

•             living in the northern hemisphere where levels of UV light are only sufficient to stimulate vitamin D production in the summer months; and

•             having dark skin, which prevents absorption of available UV light in the UK climate.

Babies born to mothers with low vitamin D levels may be born deficient. It is advised that all pregnant women take 10mcg vitamin d daily throughout pregnancy https://www.nhs.uk/pregnancy/keeping-well/vitamins-supplements-and-nutrition/

Commercial vitamin products for pregnancy may also contain Omega 3 DHA, iron, zinc and vitamin B12

Is it safe to take medication whilst pregnant?

Drugs should be prescribed in pregnancy only if the expected benefit to the mother is  thought to be greater than the risk to the foetus. All drugs should be avoided if possible, during the first trimester, although for may chronic conditions this may not be possible. Drugs which have been extensively used in pregnancy and appear to be usually safe should be prescribed in preference to new  or untried drugs; and the smallest effective dose should be used. Few drugs have  been shown conclusively to be teratogenic (harmful to an unborn baby) in humans,  but no drug is safe beyond all doubt in early pregnancy  (https://bnf.nice.org.uk/guidance/prescribing-in-pregnancy.html).

The tragedies wrought by thalidomide back in the 1960s have meant we are all more  aware of the risk of drugs taken during pregnancy. Thalidomide was associated  predominantly with limb defects, but it affected many other organs. A total of about  10,000 babies worldwide were affected. None of these abnormalities showed up in  animal tests and it was believed to be so safe it was made available over the  counter. In the original studies it was not possible to study enough pregnancies to  identify a problem, although this became apparent when millions of mothers began  to take it. 

If you have a chronic medical condition which means that you need to continue to  take drugs during your pregnancy, make sure that your doctor knows that you are  pregnant (or ideally planning to become pregnant) so that they can try to avoid prescribing drugs which are known to be potentially harmful to an unborn child. For some people, having a chronic condition means having to take extra medication to support the pregnancy e.g., changing from the regular dose of folic acid of 400mcg to 5mg daily. If you are  taking one of the drugs in the table below, please discuss the medication before  considering pregnancy. If you are taking one of the drugs in the table below and fall  pregnant accidentally or unexpectedly, please talk to your doctor as soon as possible  – it is important that you don’t just stop taking the medication. If you are taking one of the drugs in the table below, please discuss the medication before considering  pregnancy. 

ACE inhibitors e.g., enalapril, ramipril, perindoprilACE (Angiotensin-converting enzyme) inhibitors may be used to treat high blood pressure and congestive heart failure.  Women are normally advised to stop taking these when planning a pregnancy due to the risk of birth defects.
Statins e.g., simvastatin, atorvastatinStatins are prescribed to lower cholesterol and so reduce the risk of a heart attack or stroke. Women are normally advised to  stop taking these at least 3 months before conception occurs.
Anti-epilepsy Drugs (AED)Most AEDs are teratogenic, although the risk is reduced when only one drug is used. Some AEDs are less likely to cause problems than others, but the risk to the unborn baby needs to be balanced with the risk of seizures in the mother which could harm both the mother and the baby. Women with epilepsy should therefore have a chance to discuss the choice of drugs and doses with a specialist when planning their pregnancy. Most women with epilepsy have normal, healthy babies and the risk of birth defects is low if the baby is not exposed to AEDs around the time of conception1 Pregnant women who are on any AEDs are usually recommended to take 5mg folic acid per day before becoming pregnant and through the first trimester, as it is thought that this may reduce the chances of a birth defect.1 Valproate medicines must not be used in women of  childbearing potential unless the Pregnancy Prevention Programme is in place https://www.gov.uk/drug-safety update/valproate-pregnancy-prevention-programme-actions required-now-from-gps-specialists-and-dispensers See https://breastfeeding-and-medication.co.uk/fact-sheet/valproate-and-pregnancy https://breastfeeding-and-medication.co.uk/fact-sheet/carbimazole-in-women-of-childbearing-age https://breastfeeding-and-medication.co.uk/fact-sheet/topirimate-in-pregnancy-and-breastfeeding
Antibiotics Many antibiotics including penicillins, erythromycin and cephalosporins are thought to be safe in pregnancy, but some are associated with problems. · Trimethoprim interferes with folate metabolism and so should not be prescribed in the 1st trimester. · Tetracycline can cause a yellow staining of the teeth and reduces growth of long bones. · Aminoglycosides such as gentamycin can cause deafness.
WarfarinThis is a blood thinning drug used to treat or prevent blood clots. It is not usually prescribed in pregnancy because it can cause foetal warfarin syndrome which is associated with a range of physical and sometimes mental problems.   
Lithium Lithium may be used in the management of bipolar disorder. If used in pregnancy, especially in the 1st trimester, it can sometimes cause an abnormality of the heart valves. This needs to be balanced against the risks to the mother of a relapse if she stops taking Lithium. If she is advised to stop Lithium or switch to a different drug this needs to be managed gradually. Women on lithium will usually be offered a high-resolution Ultrasound scan and foetal echocardiography at 18-20 weeks of pregnancy to check for heart defects.
Other drugsOther drugs for chronic conditions include medications for diabetes, liver disease, heart conditions and mental health conditions.  Please speak to your doctor or health care team if you take routine or regular medications outside of pregnancy.

Risk of medication during pregnancy

The risk of harm coming to a baby due to medication is greatest in weeks 3-11 after  conception because this is when major organs are developing. During the second  and third trimesters, drugs can affect the growth or functional development of the foetus, or they can have toxic effects on foetal tissues. Drugs given shortly before  term or during labour can have adverse effects on labour or on the neonate after  delivery.

It can be difficult to identify whether a drug has potential to cause harm to an unborn  baby (teratogenic), because, if the problem is uncommon, a very large number of  mothers would need to be studied for it to show up. Instead, drug side-effects are  normally identified by collecting reports of problems via what is called the “yellow  card” reporting system (https://yellowcard.mhra.gov.uk/). This data is analysed  nationally and internationally so that any frequent side-effects can be identified and  monitored. This monitoring is what has enabled data to be changed on the COVID  19 vaccination which originally was not recommended in pregnancy. Now we know  that the programme is not only suitable for pregnant women but has also been seen  as important (https://www.gov.uk/government/news/pregnant-women-urged-to come-forward-for-covid-19-vaccination) 

What drugs are known to have a risk of causing birth defects?

To date, only 30 drugs have been shown to be teratogenic (harmful to an unborn  baby). If you are planning a pregnancy and are taking any of these, you can discuss  treatment options with your specialist, as a different drug or dose may be safer than  your current one. If you have already become pregnant, speak to a specialist as  soon as possible as there may be risks to stopping your medication abruptly which  need to be balanced against the risk of birth defects if you continue. If you are taking  one of these medications you should be using appropriate contraception  https://assets.publishing.service.gov.uk/media/5c936a4840f0b633f5bfd895/pregnancy_testing_and_contraception_table_for_medicines_with_teratogenic_potential_final. pdf

The following is a good resource and a place to start when learning about drugs in  pregnancy: https://www.newcastle-hospitals.nhs.uk/services/clinical-genetics/information-for healthcare-professionals/preconception-counselling/teratogenic-drugs/. There are also  other sources, listed below which cover different stages of  pregnancy.

Are there risks with non-prescription drugs or herbal remedies?

Over the counter medicines should be discussed with the pharmacist before purchase. The  Patient Information leaflet (PIL) included in the packaging should state whether pregnant  women are advised to avoid the drug. The leaflets on the BUMPS website can be really helpful https://www.medicinesinpregnancy.org/Medicine–pregnancy/UKTIS will discuss medication in pregnancy with professionals are unable to discuss medication with families. 

Aspirin (or any preparations containing it) at a dose to be used as a painkiller (600mg four times a day) is not recommended for pregnant women because it is associated with an increased risk of stillbirth, low birth weight and possibly birth defects.4 However, it is  sometimes prescribed in a low dose (75-150mg per day) to reduce the chance of  miscarriage or pre-eclampsia amongst other reasons.

Herbal medicines have generally not been tested for safety, but they are subject to the  “Yellow Card” reporting system in the same way as prescription drugs  (https://yellowcard.mhra.gov.uk/) You should check with your midwife, pharmacist or  doctor before taking any herbal medicines especially those containing multiple ingredients.

Foetal Alcohol Syndrome is seen in babies born to mothers who drink excessive amounts of  alcohol, and no safe threshold amount can be defined (https://www.nhs.uk/conditions/foetal-alcohol-spectrum-disorder/)

Vitamin A intake needs to be limited in pregnancy so additional supplements should be  avoided (https://www.nhs.uk/conditions/vitamins-and-minerals/)

Smoking also presents a risk to the developing foetus and should be avoided in pregnancy. Midwives can provide information in smoking cessation https://www.nhs.uk/pregnancy/keeping-well/stop-smoking

.Where do I find information on the drugs that I currently take?

If you have a medical condition that is being managed by a consultant or other specialist,  they will discuss your current medication ideally before you become pregnant. Your GP may look in the BNF (British National Formulary), but this information may be limited. UKTIS has information available at https://www.medicinesinpregnancy.org/Medicine–pregnancy/.  

