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/Medicine–pregnancy/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/Medicine–pregnancy/Azathioprinemercaptopurine/

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/Medicine–pregnancy/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/Medicine–pregnancy/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/Medicine–pregnancy/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/Medicine–pregnancy/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/Medicine–pregnancy/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/Medicine–pregnancy/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.

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.

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://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770826/Rotavirus_vaccination_programme__information_document_Nov_2018.pdf

• 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

• Nguyen GC, Seow CH, Maxwell C, Huang V, Leung Y, Jones J, Leontiadis GI, Tse F, Mahadevan U, van der Woude CJ The Toronto Consensus Statements for the Management of IBD in Pregnancy. Gastroenterology. 2016;150:734-57
• Julsgaard M, Christensen LA, Gibson PR, Gearry RB, Fallingborg J, Hvas CL, Bibby BM, Uldbjerg N, Connell WR, Rosella O, Grosen A, Brown SJ, Kjeldsen J, Wildt S, Svenningsen L, Sparrow MP, Walsh A, Connor SJ, Radford-Smith G, Lawrance IC, Andrews JM, Ellard K, Bell SJ. Concentrations of Adalimumab and Infliximab in Mothers and Newborns, and Effects on Infection. Gastroenterology. 2016 Jul;151(1):110-9. doi: 10.1053/j.gastro.2016.04.002. Epub 2016 Apr 8. PMID: 27063728.
• Fritzsche J, Pilch A, Mury D, Schaefer C, Weber-Schoendorfer C. Infliximab and adalimumab use during breastfeeding. J Clin Gastroenterol. 2012 Sep;46(8):718-9. doi: 10.1097/MCG.0b013e31825f2807. PMID: 22858514.

Endometriosis is a condition where tissue similar to that lining the womb, starts to grow in other places, such as the ovaries and fallopian tubes. Endometriosis can affect women of any age. The exact number of women who develop endometriosis is unknown. This is because many women have endometriosis without symptoms, or with mild symptoms, and are never diagnosed. Estimates vary, from 1 to 5 in 10 of all women having some degree of endometriosis. Symptoms typically develop between the ages of 25-40 but can begin in teenage years. The condition can run in families.

It can be incredibly painful and hard to live with as evidenced by the mothers in this factsheet who shared their stories. Sadly it is often poorly recognised

Endometriosis and breastfeeding factsheet

My baby is 10 days short of completing 5 months and I got my period last night for the first time post her birth. I had a c-section and at the time of delivery, the gynaecologist found that I have endometriosis level 2 which was the reason for my painful periods before conceiving. This was my first, spontaneous conception and I did not have a clue I have endometriosis.

At my postpartum consultation I was told that as soon as I get my period, I should start my hormonal treatment and also that the hormonal medication is not breastfeeding friendly. I am an EXCLUSIVE BREASTFEEDING mom and want to continue nursing for at least 2 years or until she self-weans. I used to take painkiller, hot water bag and ginger tea for period pain. I came to know I had endometriosis only after I delivered. Biggest thing I have found so far is how symptoms are ignored and women just cope. But I did find that yoga helped me a lot with the symptoms.

I was really worried I would not be able to breastfeed due to the pain medication I took regularly for endometriosis. I was so lucky that the pain I experienced every day for 4 years stopped once I gave birth and was able to go on birth control. The doctor was very informed about what I could and could not take. I’m now a bit scared to stop breastfeeding because I’m worried my periods and pain might return but I will need to stop before going down the frozen embryo route which is a shame as I either stop feeding before I would like or have a larger age gap than I would like.

I have severe dysfunctional uterine bleeding, PCOS and Endometriosis. Possibly adenomyosis. I was put on hormonal treatment 6month post-partum and this resulted in my milk supply depleting within a week, despite the help of domperidone to try to help increase supply. It broke my heart and given the correct information I would have denied medical treatment and continued to breastfeed for as long as possible. But I was misinformed and as a result lost the most precious bond I had. All I can say is I missed out on more than I can put into words. My rainbow boy is healthy and strong, and I am thankful, but I wish I could have done more, changed things, and provided him with the best.

