Information taken from Breastfeeding and Chronic Medical Conditions available on Amazon.

Gestational Diabetes is described as impaired glucose tolerance in pregnancy. It is also increasing in prevalence due to obesity rates and now affects some 7% of pregnancies. Most women will need oral metformin to reduce blood glucose or insulin if changes in diet and exercise do not control gestational diabetes effectively. Risk factors for gestational diabetes are.

•             BMI above 30 kg/m2

•             previous macrosomic baby weighing 4.5 kg or above

•             previous gestational diabetes

•             family history of diabetes (first‑degree relative with diabetes

•             minority ethnic family origin with a high prevalence of diabetes.

Kjos (1993) recommended that delivery should be contemplated at 38 weeks and, if not pursued, careful monitoring of foetal growth should be performed to reduce the risk of large for gestational age babies and shoulder dystocia.

Medication is normally discontinued after delivery although a proportion of mothers will go on to develop Type 2 diabetes. Women with gestational diabetes who do not breastfeed are twice as likely to develop future diabetes (Kjos 1993).

Gunderson (2012) studied 522 women diagnosed with gestational diabetes 6-9 weeks after delivery. Exclusive or mostly breastfeeding was associated with improved fasting glucose and lower insulin levels at this time. Lactation was seen to have favourable effects on glucose metabolism and insulin sensitivity that may reduce the risk of diabetes after delivery. These findings continued for 2 years after delivery (Gunderson 2015).

Infants born to diabetic mothers have a 25-40% incidence of hypoglycaemia in the first one to two hours after delivery. This is transient and resolves spontaneously.  Mothers with diabetes have delayed lactogenesis 2. This raises the risk if babies being supplemented which as Perez-Bravo reported increases the risk of future diabetes for the baby. To reduce the risk, it has become increasingly common to suggest that mothers express and store colostrum from 36 weeks gestation. The DAME trial studied 635 women with diabetes. The primary outcome of the trial was the proportion of infants admitted to the NICU post-natally. The results showed that there was no difference between groups (antenatal expression or normal care). They concluded that there was no harm in encouraging antenatal expression of colostrum twice a day in mothers with uncomplicated pregnancies.

References

• Brown A. Jones W A guide to supporting breastfeeding for professionals. Routledge 2019
• Davies HA, Clark J. D., Dalton K. J., and Edwards O. M.    Insulin requirements of diabetic women who breast feed. BMJ. 1989 May 20; 298(6684): 1357–1358.
• Forster, D A,  Moorhead AM, Jacobs SE, , Davis PG, Walker SP, McEgan KM, Opie GF, Donath SM, Gold L, McNamara C,  Aylward A, East C,  Ford R, Amir LH, Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]): a multicentre, unblinded, randomised controlled trial. The Lancet 2017;389: 2204 – 2213
• Gunderson EP, Hedderson MM, Chiang V, Crites Y, Walton D, Azevedo RA, Fox G, Elmasian C, Young S, Salvador N, Lum M, Quesenberry CP, Lo JC, Sternfeld B, Ferrara A, Selby JV. Lactation intensity and postpartum maternal glucose tolerance and insulin resistance in women with recent GDM: the SWIFT cohort. Diabetes Care. 2012 Jan;35(1):50-6.
• Hummel S Winkler C, Schoen S, Knopff A, Marienfeld S, Bonifacio E, Ziegler AG. Breastfeeding habits in families with Type 1 diabetes. Diabet Med. 2007 Jun;24(6):671-6
• Jones W Breastfeeding and Medication 2nd Ed 2018 Routledge UK
• Kjos SL, Henry OA, Montoro M, Buchanan TA, Mestman JH. Insulin-requiring diabetes in pregnancy: a randomized trial of active induction of labour and expectant management. Am J Obstet Gynecol. 1993 Sep;169(3):611-5.
• Liu B, Jorm L, Banks E Parity, breastfeeding, and the subsequent risk of maternal type 2 diabetes. Diabetes Care, 2010; 33(6): 1239-41.
• Milne N Managing diabetes in women during preconception and pregnancy Clinical Pharmacist 2017; 9 (9)
• NICE Diabetes in pregnancy: management from preconception to the postnatal period NG3
• NICE Hypertension in pregnancy: diagnosis and management CG107
• Pérez-Bravo F. Carrasco E Gutierrez-López M. D. Martínez M. T. López G. García de los Rios M.  Genetic predisposition and environmental factors leading to the development of insulin-dependent diabetes mellitus in Chilean children Journal of Molecular Medicine 1996;74(2):105-109
• Whichelow MJ, Doddridge MC. Lactation in diabetic women. Br Med J (Clin Res Ed) 1983; 3;287(6393):649–650).