There is a consortium set up by the MHRA working with many other organisations both  within the NHS and third sector to provide evidence-based information on drugs in  pregnancy (Safer Medicines in Pregnancy and Breastfeeding Consortium  https://www.gov.uk/government/publications/safer-medicines-in-pregnancy-and breastfeeding-consortium)

Specialist information sources online:

● Guidance: Use of medicines in pregnancy and breastfeeding MHRA Jan 2021  https://www.gov.uk/guidance/use-of-medicines-in-pregnancy-and-breastfeeding

● BUMPS: best use of medicines in pregnancy  https://www.medicinesinpregnancy.org/about-us/

● Mother to Baby https://mothertobaby.org/fact-sheets-parent/` 

For most common medical conditions there are support groups with a webpage  and/or a helpline.

References

1. RCOG Greentop Guide no 66 “Epilepsy in Pregnancy”, June 2016 2. Department of Health, UK Chief Medical Officer’s Alcohol Guidelines Review,  January 2016

3. Collins E. Maternal and foetal effects of acetaminophen and salicylates in  pregnancy, Obstet. Gynecol. 1981; 585 Suppl; 57S-62S 4. www.nice.org.uk/guidance/ph11/chapter/4-Recommendations#prescribing

5. Cochrane Review “Parenteral opioids for maternal pain management in labour”,  July 2011

6. Tsamantioti ES, Hashmi MF. Teratogenic Medications. [Updated 2021 Aug 9]. In:  StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.  Available from: https://www.ncbi.nlm.nih.gov/books/NBK553086/

Further Reading

  • Ainsworth SB (2014) Neonatal Formulary: Drug Use in Pregnancy and the First Year  of Life 7th Edition Wiley Blackwell and BMJ Books
  • Al-Zidan RN (2020) Drugs in Pregnancy: A Handbook for Pharmacists and  Physicians 1st Edition 
  • Briggs G et al. (2021) Briggs Drugs in Pregnancy and Lactation: A Reference Guide  to Fetal and Neonatal Risk 12th Edition. Lippincott Williams and Wilkins
  • Jones W (2018) Breastfeeding and Medication. Routledge
  • Priest J, Attawell K (1998) Drugs in Conception, Pregnancy and Childbirth Paperback 

Schaefer C, Peters PWJ, Miller RK (Editors) (2014) Drugs in Breastfeeding and Lactation 3rd Edition. Ac

What would women like professionals to understand? Breastfeeding an older baby whilst experiencing Hyperemesis.

PDF of this information is available at:

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/02/hyperemesis-and-breastfeeding-feb-2023-.pdf

see also The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69) https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.17739?fbclid=IwAR1c5ZE0_-AocuZ1bXuZSZGB9VCLHHCy4of4JkvxmYTTPWEzMAJVzTf1gQY

Thank you to everyone on the facebook group who shared their experiences and helped me to update this information.

More women are now breastfeeding their babies for longer and may still be feeding when they fall pregnant. For those who suffer from hyperemesis  gravidarum (HG) this is a tough time. Sadly, some healthcare professionals do not understand that there is benefit to a child from being breastfed to the age of two years and beyond (WHO) alongside a normal weaning diet. Being asked to abruptly wean your older child in order to take medication is not an easy option and is not necessary. Sometimes sitting quietly to breastfeed whilst you fight the feeling of nausea is helpful. Some professionals remain concerned about the teratogenicity of drugs in pregnancy despite national guidance.

“ I had an absolutely awful time while still trying to breastfeed a toddler. The GP refused to prescribe anything other than cyclizine despite me calling them in desperation many times. Nothing else was made available and I was told that I just had to wait until it cleared up.”

Symptoms of NVP and HG

Nausea and vomiting of pregnancy (NVP)  is common and  usually settles by 12-14 weeks of pregnancy (although it may be longer and even last the full pregnancy). Often known as morning sickness it can occur at any time of the day or last all day.

Hyperemesis gravidarum is a severe form and can affect up to 1 to 3 in 100 pregnant women. Sadly, some women experience such extreme symptoms that they feel that they have no choice but to terminate the pregnancy even if it is a much longed for baby.

“I ended in termination of pregnancy after first hospital visit as I didn’t want to take from my child who was already here and after how badly I dealt with it last time, it being worse instantly I couldn’t do it”

Others decide that one child is sufficient to complete their family as they cannot contemplate symptoms again. There are medications but often primary care professionals do not appreciate the severity of symptoms or impact on mothers.

“I had HG with my daughter who will be 11 next month. Hyperemesis is the primary reason I only have one child. It was physically horrendous, and I had post-traumatic stress for years afterwards”.

“I had this with my daughter. It is the reason she will be an only child. She’s 4 now and I still suffer a lot of health issues as a direct result of hyperemesis. I had the best medical care. And was lucky to be given a  lot of treatment. But it wasn’t enough, and my body still struggled. You can’t appreciate how difficult it is until you’ve experienced it.”

When asked in a facebook group (https://www.facebook.com/breastfeedingandmedication) for their experiences of suffering from morning sickness and hyperemesis, one of the overwhelming comments from women was about reluctance of GPs to prescribe medication in pregnancy, even when it had been prescribed whilst the mother was hospitalised!

“After one of my hospitalisations I was sent home with a prescription for cyclizine and when I went to my GP to renew the prescription she talked me out of it because “it wasn’t making enough of a difference for me to go back to work” so didn’t seem worth taking (mild relief from the symptoms of HG wasn’t considered a benefit.)”

Repeated comments from family, friends and professionals underestimated how the woman was feeling and she didn’t feel listened to.

“I didn’t feel I wasn’t listened to and also I didn’t feel dismissed. I just accepted this was part and parcel of my pregnancy as it was just relayed to me that it was normal.”

“It was awful. People (friends, family, healthcare workers) were quick to tell me what worked for them, and I felt very blamed that I was somehow not trying hard enough. All the admissions were almost a relief, just to lie there with fluid going in. I used to be admitted for several days each week, particularly in third trimester. I still have consequences from the prolonged malnutrition.”

For what should be a joyous family time there were repeated descriptions of an awful experience:

“ horrendous, hell on earth,  pure hell, absolutely hell, housebound for months, nothing worked”.

“ I wasn’t taken seriously until my organs started to shut down and I needed to be induced, I spent 5 months in bed, couldn’t drink water or anything else, everything made me feel nauseous.”

“ I vomited so much and so hard that every time I wet myself and my nose bled. I was told when I was 5 weeks pregnant that if I didn’t want to be sick I shouldn’t be pregnant. I ended up hospitalized at 8 weeks.”

Should this be the experience of women in the UK in 2023?

Anti emetics in breastfeeding and pregnancy

Many of the drugs used to relieve nausea in pregnancy may be associated with lowering of milk supply. However, most women find that their supply very rapidly diminishes when they are pregnant. Many also develop aversion and very sensitive nipples and wish to limit feeding. Sadly, toddler nurslings don’t always understand the loss of their comfort! Many breastfeeding dyads continue to dry nurse throughout pregnancy and may go on to tandem feed. It is the decision which works for each family which matters, without judgement from family and professionals.

Hyperemesis may result in dehydration and subsequent admission to hospital.  Signs of dehydration include  feeling very thirsty, becoming drowsy or unwell, urine changing from a light yellow to a dark yellow or brown colour. Medical help should be sought if even sips of fluid produce vomiting. Weight loss can be excessive because of the restriction of quantity of food tolerated. Hyperemesis is diagnosed when there is prolonged nausea and vomiting  with more than 5% pre pregnancy weight loss, dehydration and electrolyte imbalance. https://cks.nice.org.uk/topics/nausea-vomiting-in-pregnancy/background-information/definition/

Self-care

https://cks.nice.org.uk/topics/nausea-vomiting-in-pregnancy/management/management/

  • Rest as needed and try to avoid sensory stimuli that may trigger symptoms, such as odours, heat, and noise.
  • Try eating plain biscuits or crackers in the morning.
  • Try eating bland, small, frequent protein-rich meals which are low in carbohydrate and fat.
  • Cold meals may be more easily tolerated if nausea is smell-related.
  • Drinking little and often, rather than large amounts.
  • Ginger (can be taken in fresh, tea, capsule, or syrup form).
  • Acupressure (such as over the P6 point on the ventral aspect of the wrist using a wrist band or finger pressure).

Responses on the facebook group as to how helpful these suggestions were are exemplified by:

“Nausea and sickness with my first born I had such a heightened sense of smell. I couldn’t even open my fridge without feeling sick and running to the loo. I ended up using a cool bag instead of my fridge, and I had to call my mum to come and help me when my partner was away. I couldn’t brush my teeth without gagging and wanting to be sick.”

“I was asked what is had to eat and when I said an oat/raisin bar the doctor replied I shouldn’t be having anything sugary. That one doctor who knew her stuff had told me to eat anything I could keep down.”