Description

Endometriosis is a condition where tissue similar to that lining the womb, starts to grow in other places, such as the ovaries and fallopian tubes. Endometriosis can affect women of any age. The exact number of women who develop endometriosis is unknown. This is because many women have endometriosis without symptoms, or with mild symptoms, and are never diagnosed. Estimates vary, from 1 to 5 in 10 of all women having some degree of endometriosis. Symptoms typically develop between the ages of 25-40 but can begin in teenage years. The condition can run in families.

The main symptoms of endometriosis are:

• pain in lower tummy or back– usually worse during menstrual period
• period pain that prevents normal activities
• pain during or after sex
• pain when peeing or pooing during menstruation
• feeling sick, constipation, diarrhoea, or blood in your urine during menstruation
• difficulty getting pregnant

Farland  et al (2017) studied 72 394 women recruited through the Nurse’s Health Study. The participants  had one or more pregnancies that lasted at least six months. Of these women 3296 had laparoscopically confirmed endometriosis. The study found  that the duration of total and exclusive breast feeding was significantly associated with decreased risk of endometriosis. For every additional three months of total breast feeding per pregnancy, women experienced an 8% lower risk of endometriosis. Women who breastfed for at least 36 months in total across their reproductive lifetime had a 40% reduced risk of endometriosis compared with women who never breast fed. The authors commented that this association was partially, but not fully, influenced by postpartum amenorrhea

Treatment

There is currently no cure for endometriosis, but symptomatic treatment is available.

Analgesics: paracetamol, opioids (ideally dihydrocodeine or tramadol).

Non-steroidal anti-inflammatory drugs:

• Ibuprofen: very low levels in breastmilk. Can be used even when baby needs direct ibuprofen syrup e.g. during teething or fever
• diclofenac: has historically been widely used in breastfeeding
• naproxen: longer half-life than diclofenac or ibuprofen but levels in breastmilk low
• celecoxib: low levels in breastmilk

the combined pill, the contraceptive patch, or an intrauterine system (IUS/coil) may reduce supply in some.

norethisterone or medroxyprogesterone: may reduce

gonadotrophin-releasing hormone (GnRH) analogues e.g. leuprorelin acetate (Prostrap ™). It is not known whether leuprolide transfers into human milk, but due to its nonapeptide structure, it is not likely that its transfer would be extensive. It is unlikely it would be orally bioavailable in the human infant if ingested via milk. Its effect on lactation is unknown, but it could suppress lactation particularly early postpartum. It is of little risk to the breastfed infant, only to milk production (Hale)

surgery to cut away patches of endometriosis tissue or a hysterectomy

References

Hale TW Medications and Mothers Milk online access

Farland L V, Eliassen A H, Tamimi R M, Spiegelman D, Michels K B, Missmer S A et al. History of breast feeding and risk of incident endometriosis: prospective cohort study BMJ 2017; https://www.bmj.com/content/358/bmj.j3778

Further information

Endometriosis UK: www.endometriosis-uk.org/understanding-endometriosis

Reproduced from Jones W  Medication and Chronic Medical Conditions 2020

Indigestion (dyspepsia) produces discomfort in the upper stomach, often accompanied by belching and bloating. It is a symptom many of us are familiar with across the Christmas festive period and as a community pharmacist saw most families purchase products in anticipation. Long standing indigestion may be investigated by endoscopy. Symptoms can involve bringing up food or bitter-tasting fluids into your mouth temporarily.

GORD is reflux of the contents of the stomach into the oesophagus. It can also be associated with gastritis (inflammation of the stomach) or damage to the stomach due to use of NSAIDs such as ibuprofen, diclofenac and naproxen.  It is associated with the term heartburn and can be linked to a cough. Symptoms can be exacerbated by over-eating, obesity or pregnancy.

H. Pylori can be diagnosed by a test done on a sample of stools (faeces), by a breath test, by a blood test, or from a biopsy sample taken during a gastroscopy (endoscopy). It is treated by a variety of combinations of two antibiotics (clarithromycin, metronidazole and amoxycillin) in high dose plus a PPI for a week. The PPI may be continued for 4-8 weeks.