Interestingly I am getting more reports of mums who have taken codeine accidentally – having opened the wrong packet, or been given it by supportive partners or relatives and friends. They are terrified that they have to stop breastfeeding and ask for how long they need to pump and dump their milk (such a terrible risk of liquid gold!). Here is the answer!

Accidental codeine / one dose and breastfeeding factsheet

Codeine is no longer recommended for breastfeeding mothers following recommendations by MHRA in 2016 . However, it seems that many women are prescribed codeine by GPs or discharged with it from secondary care with instructions not to breastfeed the baby. Until the baby in Canada died (ref) we routinely used co-codamol for all post-natal mothers.

 Not everyone has the metabolism which concentrates the drug and its metabolites into milk. For them the drug is effective and neither they nor their babies exhibit side effects. For others, including my own family, codeine makes us feel sick and dizzy. It also seems to cause drowsiness in my breastfed grandchildren so that they sleep longer and more frequently if their mothers take it.

Accidental consumption of a single dose of codeine by a lactating mother need not lead to expressing and discarding of her breastmilk if her baby is term, fit and well. She should observe the baby for signs of drowsiness and if that happens make sure the co-codamol is kept out of the way in the future. But no need to panic and no need to stop breastfeeding for a single dose unless the baby develops breathing problems.

In answer to the queries it takes 15 hours for all the codeine to be removed from the body including milk.

Some mothers develop fungal nail infections in pregnancy and delay treatment. When breastfeeding, topical treatments are preferable. I am asked at least once a week about oral terbinafine – hard to answer with little research. Hope this information helps with shared decision making.

Oral terbinafine and breastfeeding factsheet

Oral Terbinafine is sometimes used to treat fungal infection of the nails if topical products have failed to resolve symptoms. Treatment generally lasts for 3 months.

The most frequent adverse effects (for the mother) after oral use of terbinafine hydrochloride are gastrointestinal disturbances such as nausea, diarrhoea and mild abdominal pain. Loss or disturbance of taste may occur and occasionally may be severe enough to lead to anorexia and weight loss. Terbinafine hydrochloride is well absorbed from the gastrointestinal tract. The bioavailability is about 80% because of first-pass hepatic metabolism. Some people are unable to tolerate the drug because of side effects.

Oral terbinafine is extensively bound to plasma proteins (99%) so passage into breastmilk might be expected to be low. The only research refers to two women given a single dose of 500 mg; the total level of terbinafine measured in breastmilk during the 72-hour post-dosing period was 0.65 mg in one mother and 0.15 mg in another. Neither woman was breastfeeding, but both were producing some breastmilk (218 ml and 41 ml, respectively). After 18 hours, the levels of terbinafine were below the level of detection.

The volume of milk being produced by the mothers makes this study questionable as an evidence base. Similarly, the single dose does not replicate normal treatment. However, the authors suggested that using the average milk concentration values over the 24-hour period in the two subjects, an exclusively breastfed infant would receive 3.8% of the maternal weight-adjusted dosage of terbinafine.

Although unlicensed terbinafine has been used to treat tinea capitis in children (Gupta et al. 2003).

Skin concentrations may be up to 75-fold higher than those in the blood. It may persist in the skin for up to 8 weeks after the drug has been discontinued and in the nails for up to a year although treatment is stopped much sooner

The BNF reports that manufacturer advises avoidance of cream or tablets as it is present in milk but less than 5% of the dose is absorbed after topical application of terbinafine.

References

•             Leachman SA, Reed BR, The use of dermatologic drugs in pregnancy and lactation, Dermatol Clin, 2006;24:167–97.

•             Gupta AK, Adamiak A, Cooper EA, The efficacy and safety of terbinafine in children, J Eur Acad Dermatol Venereol, 2003;17:627–40.

•             Thieme G, Peuckert U, Report on a pharmacokinetic study of SF 86-327 in healthy females in the ablactation period. Sandoz document number 303-019. 1986 (information taken from report in Lactmed and Hale 2017 online access).