Medical Treatment

The RCOG green top guidelines on treating are available https://www.rcog.org.uk/media/y3fen1x1/gtg69-hyperemesis.pdf

The UKTIS information on the use of drugs in pregnancy can be found at https://www.medicinesinpregnancy.org/leaflets-a-z/nausea–vomiting/

RCOG Recommended antiemetic therapies and dosages

In this fact sheet I have provided links to detailed information on the medication which can help prescribers to reach an evidence-based decision on the safety of the drug to the breastfeeding baby which is not available in standard reference texts like the British National Formulary (BNF). The linked pdf files contain information sourced from LACTMED February 2023

First Line treatments

  • Cyclizine (Valoid™)

May possibly cause some drowsiness in the nursling but anecdotally appears to happen rarely . See https://www.ncbi.nlm.nih.gov/books/NBK501749/ and https://www.e-lactancia.org/breastfeeding/cyclizine/product/

Cyclizine is an anti-emetic used to treat nausea and vomiting including motion sickness, post-operative nausea and vomiting, after radiotherapy, in drug-induced situations, as well as for nausea in pregnancy. There are no reports of levels entering breastmilk (BNF) or data on which to base conclusions. There is an unlicenced dose for children aged over 6 years. It may be given orally, by IV or IM every 8 hours. Manufacturers advise to avoid in pregnancy, but there is no evidence of teratogenicity

· 

    

Prochlorperazine (Buccastem, Stemetil)

Low levels of prochlorperazine are secreted into breastmilk and it can be used when breastfeeding. Side effects for the mother include drowsiness, restlessness and occasional extra pyramidal effects but babies seem to exhibit no adverse reactions. It is licensed to be given directly to babies weighing more than 10 kg. See https://www.ncbi.nlm.nih.gov/books/NBK501080/ and https://www.e-lactancia.org/breastfeeding/prochlorperazine/product/

Prochlorperazine is used to treat vertigo, labyrinthitis, migraine or drug-induced emesis if severe vomiting is a problem. Its oral bio-availability is low due to high first-pass metabolism but, like all phenothiazines, it has many metabolites, some active. It is not generally used in travel sickness prophylaxis. It is a member of the phenothiazine family to which children are particularly sensitive. Long-term use should be avoided in breastfeeding where possible, particularly with very young babies where there is a potential risk of apnoea. However, short-term acute use probably poses few risks as it is licenced for use in children over 10 kg. The dose is 5-10mg (one or two tablets) every 6-8 hours. It may also be given IV or IM.

  • Promethazine (Avomine™ Phenergan™, Sominex™)

 When used for hyperemesis in mother promethazine may possibly cause some drowsiness in the nursling but anecdotally appears to happen rarely. It also causes drowsiness in the mother so care should be taken with co sleeping.

See https://www.ncbi.nlm.nih.gov/books/NBK501081/ and https://www.e-lactancia.org/breastfeeding/promethazine/product/

Promethazine is widely used to reduce nausea particularly associated with travel sickness as well as symptomatic relief of urticaria and as an over-the-counter (OTC) hypnotic for short-term use. No data are available on transfer into breastmilk but it is believed that it does pass into breastmilk. It is licenced for use in children over 2 years.”

·        Doxylamine/pyridoxine (Xonvea™)

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.

Second Line Treatments

·        Metoclopramide (Maxolon™)

Metoclopramide has also been used to increase milk supply. It is associated with an increased risk of depression as well as other side effects if used long term. There are no reports of problems in the babies from the amount passing through breastmilk. https://www.ncbi.nlm.nih.gov/books/NBK501352/

Metoclopramide is a dopamine antagonist and can cause extra-pyramidal side effects, in particular acute dystonia. This adverse effect is most commonly seen in children and young adults, especially females, so it is not a drug of choice in lactating mothers who generally fall into this age group. It may also precipitate hypotension and depression. Other side effects reported include headache, diarrhoea, dry mouth and change in appetite (Ingram et al. 2011). It stimulates prolactin secretion and has been used as a galactogogue but has now been superseded by domperidone because of the latter does not cross the blood–brain barrier (Ingram et al. 2012). The bio-availability of oral metoclopramide is about 75% but varies widely between patients due to its hepatic first-pass metabolism. Concentrations higher than those in maternal plasma may be reached in breastmilk, particularly in the early puerperium, although these decrease with increased maturity. Metoclopramide has pro-kinetic and anti-emetic properties and acts directly on the gastrointestinal tract without altering acid secretion. It is more frequently used in the US where domperidone is not available. Relative infant dose is quoted as 4.7–14.3% (Hale  online access). The BNF states that only a small amount is present in breastmilk but it should be avoided.

·        Domperidone (Motilium™)

Domperidone has widely been used to increase milk supply in the past. Concerns were raised by the MHRA in 2014 about use in patients with heart defects, there has been some reticence by doctors to prescribe it. There are no reports of problems in the amounts passing through breastmilk

See https://www.ncbi.nlm.nih.gov/books/NBK501371/  and https://www.e-lactancia.org/breastfeeding/domperidone/product/

Domperidone acts at the chemoreceptor trigger zone. It stimulates gastric emptying. It causes fewer central effects such as sedation and dystonia (although there are still reports of these) because it does not cross the blood–brain barrier as metoclopramide does. Its dopamine antagonist activity stimulates prolactin release, which makes it useful as a galactagogue (see section on drugs to increase lactation, pages 285–288). Domperidone is metabolised by cytochrome P450 so care should be taken with potential interactions. It is more than 90% bound to plasma proteins and has a low bioavailability on an empty stomach (15%) when taking orally due to first-pass hepatic and intestinal metabolism. Mean serum levels of domperidone measured in babies through maternal use of 10 mg three times daily was only 1.2 ng per millilitre. The total amount of the drug that would be ingested by the infant (Da Silva et al. 2001) would be extremely small (about 180 ng per kilogramme daily, assuming a daily milk intake of 150 ml per kilogramme). Relative infant dose quoted as 0.01– 0.04% (Hale 2017 online access). The BNF states that the amount secreted into breastmilk is probably too small to be harmful.

·        Ondansetron  (Zofran™)

This is an anti-emetic originally used to treat people who have severe sickness when being treated with chemotherapy for cancer. Ondansetron is frequently used for nausea during and after caesarean section, usually in doses of 4 to 8 mg intravenously. Use during and after caesarean section appears to not affect the onset of breastfeeding. No adverse infant effects have been reported or among women who received ondansetron postpartum in a pharmacokinetic study. Use of ondansetron in nursing mothers beyond the immediate postpartum setting has not been studied well, but the drug is licensed for use in infants as young as 1 month of age. See https://www.ncbi.nlm.nih.gov/books/NBK500798/ and https://www.e-lactancia.org/breastfeeding/ondansetron/product/

This drug is a 5-HT3 antagonist with antiemetic activity. It is also for the prevention and treatment of post-operative nausea and vomiting that have not responded to other antiemetic agents. Ondansetron may also be used for nausea in pregnancy. It is licenced for use in children It is 60% orally bio-available and 70–75% plasma protein bound. The terminal half-life is three hours after oral doses. There are no studies on transfer into breastmilk although it has been found in animal studies (BNF).

A large, well-designed study found that the vast majority of babies exposed to ondansetron in the womb (at least 998 out of every 1,000) are born without cleft lip and/or palate (https://www.medicinesinpregnancy.org/Medicine–pregnancy/Morning-Sickness/)

Third Line

 Corticosteroids

Corticosteroids are sometimes prescribed for women with hyperemesis gravidarum that has not responded to other treatments including rehydration together with anti-emetics. There is no strong evidence that use of corticosteroids in early pregnancy increases the chance of cleft lip and palate or heart defects in the baby. Use in pregnancy also does not appear to increase the chance of the baby having a low birth weight. Some studies have shown that pregnant women taking corticosteroids have a higher chance of preterm delivery. However, it is thought that this is likely caused by the underlying illnesses that steroids are commonly used to treat rather than a direct effect of steroids themselves. https://www.medicinesinpregnancy.org/Medicine–pregnancy/Corticosteroids—systemic/

Pregnancy Sickness Support in the UK found that many women seeking terminations in desperation had not been offered the full range of treatments available and fewer than 10% had been offered steroids

Other non-medical treatments

·        Ginger

The conclusion from 6 randomised controlled trials with a total of 675 participants was that ginger extract at 1000 mgs per day may be effective treatment for NVP. However , the small number of patients in these studies allocated to receive ginger (n=303) may have been insufficient to properly test the safety of ginger with regards to pregnancy outcome. ( Viljoen, E., Visser, J., Koen, N. et al. A systematic review and meta-analysis of the effect and safety of ginger in the treatment of pregnancy-associated nausea and vomiting. Nutr J 13, 20 (2014).)  The authors found that Ginger did not significantly reduce the number of vomiting episodes during NVP, when compared to placebo, although there was a trend towards improvement. Many mothers have reported feeling angry and frustrated that this is recommended so frequently but that they found it caused side effects as well as not being effective. It is definitely not the answer to all NVP!

·        Acupressure

Stimulation of the acupressure point, located three fingers breadth above the wrist, has been used for many years to treat nausea from a variety of causes. Mohd Nafiah et al (2022)  concluded that the  use of acupressure wristbands at the P6 point was also able to decrease the frequency of antiemetics and increase the rate of urine ketone clearance. The implication of the  trial was the reported as the existence of an effective adjunct to alleviate the severity of nausea and vomiting in pregnant women with hyperemesis gravidarum, thereby improving their quality of life. There are no concerns about the safety of acupressure in pregnancy ( Mohd Nafiah, N.A.; Chieng, W.K.; Zainuddin, A.A.; Chew, K.T.; Kalok, A.; Abu, M.A.; Ng, B.K.; Mohamed Ismail, N.A.; Nur Azurah, A.G. Effect of Acupressure at P6 on Nausea and Vomiting in Women with Hyperemesis Gravidarum: A Randomized Controlled Trial. Int. J. Environ. Res. Public Health 2022, 19, 10886.)