Treatment                                                                                                                 

• Antacids containing calcium and sodium – there are many brands available according to choice.
• Simethicone products to absorb wind
• Alginates which form a viscous foam which floats on the stomach contents preventing the reflux
• H2 receptor antagonists such as Famotidine or nizatidine are preferred as smaller amounts pass into breast milk than cimetidine.
• PPIs (proton pump inhibitors) such as omeprazole, lansoprazole, esomeprazole are largely destroyed by stomach acids so little is available to pass into breastmilk

See also SPS Treating heartburn and dyspepsia during breastfeeding

https://www.sps.nhs.uk/articles/treating-heartburn-and-dyspepsia-during-breastfeeding

Irritable bowel disease causes distress to many. This factsheet has been developed from my books and particularly Breastfeeding and Chronic Medical Conditions available from Amazon. I hope it helps.

wendy@breastfeeding-and-medication.co.uk

In October 2023 a new paper (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01725-7/fulltext) was published on the use of low dose amitriptyline to treat IBS if anti smasmodic agents have failed to control symptoms. Amitriptyline is compatible with breastfeeding but care should be taken co-sleeping as it may cause maternal drowsiness.

“

IBS is increasingly managed in primary care, commonly with analgesics and dietary regimes as first-line approaches. Although psychotropic drugs such as tricyclic antidepressants and selective serotonin reuptake inhibitors have shown effectiveness as second-line treatment for IBS,  their use is not widespread in primary practice. Tricyclic antidepressants, such as amitriptyline or desipramine, are advocated at low doses to relieve IBS symptoms,  but so far there is no solid evidence for their effectiveness and safety in primary care.

Alexander C Ford and colleagues conducted the ATLANTIS randomised controlled trial in adult patients with IBS in primary care in the UK, comparing amitriptyline at doses of 10 mg to 30 mg once daily with placebo.  Patients were required to meet Rome IV diagnostic criteria,  and have ongoing symptoms with an IBS Severity Scoring System (IBS-SSS) score of greater than or equal to 75 despite dietary changes and first-line treatments. Patients, general practitioners, and the research team were masked for the trial medication, which is essential in IBS research, given the high placebo response in the condition. Symptom-based, subjective, and social outcome measures, including anxiety and depression, were used, in line with the broad disease effect of IBS. The primary endpoint was the IBS-SSS score at 6 months. Outcomes were measured at months 3, 6, and 12, but the month 12 outcomes had a lower sample size than intended owing to follow-up being curtailed by the COVID-19 pandemic.

The results of the ATLANTIS trial are robust and consistent, and demonstrate that a low dose tricyclic antidepressant can be effectively and safely applied for patients with IBS in primary care, as an option, not as standard treatment. Optimal IBS management requires a personalised approach, with treatment steps dependent on the type of IBS symptoms, disease history, treatment response in the past, and sensitivity to side-effects.

Irritable bowel syndrome can be treated during breastfeeding. Some remedies suit some mothers more than other remedies. There is also a  significant body of research that indicates that CBT is effective in reducing IBS symptoms of abdominal pain, diarrhoea, and constipation.

See also SPS Using gastrointestinal antispasmodics during breastfeeding https://www.sps.nhs.uk/articles/using-gastrointestinal-antispasmodics-during-breastfeeding/

Introduction

Irritable bowel syndrome (IBS) is a common, chronic, relapsing, and often life-long condition, mainly affecting people aged between 20 and 30 years. It is more common in women. Symptoms include abdominal pain or discomfort, either diarrhoea or constipation (or both alternating) and bloating. The treatment of IBS is focused on symptom control, in order to improve quality of life. It occurs in 10-20% of the population and again is more common in women than men.

Diagnosis

According to NICE CG 61 (Irritable bowel syndrome in adults: diagnosis and management) in order to diagnose IBS:

Patients must give at least a six-month history of either:

•             Abdominal pain or discomfort.

•             Bloating.

•             Change in bowel habit. Consider positively diagnosing IBS only if abdominal pain is either relieved by defecation or associated with altered bowel frequency or stool form.

AND at least 2 of the following are present:

Altered passage of stool (straining, urgency, incomplete evacuation).

•             Abdominal bloating (women >men), distention tension or hardness.

•             Symptoms aggravated by eating.

•             Passage of mucus rectally.

Before diagnosis, blood tests and a colonoscopy are commonly undertaken to rule out other conditions which may, at least initially, present with similar symptoms e.g., IBD.