Further information

•             www1.racgp.org.au/ajgp/2019/october/superficial-fungal-infections

•             https://dermnetnz.org/topics/terbinafine/

See also

https://www.e-lactancia.org/breastfeeding/terbinafine/product/

https://www.ncbi.nlm.nih.gov/books/NBK501397/

Limited information indicates that oral maternal doses of 500 mg daily produce low levels in milk and would not be expected to cause any adverse effects in breastfed infants, especially if the infant is older than 2 months. Monitor the infant for jaundice or other signs of liver toxicity, especially in younger, exclusively breastfed infants

email wendy@breastfeeding-and-medication.co.uk

see also https://breastfeeding-and-medication.co.uk/fact-sheet/coughs-colds-flu-and-covid-when-breastfeeding

There is research that pseudoephedrine can lower breastmilk supply after just one tablet. (Aljazaf K, Hale TW, Ilett KF, et al. Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin Pharmacol. 2003;56(1):18-24.) Pseudoephedrine is a decongestant ( helps to unblock your nose). It seems that mothers in late-stage lactation may be more sensitive to pseudoephedrine and have greater loss in milk production. Therefore, breastfeeding mothers with poor or marginal milk production should be cautious in using pseudoephedrine. While there are anecdotal reports of its use in mothers with engorgement, we do not know if it is effective, or recommend its use for this purpose.

Many remedies contain phenylephrine as the decongestant. Because of pseudoephedrine’s effect on milk production, concerns that phenylephrine may suppress milk production may arise; there is no evidence that this occurs at this time. Decongestants decrease secretions so it is not an unreasonable assumption that it might reduce supply but that no one has conducted trials. This is a case of lack of evidence rather then evidence of lack of activity.

Decongestant nasal sprays act only locally so will not pass into milk or affect milk supply.

Decongestant nasal sprays and nose drops should only be used for about 5-7 days at a time. If they are used for longer than this a rebound, more severe congestion of the nose often develops. Decongestant sprays and drops are thought to work better than oral tablets or capsules (https://patient.info/chest-lungs/cough-leaflet/decongestants)

Nasal decongestants can offer symptomatic relief but not cure a common cold https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6461189/. Paracetamol, ibuprofen and steam inhalation are generally as effective and much cheaper.

In September 2023 the FDA reported that oral phenylephrine is not effective at relieving nasal stuffiness. It is important to note that neither FDA nor the Non-prescription Drug Advisory Committee raised concerns about safety issues with use of oral phenylephrine at the recommended dose. (https://www.fda.gov/…/fda-clarifies-results-recent…).

According to one USA website the evidence for efficacy was first questioned in 2007. The manufacturers have cited a survey that many people find its use beneficial as shown by sales volume of cough and cold products.

The vote that formally declared phenylephrine ineffective was in line with a review of pharmacology and clinical data presented by the FDA, which found the oral bioavailability of the drug is less than 1%, compared with 38%, a number often cited in the literature and based on outdated technology. (Medscape https://www.medscape.com/viewarticle/996369).

There appears to be no current UK recommendations although I am sure there is current discussion. Most oral cough and cold remedies currently contain phenylephrine as pseudoephedrine sales have been restricted. Between 2007 and 2008, the government introduced restrictions on their use because of concern that medicines containing these active substances could be used in the illicit manufacture of the Class A controlled drug methylamphetamine https://www.gov.uk/…/pseudoephedrine-and-ephedrine…

This information has been compiled from a variety of sources and does not imply recommendation other than that nasal decongestants and steam inhalation are effective in reducing symptoms of nasal congestion during breastfeeding without potential impact on supply. The choice of products is up to individuals.

Chest rubs such as Vick ™ may be overwhelming for a breastfeeding baby who is inhaling the smell. Anecdotally applying it sparingly to the feet under socks helps.

pdf of this information

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

This year more than I can ever remember families, including my own, are coming down with viruses. Over the last 2-3 years we have restricted contacts, children were not exposed to the normal viruses and we are now catching up on the immunity they didn’t get and are sharing them with our families.

First, and most importantly, continuing to breastfeed when you are ill passes on antibodies to the breastfeeding baby. If they get a virus first your body will automatically begin production to the infection. Such is the wonder of breastfeeding. In addition to antibodies, breastmilk contains the goodness they need if they stop eating as much ( and they may breastfeed more frequently) and it is a comfort to them too. Babies feeding frequently is not a symptom of low milk supply but that babies are seeking the positive benefits of breastfeeding and comfort.

However, as mothers sometimes we may need medications to help us get through the exhausting time of having a sick child and being ill yourself.

But with the latest information, on an evidence based level save your money on compound cold relief remedies and stick to simple analgesics and the cheaper decongestant sprays!

Paracetamol and ibuprofen Steam inhalation Nasal decongestant sprays if desired (not oral products) Sore throat lozenge and sprays if desired

Treating colds when breastfeeding

Decongestants.