Conclusion

We should not underestimate how NVP and HG affect pregnant women. We should listen to how they are feeling and ask how we can help. Untreated symptoms can lead to lifetime mental health issues.

“I had morning sickness (not hyperemesis). The first 4 months I went from bed to the sofa, my husband did everything. I couldn’t look at food, walk into the kitchen to get a drink etc. I wasn’t physically that sick but the nausea was absolutely horrendous. Constantly, nothing stopping it, the minute I woke to the second I fell asleep for 4 months. I lost 6kg by my first scan. Although it got better I still felt slightly sick through the whole pregnancy. I was refused anti nausea meds by multiple doctors, even the midwife shrugged it off. The effect it has had on me even now (my daughter is 2.5) is horrible. I still can’t eat certain foods, put too much food in my mouth and the slightest nausea (which I get often due to anxiety, migraines etc) sends me into complete panic.”

What would you like professionals to understand? The struggle and how debilitating it is.”

“Medically, only one doctor seemed to have any awareness of what I was suffering from. Others told me “I’d be better in a couple of weeks” every two weeks.”

Resources

Pregnancy Sickness Support https://www.pregnancysicknesssupport.org.uk/

RCOG Green Top Guidelines https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/the-management-of-nausea-and-vomiting-of-pregnancy-and-hyperemesis-gravidarum-green-top-guideline-no-69/

UKTIS Medicines in Pregnancy https://www.medicinesinpregnancy.org/About-Us/

Vomiting in pregnancy whilst still breastfeeding

PDF of this information is available at:

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/02/hyperemesis-and-breastfeeding-feb-2023-.pdf

See also https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.17739?fbclid=IwAR1c5ZE0_-AocuZ1bXuZSZGB9VCLHHCy4of4JkvxmYTTPWEzMAJVzTf1gQY

The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69) Feb 2024

Thank you to everyone on the facebook group who shared their experiences and helped me to update this information.

More women are now breastfeeding their babies for longer and may still be feeding when they fall pregnant. For those who suffer from hyperemesis  gravidarum (HG) this is a tough time. Sadly, some healthcare professionals do not understand that there is benefit to a child from being breastfed to the age of two years and beyond (WHO) alongside a normal weaning diet. Being asked to abruptly wean your older child in order to take medication is not an easy option and is not necessary. Sometimes sitting quietly to breastfeed whilst you fight the feeling of nausea is helpful. Some professionals remain concerned about the teratogenicity of drugs in pregnancy despite national guidance.

“ I had an absolutely awful time while still trying to breastfeed a toddler. The GP refused to prescribe anything other than cyclizine despite me calling them in desperation many times. Nothing else was made available and I was told that I just had to wait until it cleared up.”

Symptoms of NVP and HG

Nausea and vomiting of pregnancy (NVP)  is common and  usually settles by 12-14 weeks of pregnancy (although it may be longer and even last the full pregnancy). Often known as morning sickness it can occur at any time of the day or last all day.

Hyperemesis gravidarum is a severe form and can affect up to 1 to 3 in 100 pregnant women. Sadly, some women experience such extreme symptoms that they feel that they have no choice but to terminate the pregnancy even if it is a much longed for baby.

“I ended in termination of pregnancy after first hospital visit as I didn’t want to take from my child who was already here and after how badly I dealt with it last time, it being worse instantly I couldn’t do it”

Others decide that one child is sufficient to complete their family as they cannot contemplate symptoms again. There are medications but often primary care professionals do not appreciate the severity of symptoms or impact on mothers.

“I had HG with my daughter who will be 11 next month. Hyperemesis is the primary reason I only have one child. It was physically horrendous, and I had post-traumatic stress for years afterwards”.

“I had this with my daughter. It is the reason she will be an only child. She’s 4 now and I still suffer a lot of health issues as a direct result of hyperemesis. I had the best medical care. And was lucky to be given a  lot of treatment. But it wasn’t enough, and my body still struggled. You can’t appreciate how difficult it is until you’ve experienced it.”

When asked in a facebook group (https://www.facebook.com/breastfeedingandmedication) for their experiences of suffering from morning sickness and hyperemesis, one of the overwhelming comments from women was about reluctance of GPs to prescribe medication in pregnancy, even when it had been prescribed whilst the mother was hospitalised!

“After one of my hospitalisations I was sent home with a prescription for cyclizine and when I went to my GP to renew the prescription she talked me out of it because “it wasn’t making enough of a difference for me to go back to work” so didn’t seem worth taking (mild relief from the symptoms of HG wasn’t considered a benefit.)”

Repeated comments from family, friends and professionals underestimated how the woman was feeling and she didn’t feel listened to.

“I didn’t feel I wasn’t listened to and also I didn’t feel dismissed. I just accepted this was part and parcel of my pregnancy as it was just relayed to me that it was normal.”

“It was awful. People (friends, family, healthcare workers) were quick to tell me what worked for them, and I felt very blamed that I was somehow not trying hard enough. All the admissions were almost a relief, just to lie there with fluid going in. I used to be admitted for several days each week, particularly in third trimester. I still have consequences from the prolonged malnutrition.”

For what should be a joyous family time there were repeated descriptions of an awful experience:

“ horrendous, hell on earth,  pure hell, absolutely hell, housebound for months, nothing worked”.

“ I wasn’t taken seriously until my organs started to shut down and I needed to be induced, I spent 5 months in bed, couldn’t drink water or anything else, everything made me feel nauseous.”

“ I vomited so much and so hard that every time I wet myself and my nose bled. I was told when I was 5 weeks pregnant that if I didn’t want to be sick I shouldn’t be pregnant. I ended up hospitalized at 8 weeks.”

Should this be the experience of women in the UK in 2023?

Anti emetics in breastfeeding and pregnancy

Many of the drugs used to relieve nausea in pregnancy may be associated with lowering of milk supply. However, most women find that their supply very rapidly diminishes when they are pregnant. Many also develop aversion and very sensitive nipples and wish to limit feeding. Sadly, toddler nurslings don’t always understand the loss of their comfort! Many breastfeeding dyads continue to dry nurse throughout pregnancy and may go on to tandem feed. It is the decision which works for each family which matters, without judgement from family and professionals.

Hyperemesis may result in dehydration and subsequent admission to hospital.  Signs of dehydration include  feeling very thirsty, becoming drowsy or unwell, urine changing from a light yellow to a dark yellow or brown colour. Medical help should be sought if even sips of fluid produce vomiting. Weight loss can be excessive because of the restriction of quantity of food tolerated. Hyperemesis is diagnosed when there is prolonged nausea and vomiting  with more than 5% pre pregnancy weight loss, dehydration and electrolyte imbalance. https://cks.nice.org.uk/topics/nausea-vomiting-in-pregnancy/background-information/definition/

Self-care

https://cks.nice.org.uk/topics/nausea-vomiting-in-pregnancy/management/management/

  • Rest as needed and try to avoid sensory stimuli that may trigger symptoms, such as odours, heat, and noise.
  • Try eating plain biscuits or crackers in the morning.
  • Try eating bland, small, frequent protein-rich meals which are low in carbohydrate and fat.
  • Cold meals may be more easily tolerated if nausea is smell-related.
  • Drinking little and often, rather than large amounts.
  • Ginger (can be taken in fresh, tea, capsule, or syrup form).
  • Acupressure (such as over the P6 point on the ventral aspect of the wrist using a wrist band or finger pressure).

Responses on the facebook group as to how helpful these suggestions were are exemplified by:

“Nausea and sickness with my first born I had such a heightened sense of smell. I couldn’t even open my fridge without feeling sick and running to the loo. I ended up using a cool bag instead of my fridge, and I had to call my mum to come and help me when my partner was away. I couldn’t brush my teeth without gagging and wanting to be sick.”

“I was asked what is had to eat and when I said an oat/raisin bar the doctor replied I shouldn’t be having anything sugary. That one doctor who knew her stuff had told me to eat anything I could keep down.”

Medical Treatment

The RCOG green top guidelines on treating are available https://www.rcog.org.uk/media/y3fen1x1/gtg69-hyperemesis.pdf

The UKTIS information on the use of drugs in pregnancy can be found at https://www.medicinesinpregnancy.org/leaflets-a-z/nausea–vomiting/

RCOG Recommended antiemetic therapies and dosages

In this fact sheet I have provided links to detailed information on the medication which can help prescribers to reach an evidence-based decision on the safety of the drug to the breastfeeding baby which is not available in standard reference texts like the British National Formulary (BNF). The linked pdf files contain information sourced from LACTMED February 2023

First Line treatments

  • Cyclizine (Valoid™)

May possibly cause some drowsiness in the nursling but anecdotally appears to happen rarely . See https://www.ncbi.nlm.nih.gov/books/NBK501749/ and https://www.e-lactancia.org/breastfeeding/cyclizine/product/

Cyclizine is an anti-emetic used to treat nausea and vomiting including motion sickness, post-operative nausea and vomiting, after radiotherapy, in drug-induced situations, as well as for nausea in pregnancy. There are no reports of levels entering breastmilk (BNF) or data on which to base conclusions. There is an unlicenced dose for children aged over 6 years. It may be given orally, by IV or IM every 8 hours. Manufacturers advise to avoid in pregnancy, but there is no evidence of teratogenicity

· 

    

Prochlorperazine (Buccastem, Stemetil)

Low levels of prochlorperazine are secreted into breastmilk and it can be used when breastfeeding. Side effects for the mother include drowsiness, restlessness and occasional extra pyramidal effects but babies seem to exhibit no adverse reactions. It is licensed to be given directly to babies weighing more than 10 kg. See https://www.ncbi.nlm.nih.gov/books/NBK501080/ and https://www.e-lactancia.org/breastfeeding/prochlorperazine/product/

Prochlorperazine is used to treat vertigo, labyrinthitis, migraine or drug-induced emesis if severe vomiting is a problem. Its oral bio-availability is low due to high first-pass metabolism but, like all phenothiazines, it has many metabolites, some active. It is not generally used in travel sickness prophylaxis. It is a member of the phenothiazine family to which children are particularly sensitive. Long-term use should be avoided in breastfeeding where possible, particularly with very young babies where there is a potential risk of apnoea. However, short-term acute use probably poses few risks as it is licenced for use in children over 10 kg. The dose is 5-10mg (one or two tablets) every 6-8 hours. It may also be given IV or IM.