Medication

The categories of drugs involved reduce spasms, control constipation or diarrhoea (see section on bowel issues). Symptoms are frequently accompanied by depression.

Dicycloverine (Dicyclomine) (Merbentyl ™ Kolanticon ™). In the past this drug was used to treat colic in babies but following reports of breathing difficulties, its license for use in infants under 6 months was withdrawn. The adverse reactions occurred in babies under the age of 6 weeks and involved sudden reactions following administration of the drug via a spoon. All children recovered normally (Williams 1994, Edwards 1984, Spoudea 1984).  There is also a single case report of a similar reaction in a 12-day old, breastfed baby whose mother took this drug (personal communication reported in Briggs 2005), so it is a drug best avoided in lactation since there are alternative preparations available.

Hyoscine (Buscopan ™) is often the drug preferred by patients with IBS. No levels in breastmilk have been reported from studies. It is licensed at half the adult dose for children over 6 years (10 milligrams three times daily) so the amount passing into breastmilk is likely to be safe.

Alverine (Relaxyl™, Spasmonal™) is widely used to treat symptoms of irritable bowel syndrome but one study shows that it was no better than placebo in providing relief of symptoms (Mitchell 2002). It is licensed for use in patients over the age of 12 years. There is no information on its passage into breastmilk. Avoid if possible.

Mebeverine (Colofac™) should be taken 20 minutes before meals for maximum effect. It is licensed for use in children above the age of three so levels passing into breastmilk are likely to be safe.

Peppermint Oil (Colpermin ™) capsules are used to relieve spasms associated with IBS but should be swallowed whole, half to one hour before food to avoid irritation of the oesophagus. There is some evidence to support the value of this product in therapy (Pittler 1998, Grigoleit 2005). Peppermint oil is believed to undergo rapid first pass metabolism so levels in breastmilk will be low. There have been anecdotal reports in internet discussions by lactation specialists in the US that it can reduce milk supply but there are currently no studies to prove or disprove these.

References

•           De Wit N   Low-dose amitriptyline in irritable bowel syndrome: ready for primary care? The Lancet Oct 2023.

• Edwards PDL. Dicyclomine in babies. BMJ 1984; 288: 1230. Reported as personal communication in Briggs GG, Freeman RK, and Yaffe SJ. Drugs in pregnancy and lactation, 7th ed. Baltimore. Williams & Wilkins. 2005

•             Grigoleit H-G, Grigoleit P. Peppermint oil in irritable bowel syndrome. Phytomedicine 2005; 12: 601-6

•             Hale T W Medications and Mothers Milk

•             Jones W Breastfeeding and Medication (Routledge 2018)

•             LactMed database http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACTMED

•             Mitchell SA, Mee AS, Smith GD, Palmer KR, Chapman RW. Alverine citrate fails to relieve the symptoms of irritable bowel syndrome: results of a double-blind, randomized, placebo-controlled trial. Aliment Pharmacol Ther. 2002 16(6):1187-95.

•             NICE QS 114 (2016) Irritable bowel syndrome in adults

•             Pittler MH, Ernst E. Peppermint oil for irritable bowel syndrome: a critical review and meta-analysis. Am J Gastroenterol 1998; 93: 1131-5.

•             Spoudeas H, Shribman S. Dicyclomine in babies. BMJ 1984; 288: 1230

•             Williams J, Watkin-Jones R. Dicyclomine: worrying symptoms associated with its use in some small babies. BMJ 1984; 288: 90

   Further information

The IBS Network https://www.theibsnetwork.org/

One of the hardest questions I have to answer. I want to help but I need to keep the breastfed baby safe too

See also SPS Treating insomnia during breastfeeding

www.sps.nhs.uk/articles/treating-insomnia-during-breastfeeding

Sleeping tablets and breastfeeding factsheet

Being asked about the safety of sleeping tablets by a breastfeeding mum is probably one of the hardest questions there is. My first problem is that I was taught as a pharmacist that sleeping tablets should only be used very short term and as a last resort. They are highly addictive. They do not solve problems long term. My second problem is that in order to induce sleep they have to cross the blood brain barrier and can therefore cause drowsiness in the baby from the amount passing through milk. The third problem is who will be looking after the baby during the night – will it be fed by someone else? Does the mum co sleep in which case how can we keep the baby safe? If mum is going to get up to feed the baby is there a risk that she will fall asleep on the sofa which is an even greater risk of SIDS.