There is research that pseudoephedrine can lower breastmilk supply after just one tablet. (Aljazaf K, Hale TW, Ilett KF, et al. Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin Pharmacol. 2003;56(1):18-24.) Pseudoephedrine is a decongestant ( helps to unblock your nose). It seems that mothers in late-stage lactation may be more sensitive to pseudoephedrine and have greater loss in milk production. Therefore, breastfeeding mothers with poor or marginal milk production should be cautious in using pseudoephedrine. While there are anecdotal reports of its use in mothers with engorgement, we do not know if it is effective, or recommend its use for this purpose.

Many remedies contain phenylephrine as the decongestant. Because of pseudoephedrine’s effect on milk production, concerns that phenylephrine may suppress milk production may arise; there is no evidence that this occurs at this time. Decongestants decrease secretions so it is not an unreasonable assumption that it might reduce supply but that no one has conducted trials. This is a case of lack of evidence rather then evidence of lack of activity.

Decongestant nasal sprays act only locally so will not pass into milk or affect milk supply.

Decongestant nasal sprays and nose drops should only be used for about 5-7 days at a time. If they are used for longer than this a rebound, more severe congestion of the nose often develops. Decongestant sprays and drops are thought to work better than oral tablets or capsules (https://patient.info/chest-lungs/cough-leaflet/decongestants)

Nasal decongestants can offer symptomatic relief but not cure a common cold https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6461189/. Paracetamol, ibuprofen and steam inhalation are generally as effective and much cheaper.

In September 2023 the FDA reported that oral phenylephrine is not effective at relieving nasal stuffiness. It is important to note that neither FDA nor the Non-prescription Drug Advisory Committee raised concerns about safety issues with use of oral phenylephrine at the recommended dose. (https://www.fda.gov/…/fda-clarifies-results-recent…).

According to one USA website the evidence for efficacy was first questioned in 2007. The manufacturers have cited a survey that many people find its use beneficial as shown by sales volume of cough and cold products.

The vote that formally declared phenylephrine ineffective was in line with a review of pharmacology and clinical data presented by the FDA, which found the oral bioavailability of the drug is less than 1%, compared with 38%, a number often cited in the literature and based on outdated technology. (Medscape https://www.medscape.com/viewarticle/996369).

There appears to be no current UK recommendations although I am sure there is current discussion. Most oral cough and cold remedies currently contain phenylephrine as pseudoephedrine sales have been restricted. Between 2007 and 2008, the government introduced restrictions on their use because of concern that medicines containing these active substances could be used in the illicit manufacture of the Class A controlled drug methylamphetamine https://www.gov.uk/…/pseudoephedrine-and-ephedrine…

This information has been compiled from a variety of sources and does not imply recommendation other than that nasal decongestants and steam inhalation are effective in reducing symptoms of nasal congestion during breastfeeding without potential impact on supply. The choice of products is up to individuals.

Chest rubs such as Vick ™ may be overwhelming for a breastfeeding baby who is inhaling the smell. Anecdotally applying it sparingly to the feet under socks helps.

When babies have colds

Babies may want to feed frequently both for extra fluid and for comfort when they have cold symptoms. Babies with blocked noses may find it hard to feed and may keep coming off the breast. Sodium Chloride nasal drops used before feeds may help as may a manual decongester (a mini suction pump used to suck out mucus from the baby’s nose) or using breastmilk as a drop is anecdotally purported to help. 

Sometimes babies pull away from the breast and cry – this may be because it increases in the pressure in their ears causing earache. This is particularly common overnight or after a longer sleep.

Babies may have a croaky, hoarse cry which is different to normal, indicating a sore throat.

Age appropriate paracetamol and ibuprofen can be given to the baby even if the breastfeeding mother is taking full dose.

If you have any concerns over the well-being of the baby medical advice should be sought urgently. It is better to err on the side of caution with young children whose condition can deteriorate rapidly.

Children’s chest rubs and vapourisers are available.

Sore throat remedies

Viral sore throats are self limiting and symptoms can be relieved by gargling with salt water, sucking ice cubes or lollies or sipping glycerine and honey. Most of us have our favourite commercial products e.g. (but not exclusively). Stepsils ( of all types) ™, Halls™, Tunes™, Lockets™,  Difflam™, Chloraseptic. The demulcent, antiseptic and anaesthetic activities do not pass into breastmilk.