  • Promethazine (Avomine™ Phenergan™, Sominex™)

 When used for hyperemesis in mother promethazine may possibly cause some drowsiness in the nursling but anecdotally appears to happen rarely. It also causes drowsiness in the mother so care should be taken with co sleeping.

See https://www.ncbi.nlm.nih.gov/books/NBK501081/ and https://www.e-lactancia.org/breastfeeding/promethazine/product/

Promethazine is widely used to reduce nausea particularly associated with travel sickness as well as symptomatic relief of urticaria and as an over-the-counter (OTC) hypnotic for short-term use. No data are available on transfer into breastmilk but it is believed that it does pass into breastmilk. It is licenced for use in children over 2 years.”

·        Doxylamine/pyridoxine (Xonvea™)

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.

Second Line Treatments

·        Metoclopramide (Maxolon™)

Metoclopramide has also been used to increase milk supply. It is associated with an increased risk of depression as well as other side effects if used long term. There are no reports of problems in the babies from the amount passing through breastmilk. https://www.ncbi.nlm.nih.gov/books/NBK501352/

Metoclopramide is a dopamine antagonist and can cause extra-pyramidal side effects, in particular acute dystonia. This adverse effect is most commonly seen in children and young adults, especially females, so it is not a drug of choice in lactating mothers who generally fall into this age group. It may also precipitate hypotension and depression. Other side effects reported include headache, diarrhoea, dry mouth and change in appetite (Ingram et al. 2011). It stimulates prolactin secretion and has been used as a galactogogue but has now been superseded by domperidone because of the latter does not cross the blood–brain barrier (Ingram et al. 2012). The bio-availability of oral metoclopramide is about 75% but varies widely between patients due to its hepatic first-pass metabolism. Concentrations higher than those in maternal plasma may be reached in breastmilk, particularly in the early puerperium, although these decrease with increased maturity. Metoclopramide has pro-kinetic and anti-emetic properties and acts directly on the gastrointestinal tract without altering acid secretion. It is more frequently used in the US where domperidone is not available. Relative infant dose is quoted as 4.7–14.3% (Hale  online access). The BNF states that only a small amount is present in breastmilk but it should be avoided.

·        Domperidone (Motilium™)

Domperidone has widely been used to increase milk supply in the past. Concerns were raised by the MHRA in 2014 about use in patients with heart defects, there has been some reticence by doctors to prescribe it. There are no reports of problems in the amounts passing through breastmilk

See https://www.ncbi.nlm.nih.gov/books/NBK501371/  and https://www.e-lactancia.org/breastfeeding/domperidone/product/

Domperidone acts at the chemoreceptor trigger zone. It stimulates gastric emptying. It causes fewer central effects such as sedation and dystonia (although there are still reports of these) because it does not cross the blood–brain barrier as metoclopramide does. Its dopamine antagonist activity stimulates prolactin release, which makes it useful as a galactagogue (see section on drugs to increase lactation, pages 285–288). Domperidone is metabolised by cytochrome P450 so care should be taken with potential interactions. It is more than 90% bound to plasma proteins and has a low bioavailability on an empty stomach (15%) when taking orally due to first-pass hepatic and intestinal metabolism. Mean serum levels of domperidone measured in babies through maternal use of 10 mg three times daily was only 1.2 ng per millilitre. The total amount of the drug that would be ingested by the infant (Da Silva et al. 2001) would be extremely small (about 180 ng per kilogramme daily, assuming a daily milk intake of 150 ml per kilogramme). Relative infant dose quoted as 0.01– 0.04% (Hale 2017 online access). The BNF states that the amount secreted into breastmilk is probably too small to be harmful.

·        Ondansetron  (Zofran™)

This is an anti-emetic originally used to treat people who have severe sickness when being treated with chemotherapy for cancer. Ondansetron is frequently used for nausea during and after caesarean section, usually in doses of 4 to 8 mg intravenously. Use during and after caesarean section appears to not affect the onset of breastfeeding. No adverse infant effects have been reported or among women who received ondansetron postpartum in a pharmacokinetic study. Use of ondansetron in nursing mothers beyond the immediate postpartum setting has not been studied well, but the drug is licensed for use in infants as young as 1 month of age. See https://www.ncbi.nlm.nih.gov/books/NBK500798/ and https://www.e-lactancia.org/breastfeeding/ondansetron/product/

This drug is a 5-HT3 antagonist with antiemetic activity. It is also for the prevention and treatment of post-operative nausea and vomiting that have not responded to other antiemetic agents. Ondansetron may also be used for nausea in pregnancy. It is licenced for use in children It is 60% orally bio-available and 70–75% plasma protein bound. The terminal half-life is three hours after oral doses. There are no studies on transfer into breastmilk although it has been found in animal studies (BNF).

A large, well-designed study found that the vast majority of babies exposed to ondansetron in the womb (at least 998 out of every 1,000) are born without cleft lip and/or palate (https://www.medicinesinpregnancy.org/Medicine–pregnancy/Morning-Sickness/)

Third Line

 Corticosteroids

Corticosteroids are sometimes prescribed for women with hyperemesis gravidarum that has not responded to other treatments including rehydration together with anti-emetics. There is no strong evidence that use of corticosteroids in early pregnancy increases the chance of cleft lip and palate or heart defects in the baby. Use in pregnancy also does not appear to increase the chance of the baby having a low birth weight. Some studies have shown that pregnant women taking corticosteroids have a higher chance of preterm delivery. However, it is thought that this is likely caused by the underlying illnesses that steroids are commonly used to treat rather than a direct effect of steroids themselves. https://www.medicinesinpregnancy.org/Medicine–pregnancy/Corticosteroids—systemic/

Pregnancy Sickness Support in the UK found that many women seeking terminations in desperation had not been offered the full range of treatments available and fewer than 10% had been offered steroids

Other non-medical treatments

·        Ginger

The conclusion from 6 randomised controlled trials with a total of 675 participants was that ginger extract at 1000 mgs per day may be effective treatment for NVP. However , the small number of patients in these studies allocated to receive ginger (n=303) may have been insufficient to properly test the safety of ginger with regards to pregnancy outcome. ( Viljoen, E., Visser, J., Koen, N. et al. A systematic review and meta-analysis of the effect and safety of ginger in the treatment of pregnancy-associated nausea and vomiting. Nutr J 13, 20 (2014).)  The authors found that Ginger did not significantly reduce the number of vomiting episodes during NVP, when compared to placebo, although there was a trend towards improvement. Many mothers have reported feeling angry and frustrated that this is recommended so frequently but that they found it caused side effects as well as not being effective. It is definitely not the answer to all NVP!

·        Acupressure

Stimulation of the acupressure point, located three fingers breadth above the wrist, has been used for many years to treat nausea from a variety of causes. Mohd Nafiah et al (2022)  concluded that the  use of acupressure wristbands at the P6 point was also able to decrease the frequency of antiemetics and increase the rate of urine ketone clearance. The implication of the  trial was the reported as the existence of an effective adjunct to alleviate the severity of nausea and vomiting in pregnant women with hyperemesis gravidarum, thereby improving their quality of life. There are no concerns about the safety of acupressure in pregnancy ( Mohd Nafiah, N.A.; Chieng, W.K.; Zainuddin, A.A.; Chew, K.T.; Kalok, A.; Abu, M.A.; Ng, B.K.; Mohamed Ismail, N.A.; Nur Azurah, A.G. Effect of Acupressure at P6 on Nausea and Vomiting in Women with Hyperemesis Gravidarum: A Randomized Controlled Trial. Int. J. Environ. Res. Public Health 2022, 19, 10886.)

Conclusion

We should not underestimate how NVP and HG affect pregnant women. We should listen to how they are feeling and ask how we can help. Untreated symptoms can lead to lifetime mental health issues.

“I had morning sickness (not hyperemesis). The first 4 months I went from bed to the sofa, my husband did everything. I couldn’t look at food, walk into the kitchen to get a drink etc. I wasn’t physically that sick but the nausea was absolutely horrendous. Constantly, nothing stopping it, the minute I woke to the second I fell asleep for 4 months. I lost 6kg by my first scan. Although it got better I still felt slightly sick through the whole pregnancy. I was refused anti nausea meds by multiple doctors, even the midwife shrugged it off. The effect it has had on me even now (my daughter is 2.5) is horrible. I still can’t eat certain foods, put too much food in my mouth and the slightest nausea (which I get often due to anxiety, migraines etc) sends me into complete panic.”