Most mothers who ask about the use of sleeping tablets are suffering from anxiety or depression. It is a chicken and egg situation – does the lack of sleep cause anxiety/depression or is the inability to sleep a symptom of the anxiety/depression?

Many people find that they can be helped to sleep by using the self-hypnosis sites similar to those used for labour and hypno-birthing. Others by meditation or mindfulness and I cannot praise the Headspace app enough. These practices may take several days to work and are not an instant cure for lack of ability to sleep but they do not affect breastfeeding.

Some people find that herbs such as Valerian help. There is limited research on safety but anecdotally they do not appear to cause drowsiness in the baby. LactMed states that  “ Valerian has no specific uses in nursing mothers, but is most commonly used to treat anxiety and sleep disturbances, and occasionally for self-treatment of postpartum blues or depression. No data exist on the safety and efficacy of valerian in nursing mothers or infants. In general, valerian is well tolerated, with side effects such as dizziness, hangover or headache reported occasionally. Valerian is “generally recognized as safe” (GRAS) for use in food by the U.S. Food and Drug Administration. Valerian is often not recommended during lactation because of the theoretical concerns over its valepotriates and baldrinals which have been shown to be cytotoxic and mutagenic in vitro. Because there is no published experience with valerian during breastfeeding, an alternate therapy may be preferred, especially while nursing a newborn or preterm infant.”

Symptoms of anxiety is better managed by the use of SSRI antidepressants and/or betablockers such as propranolol both of which pass into milk in very low levels. The gold standard is CBT therapy

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

Depression can be managed by the use of SSRI antidepressants and CBT

https://breastfeeding-and-medication.co.uk/fact-sheet/depression-and-breastfeeding-2

Prescribed sleeping tablets

Insomnia is defined as the inability to achieve or maintain sleep. It may occur short term or become chronic. Insomnia may be a manifestation of an underlying condition such as depression or anxiety. The use of hypnotics is generally only recommended at the lowest effective dose for as short a period as possible with an emphasis on sleep hygiene and non-pharmacological measures. Tolerance develops within a very short space of time (3–14 days). Benzodiazepines are generally regarded as the drugs of first choice. Dependence can become a problem with regular or frequent use and withdrawal leads to rebound insomnia. Use during lactation should be discouraged, as the mother may be unresponsive to the needs of the baby. Co-sleeping after taking sedatives produces an increased risk of SIDS (see Caring for your baby at night, Baby Friendly UK 2017, www.unicef.org.uk/BabyFriendly/Resources-for-parents/Caring-for-your-baby-at-night).

Zopiclone : has similar sedative and anxiolytic activity to those of the benzodiazepines. It is claimed to initiate sleep rapidly, without reduction of total rapid-eye-movement (REM) sleep. Matheson et al. (1990) studied 12 women who took a single dose of zopiclone 7.5 mg in the early post-natal period. They found low levels of transfer via breastmilk equivalent to 1.4% of the weight-adjusted maternal dose. The babies were not allowed to breastfeed for up to ten hours but displayed no adverse effects when they resumed breastfeeding. The BNF reports that it is secreted into breastmilk and that it should be avoided.

Reference

• Matheson I, Sande HA, Gaillot J, The excretion of zopiclone into breastmilk, Br J Clin Pharmacol, 1990;30:267–71.

Zolpidem: an imidazopyridine with similar sedative properties to the benzodiazepines but minimal anxiolytic properties. It has a rapid onset and a short duration of action, and is used as a hypnotic in the short-term management of insomnia. It undergoes first-pass metabolism and has an oral bio-availability of 70%. It is 92% bound to plasma proteins. Hale reports a personal communication case report of a baby who became excessively somnolent when its mother took 100 mg sertraline and 10 mg zolpidem, which resolved when the hypnotic was discontinued (Hale 2017 online access). In five women given a 20-mg dose of zolpidem (normal dose 10 mg), after three hours the amount of drug detected in breastmilk ranged between 0.76 and 3.88 µg. This is taken to indicate the peak level to which the baby would be exposed (Pons et al. 1989). No detectable zolpidem was found in subsequent milk samples. The BNF reports that there is only a small amount secreted into breastmilk but that it should be avoided.