Cough remedies

There is little evidence that cough remedies work but many of us have favourites which we find help to relieve symptoms. Expectorant cough medicines containing guaiphenesin are compatible with breastfeeding. Soothing medicines such as simple linctus and glycerine and honey also help. Multiple ingredient products should be avoided especially where there is a decongestant included. Inhaling steam and keeping the atmosphere in a room moist by using vapourisers, steam generators or a damp towel over a radiator.

Treating flu when breastfeeding

The difference between colds and flu is that symptoms of flu develop very rapidly and if your major heart throb was to knock your front door you wouldn’t be able to get up.

Flu symptoms include a sudden high temperature, aches everywhere in your body, feeling tired or exhausted, a dry cough, a sore throat, a headache and may include gastric symptoms.

The treatment is paracetamol and ibuprofen, plenty of fluids and rest.  Sore throat remedies and cough linctus may soothe but not cure.

We have all become used to the way that respiratory illnesses spread over the past 3 years. Symptoms of flu are very similar to COVID and the only way to differentiate is a Lateral Flow Test. Even if it is negative stay away from other people and just rest until symptoms pass in about a week.

Treating COVID 19 when breastfeeding

Although COVID 19 infections are less severe thanks to the vaccination programme there are still many people testing positive. At the time of writing around 1 in 30.

According to the Zoe covid app the presence of COVID is more likely where there is a dry, rasping throat and is more likely to be a cold/flu if there is sneezing.

Treatment is as for flu: paracetamol and ibuprofen, rest and fluids.

If you are immunocompromised you may be offered anti retroviral therapy although recommendations seem to change frequently https://breastfeeding-and-medication.co.uk/fact-sheet/clinically-extremely-vulnerable-covid-19-infection-and-breastfeeding

Prevention of Flu and Covid through vaccination

Although not a 100% protection both flu and covid vaccinations are compatible with breastfeeding

https://breastfeeding-and-medication.co.uk/fact-sheet/flu-and-covid-vaccine-in-autumn-booster-programme

Flu and covid vaccine in autumn booster programme

Having nursed my husband post-op this week the topic of laxatives is at the fore front of my mind particularly after opioid analgesics! But also very relevant post birth particularly after a c section or instrumental delivery

What is constipation:

It’s likely to be constipation if:

• you have not had a poo at least 3 times during the last week
• the poo is often large and dry, hard or lumpy
• you are straining or in pain when you have a poo
• You may also have a stomach ache and feel bloated or sick.

The most common causes of constipation include:

• not eating enough fibre, ( fruits, vegetables and cereals)
• not drinking enough fluids
• not moving enough and spending long periods sitting or lying down
• being less active and not exercising
• often ignoring the urge to go to the toilet
• changing your diet or daily routine
• a side effect of medicine especially opioid painkillers
• stress, anxiety or depression

Constipation is also common during pregnancy and for 6 weeks after giving birth.

Even if you decide you need medication you do need to make changes to your diet and toilet habits which can be particularly challenging with a new baby who needs you 24 hours a day and under whom you may be stuck feeding or sleeping when you need “ to go”.

Management of constipation

• In the management of short-duration constipation (where dietary measures have proved ineffective) start with a bulk-forming laxative, ensuring adequate fluid intake. Eg, ispaghula husk (Fybogel ™).
• If stools remain hard, add or switch to an osmotic laxative. Osmotic laxatives increase the amount of water in the large bowel, either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with. Eg Lactulose, Macrogols(Movicol™)
• Stool softeners act by decreasing surface tension and increasing penetration of intestinal fluid into the faecal mass Eg docusate (DulcoEase™)
• If stools are soft but difficult to pass or you feel inadequate emptying, a stimulant laxative should be added. Eg Senna (Sennokot™), Bisacodyl (Dulcolax™)
• Glycerol suppositories act as a lubricant and as a rectal stimulant by virtue of the mildly irritant action of glycerol.

Laxatives and breastfeeding

• Bulk forming laxatives just add to the bulk of faeces and are not absorbed into the body
• Osmotic laxatives just increase the volume of water in the faeces and are not absorbed into the body or breastmilk. Anecdotally some babies do develop loose bowel motions but there seems to be no reason for this.
• Stool softeners are poorly orally bioavailable. There are no studies on passage into breastmilk but it is believed to be minimal and should not affect the baby. (Hale 2023)
• Senna : In one dated uncontrolled study of 23 women who received Senokot (100 mg containing 8.602 mg of sennosides A and B), no sennoside A or B was detectable in their milk.[ Werthmann MW Jr, Krees SV. Quantitative excretion of Senokot in human breast milk. Med Ann Dist Columbia. 1973;42:4–5.] Of 15 mothers reporting loose stools, two infants had loose stools. Several controlled studies using modern senna products found no effect on the infant (LactMed 2023). Senna should only be used short term to treat constipation
• Bisacodyl: Bisacodyl is not absorbed from the gastrointestinal tract, and its active metabolite, which is absorbed, is not detectable in breastmilk. Bisacodyl can be taken during breastfeeding and no special precautions are required. (LactMed 2023). It’s oral bioavailability is less than 5% (Hale 2023)