What would you like professionals to understand? The struggle and how debilitating it is.”

“Medically, only one doctor seemed to have any awareness of what I was suffering from. Others told me “I’d be better in a couple of weeks” every two weeks.”

Resources

Pregnancy Sickness Support https://www.pregnancysicknesssupport.org.uk/

RCOG Green Top Guidelines https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/the-management-of-nausea-and-vomiting-of-pregnancy-and-hyperemesis-gravidarum-green-top-guideline-no-69/

UKTIS Medicines in Pregnancy https://www.medicinesinpregnancy.org/About-Us/

Breastfeeding after CT and MRI scans

Virtually every day I get messages from mothers and health visitors querying whether mothers can continue to breastfeed after CT and MRI scans. I was told that the national guidelines had been updated some years ago to align with RANZR guidelines . Sadly guidelines dont seem to have been updated by all radiology departments from my experience despite an update on 25.1.22 (see below)

Mannitol and hyoscine can also be given without interrupting breastfeeding

Other medications used in MRI

To enable a detailed examination mannitol and Hyoscine (Buscopan™) may be administered in addition to the contrast medium.

Mannitol has low oral bioavailability (17%). Passage into milk is likely only in the first few days after birth when the junctions in the alveolar ducts remain open. (Hale)

Hyoscine (Buscopan™) is widely used to treat symptoms of irritable bowel syndrome https://breastfeeding-and-medication.co.uk/fact-sheet/irritable-bowel-syndrome-ibs-and-breastfeeding No levels in breastmilk have been reported from studies. However, it is licensed at half the adult dose for children over 6 years (10 milligrammes three times daily) so the amount passing into breastmilk is likely to be compatible with breastfeeding after a single dose.

I was lucky enough to work with Dr Gabrielle Cronin on this paper which was published in the Irish BMJ

https://rb.gy/opvtzx


http://imj.ie/ct-and-mr-contrast-in-breastfeeding-mothers-is-current-practice-evidence-based/?fbclid=IwAR3k_GEfKmTeSdLDL7ZiClwZjQ9yIo1Q1gNhXaZ2OXFjvMhV7nAK7fINCtU

Most mothers are advised to stop breastfeeding for 24 hours but there is no evidence for this as most contrast media are not orally bio available and have half lives which do not justify this duration.

On 25 January 2022 this was published by the Society of Radiologists :

https://www.sor.org/news/sor/sor-issues-joint-statement

The Society has issued guidance to reassure patients after recent research showed a lack of awareness among imaging teams on the most up-to-date evidence and guidance for breast-feeding patients who require a CT or MRI with contrast.The current Royal College of Radiologists (RCR) guidance published in 2019 relating to MR states:While no special precaution or cessation of breastfeeding is required the continuation or cessation of breastfeeding for 24 hours should be at the discretion of the lactating mother in consultation with the clinician.The SoR and RCR refer to the guidance published by The Royal Australian and New Zealand College of Radiologists (RANZCR) regarding CT contrast which says:Cessation of breast feeding or expression and discarding of breast milk after iodinated contrast media administration are not required.The Breastfeeding Network has summarised the advice of a number of expert organisations across the globe which is available on their website .The very small potential risk associated with absorption of contrast medium is considered insufficient to warrant suspending breastfeeding for any period following iodinated contrast agent administration.It is the view of the RCR and SoR that patients who wish to continue breastfeeding after being administered with contrast agent should be able to do so as there is no evidence of risk to the baby/child.Position statement – for patients. The Society of Radiographers (SoR) and the Royal College of Radiologists (RCR) are aware of conflicting opinions about whether patients who are administered with contrast agents – usually as part of a CT or MRI scan– can breast feed as part of their normal routine.It is the view of both the RCR and the SoR that patients who wish to continue breastfeeding after being administered with contrast agent – usually given in advance of a CT or MRI scan – should be able to do so as there is no evidence of risk to the baby/child. If you have any concerns please, speak with your radiographer or radiologist.

More information

https://www.breastfeedingnetwork.org.uk/ct/ https://www.breastfeedingnetwork.org.uk/mri/

RANZR guidelines

Inflammatory Bowel Disease (IBD)  and Pregnancy

I have written quite a lot about IBD and breastfeeding and compiled information on medication and tests https://breastfeeding-and-medication.co.uk/wp-content/uploads/2022/04/IBD-and-breastfeeding-factsheet-June-2021.pdf. The use of medication in pregnancy is not my area of expertise and I am purely providing links to those who know more.

This information is taken from The medicines Use in Pregnancy Site BUMPS https://www.medicinesinpregnancy.org/About-Us/ and is presented here for ease of access for parents and professionals.

Health professionals can consult the team https://uktis.org/contact-us/ but not members of the public.

Further information is also available https://crohnsandcolitis.org.uk/info-support/information-about-crohns-and-colitis/all-information-about-crohns-and-colitis/living-with-crohns-or-colitis/pregnancy-and-breastfeeding

Links to information on medication

Do not stop taking medication without discussing with your GP or IBD team

For many of the medications used to control symptoms of IBD in pregnancy live vaccines (rotavirus and if necessary BCG) should not be given to a baby under 6 months. If rotavirus is given to the baby then the mother should wear gloves during nappy changes for 2 weeks to avoid exposure to live viral fragments shed in faeces. https://breastfeeding-and-medication.co.uk/fact-sheet/live-vaccinations-and-immunosuppressant-medication-taken-by-breastfeeding-mothers

Prednisolone https://www.medicinesinpregnancy.org/leaflets-a-z/prednisolone/

What are the benefits of using a systemic corticosteroid in pregnancy?

Corticosteroids reduce inflammation by stopping the immune system from attacking the body’s tissues. This is important to reduce unpleasant symptoms and prevent long-term damage. It may also lower the chance of some pregnancy problems linked to uncontrolled inflammation, including miscarriage and lower birth weight.

Are there any risks of using a systemic corticosteroid in pregnancy?

Corticosteroid use in early pregnancy has been linked in some (but not all) studies to a higher chance of having a baby with a cleft lip and/or palate. However, it is clear that the vast majority of babies exposed in the womb to systemic corticosteroids are born without these conditions.

Women taking a systemic corticosteroid in pregnancy may have a higher chance of having a preterm birth. However, it is thought likely that at least some of this effect is due to the underlying inflammatory conditions in these women which have themselves been linked to preterm birth.

Are there any alternatives to using a systemic corticosteroid in pregnancy?

Possibly. Other medicines can often be used to treat inflammatory conditions during pregnancy. However, systemic corticosteroids are usually considered to be among the safest options and are often recommended as a first-choice medicine to treat rheumatic and auto-immune disease during pregnancy.

Some women may find that their symptoms improve during pregnancy; if so, their specialist may advise that their medicine(s) can be altered. However, women should not change or stop their medication without speaking to their doctor.

Azathioprine https://www.medicinesinpregnancy.org/leaflets-a-z/azathioprine/

What are the benefits of using azathioprine/mercaptopurine in pregnancy?

Azathioprine and mercaptopurine reduce inflammation by stopping the immune system from attacking the body’s tissues. This is important to reduce unpleasant symptoms and prevent long-term damage. It may also lower the chance of some pregnancy problems linked to uncontrolled inflammation, including miscarriage and lower birth weight. It is also vital for both mother and baby that a transplanted organ continues to function well during pregnancy.

What are the risks of using azathioprine/mercaptopurine in pregnancy?:

There is no evidence that use of azathioprine or mercaptopurine harm the baby if taken in pregnancy.

Sulfasalazine https://www.medicinesinpregnancy.org/leaflets-a-z/sulfasalazine/

What are the benefits of taking sulfasalazine in pregnancy?

Sulfasalazine reduces ongoing tissue damage caused by ulcerative colitis, Crohn’s disease, and rheumatoid arthritis. It also controls unpleasant symptoms that can affect quality of life, and can help to prevent the pregnancy complications that have been associated with these illnesses.

Are there any risks of taking sulfasalazine during pregnancy?

There are no concerns that taking sulfasalazine in pregnancy causes problems in the baby and it is routinely prescribed for pregnant women with ulcerative colitis, Crohn’s disease, and rheumatoid arthritis.

Because sulfasalazine can potentially affect folic acid levels, women taking it while trying to conceive and during pregnancy should be prescribed a high dose folic acid supplement.

Infliximab https://www.medicinesinpregnancy.org/leaflets-a-z/infliximab/

What are the benefits of using infliximab in pregnancy?

Infliximab helps to stop the immune system from attacking the body. It controls the unpleasant and often disabling symptoms of some autoimmune diseases and helps to prevent ongoing damage to tissues and organs.

What are the risks of using infliximab in pregnancy?

The available data suggests that infliximab is unlikely to affect the baby’s development. There are reports of some babies being born with a low infant birth weight following infliximab exposure. However, it is unclear if this is caused by the drug itself or the underlying illnesses in pregnant women taking infliximab.

Certolizumab https://www.medicinesinpregnancy.org/leaflets-a-z/certolizumab/

What are the benefits of using certolizumab in pregnancy?

Certolizumab reduces inflammation by stopping the immune system from attacking the body’s tissues. This is important to reduce unpleasant symptoms and prevent long-term damage. It may also lower the chance of some pregnancy problems linked to uncontrolled inflammation, including miscarriage and lower infant birth weight. Certolizumab does not easily cross the placenta so only tiny amounts reach the baby. It is therefore not expected to cause problems in pregnancy.