References

• Reported in Hale T, Medications and Mothers’ Milk (2010) as a personal communication.
• Pons G, Francoual C, Guillet P, Moran C, Hermann P, Bianchetti G, Thiercelin JF, Thenot JP, Olive G, Zolpidem excretion in breastmilk, Eur J Clin Pharmacol, 1989;37:245–8.

Temazepam: is 96% plasma protein bound. It is a short-acting benzodiazepine with a half-life reportedly between 8 and 15 hours. It is used in short-term management of insomnia but should not be used for more than 14–28 days. Lebedevs et al. (1992) studied ten women all with babies less than 15 days old. The mothers were given 10–20 mg for two nights before milk levels were studied. No adverse effects were noted in any of the babies. Temazepam levels were detected in breastmilk in only one of the ten mothers. The authors considered that breastfed neonates would ingest negligible amounts of temazepam. It is not licenced for use in children. The BNF recommends that benzodiazepines are present in milk, and should be avoided if possible during breastfeeding.

Reference

• Lebedevs TH, Wojnar-Horton RE, Yapp P, Roberts MJ, Dusci LJ, Hackett LP, Ilett KF, Excretion of temazepam in breastmilk, Br J Clin Pharmacol, 1992;33:204–6.

Nitrazepam: Matheson et al. (1990) studied nine women who received 5 mg nitrazepam nightly for five nights. No adverse effects were noted in the infants. The average amount of nitrazepam received by the breastfed baby in the morning was calculated to increase from 1 to 1.5 µg per 100 millilitres. The authors concluded that nitrazepam was compatible with breastfeeding in the immediate post-natal period but that further studies were necessary to confirm safety in the longer term. Relative infant dose is quoted as 2.9% (Hale 2017 online access). It is not licenced for use in children. It is 87% plasma protein bound. Half-lives of 24–30 hours have been reported (Martindale 2017). The BNF recommends that benzodiazepines are present in milk and should be avoided if possible during breastfeeding.

Reference

• Matheson I, Lunde PK, Bredesen JE, Midazolam and nitrazepam in the maternity ward: milk concentrations and clinical effects, Br J Clin Pharmacol, 1990;30:787–93.

Prescribed sedatives for anxiety

Diazepam: Diazepam has a long half-life (with terminal metabolite being present for two to five days) and accumulation is possible. The plasma elimination is further extended in neonates due to poor hepatic function. It is 98% plasma protein bound. A shorter-acting anxiolytic is preferable for use for more than a few days, 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 six 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 licenced for use in children only to control convulsions. Diazepam is also a drug that may be abused in large doses. Close observation of the baby should be undertaken and the mother encouraged to reduce the dosage as far as possible under supervision of a detoxification service if necessary. The BNF suggests that benzodiazepines are present in milk and should be avoided if possible during breastfeeding. Diazepam is used to relieve muscular spasm following back injuries and use for a short period of time should not preclude it from use by lactating mothers in these circumstances. However, babies should be observed for sedation. 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

References

• Brandt R, Passage of diazepam and desmethyldiazepam into breastmilk, Arzneimittelforschung, 1976;26:454–7.
• Erkkola R, Kanto J, Diazepam and breastfeeding, The Lancet, 1972;299:1235–6, Letter.
• Patrick MJ, Tilstone WJ, Reavey P, Diazepam and breastfeeding, The Lancet, 1972;299:542–3, Letter.

Alprazolam (Xanax): a benzodiazepine but is preferred due to the shorter half-life (12–15 hours). Oo et al. (1995) obtained multiple milk and serum samples from eight lactating subjects up to 36 hours after a single oral dose 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 and McGuire 1989). Hale quotes a relative infant dose of 8.5% (Hale 2017 online access). The BNF states that all benzodiazepines are present in milk and should be avoided if possible during breastfeeding.