See also https://www.sps.nhs.uk/articles/using-laxatives-during-breastfeeding

SPS Using laxatives and breastfeeding

Bristol Stool Chart

Type 1: Separate hard lumps (hard to pass)

Type 2: Lumpy, hard, sausage-shaped.

Type 3: Sausage-shaped with cracks on the surface.

Type 4: Sausage-shaped or snake-like; smooth and soft.

Type 5: Soft blobs with clear-cut edges (easy to pass)

Type 6: Fluffy pieces with ragged edges; mushy.

Many women who are breastfeeding will be offered flu vaccine, and maybe also covid boosters, shortly as the NHS expect yet another difficult season ahead.

You can have both flu and covid-19 vaccines when breastfeeding as the molecules are too large to pass into breastmilk. Your nursling will however receive antibodies, which you make to the vaccine, which will help to protect them as well.

There are now numerous studies on the compatibility of the vaccines in breastfeeding which I have linked to on my facebook pages over the months.

MHRA Guidance Sept 2022 https://www.gov.uk/government/publications/covid-19-vaccination-women-of-childbearing-age-currently-pregnant-planning-a-pregnancy-or-breastfeeding/covid-19-vaccination-a-guide-for-women-of-childbearing-age-pregnant-planning-a-pregnancy-or-breastfeeding#:~:text=Getting%20pregnant,-There%20is%20no&text=There%20is%20no%20evidence%20that,your%20chances%20of%20becoming%20pregnant.

Sources of information used

Flu Vaccines

The Green Book: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1102862/Influenza-green-book-chapter-19-2September22.pdf)

A UK study of co-administration of AstraZeneca and Pfizer BioNTech COVID-19 vaccines with inactivated influenza vaccines confirmed acceptable immunogenicity and reactogenicity (Lazarus et al, 2021). Where co-administration does occur, patients should be informed about the likely timing of potential adverse events relating to each vaccine. If the vaccines are not given together, they can be administered at any interval, although separating the vaccines by a day or 2 will avoid confusion over systemic side effects.

NHS (https://www.nhs.uk/pregnancy/keeping-well/flu-jab/)

It’s safe for women who are breastfeeding to have a flu vaccine if they’re eligible (for example, because of a long-term health condition).

Hale Medications and Mother’s Milk

The influenza vaccine is prepared from inactivated, non-viable influenza viruses and infection of the neonate via milk would not be expected. There are no reported side effects, nor published contraindications for using influenza virus vaccine during lactation.[1,2] Influenza vaccine is now indicated for breastfeeding mothers and their infants by the American Academy of Pediatrics.

LactMed (https://www.ncbi.nlm.nih.gov/books/NBK500990/)

Summary of Use during Lactation: The Centers for Disease Control and Prevention and several health professional organizations state that vaccines given to a nursing mother do not affect the safety of breastfeeding for mothers or infants and that breastfeeding is not a contraindication to either the live, attenuated (i.e., inhaled) or inactivated (i.e., injected) influenza vaccine, including H1N1 (swine) influenza vaccine. Immunization of the mother during pregnancy increases the amount of influenza antibodies and influenza-specific CD8 T cells in breastmilk and may offer added protection of their breastfed infants against influenza.[1-3] Breastmilk antibody responses are higher with the inactivated influenza vaccine than with the live oral vaccine.[4] Breastfed infants should be vaccinated according to the routine recommended schedules

COVID 19 Vaccines

The Green Book: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1102459/Greenbook-chapter-14a-4September22.pdf)

NHS (https://www.nhs.uk/conditions/coronavirus-covid-19/coronavirus-vaccination/pregnancy-breastfeeding-fertility-and-coronavirus-covid-19-vaccination/)

If you’re breastfeeding, It’s safe to get the COVID-19 vaccine if you are breastfeeding. You cannot catch COVID-19 from the vaccines and cannot pass it to your baby through your breast milk.