What are the risks of using certolizumab in pregnancy?

There are no known risks. Use of certolizumab has been studied in around 1,400 pregnant women and there is no evidence that it affects the baby’s development.

Adalimumab https://www.medicinesinpregnancy.org/leaflets-a-z/adalimumab/

What are the benefits of using adalimumab in pregnancy?

Adalimumab reduces inflammation by stopping the immune system from attacking the body’s tissues. This is important to reduce unpleasant symptoms and prevent long-term damage. It may also lower the chance of some pregnancy problems linked to uncontrolled inflammation, including miscarriage and lower infant birth weight.

What are the risks of using adalimumab in pregnancy?

Use of adalimumab in pregnancy has been studied in around 1,500 women. There is no suggestion that adalimumab affects the baby’s development, but ongoing data collection is ideally required to confirm this.

Etanercept https://www.medicinesinpregnancy.org/leaflets-a-z/etanercept/

What are the benefits of using etanercept in pregnancy?

Etanercept reduces inflammation by stopping the immune system from attacking the body’s tissues. This is important to reduce unpleasant symptoms and prevent long-term damage. It may also lower the chance of some pregnancy problems linked to uncontrolled inflammation, including miscarriage and lower infant birth weight.

What are the risks of using etanercept in pregnancy?

Use of etanercept in pregnancy has been studied in around 1,200 women. There is no suggestion that etanercept affects the baby’s development but ongoing data collection is ideally required to confirm this.

Ustekinumab https://www.medicinesinpregnancy.org/leaflets-a-z/ustekinumab/

What are the benefits of using ustekinumab in pregnancy?

Ustekinumab helps to stop the immune system from attacking the body. It controls the unpleasant and often disabling symptoms of some autoimmune diseases, and helps to prevent ongoing damage to tissues and organs. It can also reduce the risk of some adverse pregnancy outcomes that have been linked to poorly controlled autoimmune disease, including miscarriage, preterm delivery and low infant birth weight.

Are there any risks of using ustekinumab during pregnancy?

The small amount of data available suggests that ustekinumab is unlikely to harm the baby but further studies are ideally required.

Quetiapine and breastfeeding

One of the questions that comes up frequently. Often mothers told that they cannot breastfeeding if they need quetiapine for their own menatl health

Hope this information helps them make an infomed decision

PDF of factsheet available here

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

The information on this sheet is based upon my professional experience as a pharmacist with a specialised interest in the safety of drugs in breastmilk, supported by evidence from expert sources. However, I cannot take responsibility for the prescription of medication which remains with the healthcare professionals involved. I am happy to discuss the evidence by email wendy@breastfeeding-and-medication.co.uk

Quetiapine is probably compatible with use during breastfeeding in dose less than 400mg daily based on limited studies and low theoretical infant dose. Be aware of possibility of drowsiness in the baby. Mother should not fall asleep with the baby in bed, on a settee or chair.

Bipolar disease description

Bipolar disorder is a mental health condition that affects moods. The latter can swing from one extreme of lethargy and depression to a feeling of being high and overactive hence the original name of manic depression. During bouts of depression, it is not uncommon to feel suicidal or worthless and it is important to recognise this and seek a place of safety or a person you trust as quickly as possible. During a manic phase there may be feelings of having lots of energy, ambitious plans and idea. It is not uncommon to spend large amounts of money on expensive, unwanted goods and some people ask their banks to block spending above a certain level to avoid debt. It is also common to not feel like eating or sleeping, to talk quickly and become easily annoyed. For some this phase is a positive experience and a time of creativity so may reject medication. It may also become a psychotic phase where things which do not exist may be seen and heard (voices controlling actions). It is a complex condition which may need adjustments. Around one in every 100 people will be diagnosed with it at some point in their life. It frequently develops between 15 and 19 years of age but rarely after 40. The incidence is the same in men and women. The pattern of mood swings in bipolar disorder varies widely. Some people only have a couple of episodes in their lifetime and are stable in between, while others have many episodes. Diagnosis is made only after one episode of mania as well as the depression. In this state the mother may have an elated mood or alternatively she may feel irritable and angry. She may experience racing thoughts rapidly changing from one area to another. It may be impossible for her to be still, but the activity may be unproductive. It is reported to affect a higher proportion of intelligent people with gifted creativity.

Quetiapine (Seroquel™)

Quetiapine is an Atypical anti-psychotic. Quetiapine may also be used in severe depression. In general, atypicals may be better tolerated with fewer extra-pyramidal side effects than the older drugs e.g., chlorpromazine and haloperidol . However, they do produce weight gain and a risk of hyperglycaemia which may need to be monitored regularly. Quetiapine has been associated with a low incidence of extra-pyramidal symptoms, but tardive dyskinesia may occur after long-term treatment. The most frequent adverse effects with quetiapine are somnolence and dizziness. Weight gain, particularly during early treatment, has also been noted. It appears to have a minimal effect on prolactin levels Lee et al. (2004) studied one mother taking 200 mg daily throughout pregnancy. Breastfeeding was not initiated in the absence of safety data until measurement of her breastmilk samples were available. Levels measured indicated that an exclusively breastfed baby would normally ingest only 0.09% of the weight adjusted dose (maximum 0.43%). The mother initiated breastfeeding 8 weeks after delivery. Follow up at 4.5 months indicated normal development with no adverse effects. Misri et al. (2006) studied six mothers taking 25 to 400 mg daily together with an antidepressant. In mothers taking less than 75 mg, milk levels were below the level of detection. One mother taking 400 mg daily had a level of drug in her milk of 101 µg per litre. Mental and psychomotor tests were below the norm in two of the infants when monitored up to 18 months of age although within the norm. The authors concluded this result was due to effects other than exposure to the drug. Several other case study reports of quetiapine use have been reported with low levels of drug reported in the babies and no adverse reactions directly attributable to the drug identified (Rampono et al. 2007; Kruninger et al. 2007; Balke 2001; Seppala 2004; Ritz 2005; Gentile 2006). A relative infant dose quoted as 0.070.1% is quoted (Hale online access).

Summary of Use during Lactation (LactMed https://www.ncbi.nlm.nih.gov/books/NBK501087/

Maternal quetiapine doses of up to 400 mg daily produce doses in milk that are less than 1% of the maternal weight-adjusted dosage. Limited long-term follow-up of infants exposed to quetiapine indicates that infants generally developed normally. A safety scoring system finds quetiapine to be possible to use during breastfeeding.[1] Systematic reviews of second-generation antipsychotics concluded that quetiapine seemed to be the first- or second-choice agent during breastfeeding.[2-4] Monitor the infant for drowsiness and developmental milestones, especially if other antipsychotics are used concurrently. E Elactancia https://www.e-lactancia.org/breastfeeding/quetiapine-fumarate/product/ Quetiapine is excreted into breast milk in clinically insignificant amounts. (Yazdani 2018, Aydin 2015, Van Boekholt 2015, Rampono 2007, Misri 2006, Lee 2004, Seppala 2004). Clinical or development problems in infants whose mothers were treated have not been observed, whether at the short or long term. (Levesque 2016, Sharma 2016, Aydin 2015, Van Boekholt 2015, Newport 2009, Rampono 2007, Misri 2006, Ritz 2005, Gentile 2005, Seppala 2004, Lee 2004). Very low plasma-levels of quetiapine in these infants were found. (Rampono 2007). Galactorrhoea may occur with or without an increase of prolactin. (Glocker 2021, Suttajit 2013, Mushtaq 2012, Sethi 2010, Gupta 2007, Atmaca 2002). Expert authors consider the use of quetiapine to be safe or very probably safe during breastfeeding. (Hale, Lactmed, Uguz 2021, Teodorescu 2020, Rybakowski 2019, Pacchiarotti 2016, Schaefer 2015, Grover 2005, Larsen 2015, Parikh 2014, Rowe 2013) Pharmacokinetics (Hale) Quetiapine is 83% plasma protein bound. The half-life is 6 to 7 hours. Milk plasma ratio 0.3. Relative infant dose 0.02% – 0.1% Other a typical drug options • risperidone (Risperidal™): Limited information indicates that maternal risperidone doses of up to 6 mg daily produce low levels in milk. Observe baby for drowsiness but no adverse events reported to date. • olanzapine (Zyprexa™): Maternal doses of olanzapine up to 20 mg daily produce low levels in milk and undetectable levels in the serum of breastfed infants. Monitor the baby for drowsiness and effective feeding. • aripiprazole (Ablify ™): Limited information indicates that maternal doses of aripiprazole up to 15 mg daily produce low levels in milk. However, it inhibits prolactin levels and despite expert advice it may not be possible to achieve a full milk supply ((Mendhekar 2006, Nordeng 2014). References

• Balke LD, Quetiapine effective in the treatment of bipolar affective disorder during pregnancy, World J Biol Psychiatry, 2001;2:303S. Abstract P02115.

• Drugs and Lactation Database (LactMed) https://www.ncbi.nlm.nih.gov/books/NBK501922/ • E Elactancia https://www.e-lactancia.org/

• Gentile S, Quetiapine-fluvoxamine combination during pregnancy and while breastfeeding, Arch Women’s Ment Health, 2006;9:158–9.