References

• Oo CY, Kuhn RJ, Desai N, Wright CE, McNamara PJ, Pharmacokinetics in lactating women: prediction of alprazolam transfer into milk, Br J Clin Pharmacol, 1995;40(3):231–6.
• Anderson PO, McGuire GG, Neonatal alprazolam withdrawal—possible effects of breast feeding, DICP, 1989;23(7–8):614.

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 five 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 in this study is more than the usual maximum of 2 mg daily. Relative infant dose is quoted as 2.5% (Hale 2017 online access). It is licenced 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 safest benzodiazepines if use is important.

References

• Kelly LE, Poon S, Madadi P, Koren G, Neonatal benzodiazepines exposure during breastfeeding, J Pediatr, 2012;161:448–51.
• Summerfield RJ, Nielsen MS, Excretion of lorazepam into breastmilk, Br J Anaesth, 1985; 57:1042–3.
• Whitelaw AG, Cummings AJ, McFadyen IR, Effect of maternal lorazepam on the neonate, BMJ (Clin Res Ed), 1981;282(6270):1106–8.

As the MMR cases continue to spread I am aware that adults without documented vaccine are being called in to receive their immunisation especially in areas where cases are high like Birmingham and London.

If you are breastfeeding you can have the MMR jab and breastfeed as normal.

From the Green Book https://assets.publishing.service.gov.uk/media/5e021b9140f0b6665e80187b/Greenbook_chapter_21_Measles_December_2019.pdf

“Breast-feeding is not a contraindication to MMR. Immunisation, and MMR vaccine can be given to breast-feeding mothers without any risk to their baby. Very occasionally, rubella vaccine virus has been found in breast milk, but this has not caused any symptoms in the baby (Buimovici-Klein et al., 1997; Landes et al., 1980; Losonsky et al., 1982). The vaccine does not work when taken orally. There is no evidence of mumps and measles vaccine viruses being found in breast milk.”

MMR vaccine is not recommended for patients with severe immunosuppression as it is a live vaccine

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

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

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

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

PDF of factsheet available:

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

The Menopause And Breastfeeding

There remains no conclusive research on the passage of HRT medication into breastmilk. It appears anecdotally that there is less impact from using transdermal preparations than oral medication. There remains the possibility of reduction in lactation due to the oestrogen contact inhibiting prolactin. Anecdotally HRT has been used by breastfeeding women without impact on the nursling or supply. The decision should be that of the lactating mother after discussion with her healthcare professional.

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

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

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

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

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

Premature ovarian insufficiency (POI)

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

Perimenopause

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

Menopause

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

Typical menopausal symptoms, include:

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

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

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

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

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

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

Post menopause

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

HRT and Breastfeeding

HRT contains oestrogen and sometimes a progesterone e.g., norethisterone, not that dissimilar to that in the combined oral contraceptive which can be used in breastfeeding. The ethinylestradiol content of COCs range from 20–40 micrograms whilst that in HRT products contain 1 – 4 milligrams of estradiol (there are 1000 micrograms in a milligram).

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

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

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

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

Pharmacokinetics of HRT (Taken from Hale)

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

References

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

This information came from a tag on Twitter at the weekend from a mum newly diagnosed with cancer weaning her baby from the breast prior to starting chemo. Hard enough I know but after the surgery she had been prescribed domperidone to control nausea – it stimulates milk production and no one seemed to know or have thought about this. She was prescribed ondansetron instead but only after providing her team with the information about domperidone.

I havent included lots of facts about the drugs as the data can change with research but it contains some of the things I have heard from mothers over the years and some sources of support.

If you need more information please contact me. I will do all I can to support your journey as cancer has raised its ugly head too often in my own family.

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2022/08/breast-cancer-and-breastfeeding-.pdf

Breastfeeding can significantly reduce the risk of triple negative breast cancer (TNBC, the most aggressive breast cancers), probably in pre-menopausal women.