Hale Medications and Mother’s Milk

With much research now available on COVID-19 vaccines during breastfeeding, there is no evidence of harm to the mother or infant. Offering these vaccines to breastfeeding women is now the universal recommendation by governmental bodies and professional organizations. Compassion and understanding should be shown to moms hesitant to receive the vaccine. Their prime concerns are making the best decision during this vulnerable time and evidence should be provided to assist them in combatting their fears. The risk and benefit of the vaccine should be compared to each mother’s individual risk for getting COVID-19 as well as how well she is expected to tolerate the disease. In general, protection through any FDA authorized COVID-19 vaccination is expected to outweigh the risks associated with the injection.

No COVID-19 vaccines contain live viruses, so none of these vaccines are capable of causing COVID-19 upon administration. Neutralizing antibodies against COVID-19 have been found in the milk of breastfeeding mothers.[1-5] In a survey of 4,455 breastfeeding women, very few notable adverse effects were noted. 98% of respondents reported their vaccination had no impact on lactation. 93% of respondents noticed no impacts on their breastfeeding child. Of the 7% who reported infant adverse events, changes in fussiness or sleep, or diarrhea were the most commonly noted. Mothers also reported impacts on their ability to perform work duties, childcare duties, and household duties, particularly after the second dose.[6] Mothers considering getting these vaccines may consider timing the injection so that they may have additional support as they recover.

LactMed (https://www.ncbi.nlm.nih.gov/books/NBK565969/)

Summary of Use during Lactation: Many studies involving hundreds of women and their infants have been reported in the literature. No evidence suggests that women receiving a vaccine against SARS-CoV-2 is harmful to either the nursing mother or the breastfed infant. Antibodies and T-cells that neutralize the SARS-CoV-2 virus appear in the milk after maternal vaccination.[1-3] Nursing mothers experienced minimal disruption of breastfeeding after vaccination although a few reported to blue or blue-green discoloration of their milk.[4-8] Numerous professional organizations and governmental health authorities recommend that COVID-19 vaccines be offered to those who are breastfeeding because the potential benefits of maternal vaccination during lactation outweigh any theoretical risks.

I think we are all much more aware of the incidence of flu and its complications after the COVID pandemic. The best form of protection (although still not 100%) is flu vaccination which can be undertaken whilst breastfeeding with no risk to the baby. The symptoms of flu usually last for a week. Symptoms develop approximately 4 days after infection. Lateral flow tests should be used to differentiate between flu and covid.

Ways to try to avoid flu

• Wash hands with soap and water regularly
• regularly clean surfaces such as your computer keyboard, telephone and door handles to get rid of germs
• Wash hands before eating or touching face – the virus can be spread from door handles and other surfaces
• Try to avoid crowded venues if possible. Wearing a mask may offer protection

People with flu can spread it to others up to about 6 feet away. Most experts think that flu viruses are spread mainly by droplets made when people with flu cough, sneeze or talk. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. Less often, a person might also get flu by touching a surface or object that has flu virus on it and then touching their own mouth or nose.

Symptoms of flu include a sudden fever – a temperature of 38C or above, aching body, feeling tired or exhausted, dry or less frequently chesty cough, sore throat, headache, difficulty sleeping, loss of appetite, diarrhoea or tummy pain, nausea and being sick. You may feel too weak to get out of bed so need help to care for your baby/children. The symptoms are similar for children, but they can also get pain in their ear and appear less active. ( https://www.nhs.uk/conditions/flu/)

A cold develops more slowly and affects mainly the nose and throat. With ‘flu it is impossible to carry on with life as normal. Imagine if your favourite singer or actor knocked at your front door. If you have flu you wont care!

If you catch flu

•             Take regular paracetamol and ibuprofen

•             Keep drinking fluids

•             Rest as much as possible

•             Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the bin after you use it.

There is usually no reason to consult a doctor if you are normally fit and well, unless the symptoms have persisted for more than 7 days or you have difficulty breathing. Antibiotics do not help the flu virus itself although may be necessary for secondary infections. You are at greater risk of complications if you are pregnant.

People at high risk may be prescribed antiviral medications to help reduce the symptoms of influenza. They must be taken within two days of the start of symptoms to be effective.

• Oseltamivir (Tamiflu ®) – oral medication

Limited data indicate that oseltamivir and its active metabolite are poorly excreted into breastmilk. Maternal dosages of 150 mg daily produce low levels in milk and would not be expected to cause any adverse effects in breastfed infants, especially if the infant is older than 2 months (normal dose 75mg daily). Infants over 1 year of age can receive oseltamivir directly in doses much larger than those in breastmilk (Lactmed 2023, Wentges-van HN, van EM, van der Laan JW. Oseltamivir and breastfeeding. Int J Infect Dis. 2008).