• Hale TW Medications and Mothers Milk online access Springer Publishing

• Jones W Breastfeeding and Medication Routledge 2018 • Jones W Breastfeeding and Chronic Medical Conditions Amazon 2020

• Kruninger U, Meltzer V, Hiemke C et al. [Pregnancy and lactation under treatment with quetiapine Psychiatr Prax Suppl, 2007;34:S756.

• LactMed

• Lee A, Giesbrecht E, Dunn E, Ito S, Excretion of quetiapine in breastmilk, Am J Psychiatry, 2004;161:17156.

• Misri S, Corral M, Wardrop AA, Kendrick K. Quetiapine augmentation in lactation: a series of case reports. J Clin Psychopharmacol. 2006;26:508-11.

• Pacchiarotti I, Leon-Caballero J, Murru A et al. Mood stabilizers and antipsychotics during breastfeeding: Focus on bipolar disorder. Eur Neuropsychopharmacol. 2016;26:1562-78

• Rampono J, Kristensen JH, Ilett KF, Hackett LP, Kohan R, Quetiapine and breastfeeding, Ann Pharmacother, 2007;41:7114.

• Ritz S, Quetiapine monotherapy in post-partum onset bipolar disorder with a mixed affective state, Eur Neuropsychopharmacol, 2005;15 (Suppl. 3):S407. Abstract.

• Seppala J, Quetiapine (‘Seroquel’) is effective and well tolerated in the treatment of psychotic depression during breastfeeding, Int J Neuropsychopharmacol, 2004;7 (Suppl. 1):S245. Abstract P01.431.

Specialist Pharmacy Service Safety in Lactation: Antipsychotics 2020

E Lactancia Quetiapine : https://www.e-lactancia.org/breastfeeding/quetiapine-fumarate/product/ : Very low risk

Fluoxetine and Breastfeeding

In the final of the sheets on antidepressant / anti anxiety SSRIs is fluoxetine. It is often looked on as the least compatible with breastfeeding because of its long half life and greater passage into milk. However, it is often used in pregnancy because there are a significant number of studies https://www.medicinesinpregnancy.org/leaflets-a-z/fluoxetine/

What is perhaps less well known is that if a mother has taken it throughout pregnancy the baby MAY be very drowsy in the first few days after delivery as it withdraws from the higher levels achieved through placental transfer.

My recommendation for any mother taking fluoxetine during pregnancy and wishing to breastfeed is to learn hand expression in preparation

https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/breastfeeding-resources/hand-expression-video/

and to maybe discuss antenatal expression of colostrum with the midwife, just in case the baby is sleepy and taking time to latch effectively. Colostrum can raise blood sugars in very small amounts. (This is really helpful info for the red flags of low sugar and in my opinion explains everything well https://www.guysandstthomas.nhs.uk/resources/patient-information/maternity/protecting-your-baby-from-low-blood-glucose.pdf)

So you can breastfeed after delivery if you have taken fluoxetine but you may need a little help and support. Seek this antenatally so you are well prepared.

I would also add that if fluoxetine has been the SSRI that you have used and found effective in the past, then that would make it the first choice in breastfeeding. Some babies are colicky, some are drowsy, some vomit, some have loose diarrhoea – but we cant tell in advance.

I remember the very first study I looked at on fluoxetine some 25 or more years ago that the mother and the baby’s paediatrician thought the baby hadnt changed behaviour when exposed to fluoxetine via his mother’s breastmilk. The baby’s father (also a paediatrician) perceived it as more irritable and on that anecdotal basis back then it was said that fluoxetine made babies irritable. I cant find the report any more but if we had been able to see into the family unit we may have seen a dad trying to help his partner whilst working and feeling stressed himself. Who knows?

I hope this information is useful to anyone taking fluoxetine whilst breastfeeding

Fluoxetine and breastfeeding factsheet

The Importance of Dads and Grandmas to the Breastfeeding Mother, Wendy Jones
Breastfeeding and Chronic Medical Conditions, Wendy Jones

Anxiety and breastfeeding – need to take a drug to relieve symptoms

I was very proud to have co written a fact sheet for BfN on anxiety and breastfeeding which affects so many new mothers, with my daughter. Beth is a CBT therapist and approached the treatment with non pharmacological methods available via IAPT and IESO (although with a waiting list sadly for most).

https://www.breastfeedingnetwork.org.uk/anxiety

I looked at the relief of symptoms with long-term treatments such as SSRI drugs e.g. sertraline, citalopram, fluoxetine and paroxetine. Mothers may also be helped with propranolol to relieve palpitations and racing heart.

Recently there have been more requests from mothers with anxiety or post traumatic stress to take benzodiazepine to reduce symptoms or to treat a panic attack. Occasional use might be acceptable with monitoring of the baby for drowsiness and effective feeding. However, regular use is not encouraged – particularly of diazepam – because of its long half life and potential to accumulate in breastmilk and the baby, but also because this family of drugs is addictive with as little as 28 days treatment.

I have written this factsheet to provide as much information as possible on the use of anxiolytics diazepam, loprazolam and alparazolam during breastfeeding.

anxiolytics and breastfeeding factsheet

The information is taken from Breastfeeding and Medication which includes full references . Please consider buying the book if this information is useful

Anxiolytics can be used to relive anxiety disorders. Management of anxiety is best achieved by non-pharmacological methods such as counselling and cognitive behavioural therapy. Anxiolytics are not as useful to treat acute panic attacks which will dissipate naturally before the drug is absorbed.

Use of anxiolytics in lactating women is generally discouraged due to the possibility of sedation of the infant and consequential reduction in feeding efficacy and limited weight gain

Anti-depressants are used for generalised anxiety disorders, particularly selective serotonin re-uptake inhibitors (SSRIs). Beta blockers such as propranolol may also be beneficial if symptoms of palpitations predominate.

Diazepam ( Valium®)

Diazepam has a long half-life of 43 hours (with terminal metabolite being present for 2 to 5 days) and accumulation is possible with repeated doses. The plasma elimination is further extended in neonates due to poor hepatic function. A shorter-acting anxiolytic is preferable for use particularly in neonates.

Brandt (1976) conducted a study of four post-natal women who were given 10 mg diazepam at bedtime for six nights. He concluded that even with a neonate, a maternal dose of 10 mg produced breastmilk levels too small to cause any untoward effects in the baby. Erkkola and Kanto (1972) studied three infants whose mothers were taking 10 mg diazepam three times daily from delivery. The babies were observed for 6 days during which period no symptoms of sedation were noticed. However, Patrick et al. (1972) reported on a single mother taking the same dose. At 8 days of age (three days after the mother commenced diazepam) symptoms of lethargy, EEG changes and weight loss were apparent in the infant and attributed to the diazepam exposure. Relative infant dose quoted as 7.1% (Hale 2017 online access). It is licensed for use in children only to control convulsions.

Diazepam is also a drug which may be abused in large doses. It is also possible to become addicted with daily doses over just one month.

The BNF suggests that benzodiazepines are present in milk, and should be avoided if possible during breastfeeding.

Single doses of diazepam may also be used in situations such as fear of flying, before surgery or other anxiety provoking situations with continued breastfeeding as normal.

Avoid if possible. Use for a short a time as possible. Observe baby for drowsiness. Avoid falling asleep with the baby in bed on a settee or chair.

Lorazepam (Ativan®)

Lorazepam is 85% bound to plasma proteins and is 90% bio-available. Half-life is reported as 10 to 20 hours. A post-partum study (Summerfield and Nielsen 1985) found clinically insignificant amounts of lorazepam in breastmilk even at a dose of 2.5 mg twice daily for the first 5 days post-natally. Whitelaw et al. (1981) estimated that an exclusively breastfed infant would be exposed to 7 µg per kilogramme per day with a maternal dose of 2.5 mg twice daily The single infant studied showed no signs of sedation. The dose used is in this study is more than the usual maximum of 2 mg daily. Relative infant is dose quoted as 2.5% (Hale 2017 online access). It is licensed for use in children only to control convulsions.

The BNF suggests that benzodiazepines are present in milk, and should be avoided if possible during breastfeeding.

LactMed reports that : Lorazepam has low levels in breastmilk, a short half-life relative to many other benzodiazepines, and is safely administered directly to infants. Evidence from nursing mothers indicates that lorazepam does not cause any adverse effects in breastfed infants with usual maternal dosages and that no special precautions are required.

Using Kelly (2012) data lorazepam may be taken as one of the safer benzodiazepines if use is essential. 

Avoid if possible. Use for a short a time as possible. Observe baby for drowsiness. Avoid falling asleep with the baby in bed on a settee or chair. May be preferable to diazepam as it has a shorter half-life and no active metabolites.

Alprazolam (Xanax®)

Alprazolam is a benzodiazepine but preferred due to the shorter half life (12-15 hours). Oo obtained multiple milk and serum samples from  eight lactating subjects up to 36 hours after a single oral

doses of 0.5 mg alprazolam. The milk plasma ratio was determined to be 0.36 a level too low to produce clinically significant levels. No outcomes were available as the infants were not breastfed. Reports of withdrawal in infants exposed in utero and breastfed are documented (Anderson 1989).

The BNF states that all benzodiazepines are present in milk, and should be avoided if possible during breast-feeding.

Avoid if possible. Use for a short a time as possible. Observe baby for drowsiness. Avoid falling asleep with the baby in bed on a settee or chair. May be preferable to diazepam as it has a shorter half-life

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