Breastfeeding may not affect the incidence or risk of hormone receptor positive disease (oestrogen and/or progesterone receptors) or HER2 disease.

https://gpifn.org.uk/breast-cancer-risk-reduction/)

Breastfeeding can lower breast cancer risk, especially if a woman breastfeeds for longer than 1 year. https://www.breastcancer.org/risk/factors/breastfeed_hist

Evidence on cancer and other diseases shows that sustained, exclusive breastfeeding is protective for the mother as well as the child https://www.wcrf.org/dietandcancer/recommendations/breastfeed-your-baby

Breastfeeding lowers the risk of developing breast cancer, particularly if you have your children when you are younger. The longer you breastfeed, the more the risk is reduced. It is not completely clear why this is. But the reduced risk might be because the ovaries don’t produce eggs so often during breastfeeding. Or it might be because breastfeeding changes the cells in the breast so they might be more resistant to changes that lead to cancer. https://www.cancerresearchuk.org/about-cancer/breast-cancer/risks-causes/protective-factors

So why have you been diagnosed with breast cancer?

A small number of women (approximately 100-120 each year in the UK) who breastfeed will still develop aggressive breast cancers (https://gpifn.org.uk/breast-cancer-risk-reduction/).  There are no certainties in life unfortunately and definitely no absolute protection against cancer because you are breastfeeding. Each year I hear from women who have been given the diagnosis that we all fear and are being forced to wean their babies in order to have treatment. So, a double loss is often described – the loss of life as it had been and the feelings around breastfeeding which is about so much more than milk.

Over the years I have “spoken” with many mothers who are looking for information on how long it takes for the chemotherapy drugs to leave their systems so that they can return to breastfeeding. That data is available particularly from the online database I can access Medications and Mothers Milk by Dr T H Hale, as well as LactMed.

Some mothers are determined to maintain their supply by pumping and dumping throughout treatment. That is a hard thing to do especially when dealing with the side effects of the drugs but I would do all in my power to support that choice. It is possible to relactate at the end of treatment when the drugs have left the body. The possible difficulty is that the baby may be reluctant to resume breastfeeding particularly if older as they can lose their suck. But who knows? Every mother and baby pair are individuals.

The decisions should always be those of the mother with as much information as can possible be ascertained from evidence-based sites and research.

Sources of support

You may feel lonely in the face of the diagnosis. Everyone will be focussing on your treatment and you may find that the advice to stop breastfeeding is almost a throw away comment. As mothers we know that stopping may not be as simple as it sounds. Our babies are reliant on breastfeeding not just for nutrition but also for comfort, for relief when they feel unwell, just because it feels good. To take that away suddenly is hard. It may be that your treatment will not take place for a little while and you can wean your baby from the breast slowly. However, for some it may need to be sudden and rapid. I have heard from mothers who want to continue to feed as normal until the very last moment, others who want to feel well enough to comfort their child during the period. Everyone has their own approach. There are medications to dry up the milk but they can have nasty side effects for some people although not all. Cabergoline is the best option. If weaning slowly the herb sage may be useful https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-lowering-stopping-milk-supply. Support from an experienced breastfeeding person can be invaluable so that you avoid symptoms of engorgement or mastitis. In the team supporting you there may be someone able to provide information, Lactation Consultants may be able to help or any of the voluntary breastfeeding charities will be knowledgeable in support.

Mummy’s Star supports women and their families with a diagnosis of during pregnancy or the postnatal period. https://www.mummysstar.org/  or on Facebook https://www.facebook.com/MummysStar

Depending on the age of your baby when you are diagnosed the Hearts Milk Bank may be able to provide donor breastmilk for a period (depending on availability) https://heartsmilkbank.org/ or on Facebook https://www.facebook.com/heartsmilkbank

Treatment Options

Your treatment plan will be individual to you but may involve surgery, chemotherapy, radiotherapy or a mixture of these.

As part of all of these interventions you may feel nauseous. Two of the drugs frequently prescribed are anti-emetic drugs which stimulate milk supply! These are domperidone and metoclopramide (this can also precipitate depression). Make sure that your team are aware of the potential difficulties of taking these drugs when you are trying to reduce your supply or dump what you are producing. There are alternatives such as ondansetron. Many anaesthetists, oncologists and GPs seem unaware of the potential to increase prolactin as they focus on treating you.

There are many chemotherapy agents and I do not intend to try to provide information on all of them in this sheet. If you want to email me wendy@breastfeeding-and-medication.co.uk I will be happy to discuss your regime with you and supply full information to your oncology team.

Email me wendy@breastfeeding-and-medication.co.uk or message me through the Facebook Page Breastfeeding and Medication