• Zanamivir (Relenza ®) – inhaled drug

No information is available on the use of zanamivir during breastfeeding. One group of authors estimated that an exclusively breastfed 5 kg infant would receive about 0.075 mg daily in breastmilk after an inhaled maternal dose of 10 mg, which is less than 1% of the dose in older children. In addition, because zanamivir is poorly absorbed orally, it is not likely to reach the bloodstream of the infant in clinically important amounts. ( LactMed 2023, Tanaka T, Nakajima K, Murashima A et al. Safety of neuraminidase inhibitors against novel influenza A (H1N1) in pregnant and breastfeeding women. CMAJ. 2009;181:55-8

The manufacturer reports that it is present in the milk of rodents although no human data are available. Due to the poor oral or inhaled absorption and the incredibly low plasma levels, it is unlikely to produce untoward effects in breastfed infants (Hale Medications & Mothers Milk 2023)

see also https://breastfeeding-and-medication.co.uk/fact-sheet/coughs-colds-flu-and-covid-when-breastfeeding

Mother and breastfed baby

• The baby should not be separated from the mother unless she is too unwell to care for it. I Her breastmilk contains antibodies against flu which can protect the baby from more serious infection just as we saw with COVID infection.
• Children under the age of 2 years are at greater risk of secondary infections and professional support should be sought. It is important that babies and children are monitored for symptoms of dehydration (dry nappies, sunken fontanel, lethargy).

References

• F.O. Uruakpa, M.A.H. Ismond, E.N.T. Akobundu Colostrum and its benefits: a review. Nutrition Research 22 (2002) 755–767

• https://www.cdc.gov/flu/
• https://www.sps.nhs.uk/articles/using-oseltamivir-and-zanamivir-during-breastfeeding/
• Schlaudecker EP, Steinhoff MC, Omer SB, McNeal MM, Roy E, Arifeen SE, et al. (2013) IgA and Neutralizing Antibodies to Influenza A Virus in Human Milk: A Randomized Trial of Antenatal Influenza Immunization. PLoS ONE 8(8): e70867. http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0070867
• Trend S de Jong E, Lloyd ML, Kok CH, Richmond P, Doherty DA, Simmer K, Kakulas F Strunk T, Currie A.Leukocyte Populations in Human Preterm and Term Breast Milk Identified by Multicolour Flow Cytometry . PLoS One. 2015 A http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0135580
• Trend S, Strunk T, Lloyd ML, Kok CH, Metcalfe J, Geddes DT, Lai CT, Richmond P, Doherty DA, Simmer K, Currie A. Levels of innate immune factors in preterm and term mothers’ breast milk during the 1st month postpartum. Br J Nutr. 2016 Apr 14;115(7):1178-93

With thanks to Dr K.J Klottrup-Rees for her help with the biomedical science aspect of this information

I am so very frustrated for breastfeeding mothers who need colonoscopies and endoscopies being told that they need to interrupt breastfeeding. I was able to engage with the national body to update national guidelines which should be released soon.

Interestingly it is the same old story – we dont see breastfeeding women needing these examinations. So how come I do?

Some 3 years ago I began working with British Society of Gastroenterology on guidelines for sedation in gastrointestinal endoscopy. Much of the review was outside of my experience but I remain an author of the paper “British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy. It was published in BMJ Gut in October 2023. As regards sedation in breastfeeding mothers it recommends:

47. We recommend that breast feeding does not need to be suspended after a single intravenous dose of midazolam, fentanyl or pethidine or when used in combination, or after administration of propofol.

Grade of evidence: Low. Strength of recommendation: Strong.

Level of agreement: 100%

This guideline superceedes the information from 2012 (Shergill et al ASGE)

What are lactating mothers currently advised following procedures?

Many mothers who are lactating are questioning information provided by their gastroenterology team about lactation (18 queries identified in 6 weeks July and August 2020 to the Breastfeeding Network Drugs in Breastmilk service). In each case the mothers had been advised in three different ways:

• To stop breastfeeding during bowel preparation
• That they should stop breastfeeding for 24 hours after sedation for either procedure
• Or that if they were unwilling to stop breastfeeding after sedation that the procedure could only be undertaken with gas and air as analgesia

Whilst it is accepted that not all patients need sedation in order to undertake colonoscopy or endoscopy these women were not offered the choice.

This data has not changed significantly from a study published as a poster at the Baby Friendly Initiative Conference 2016

In that data 19 emails to the Drugs in Breastmilk helpline over a 6-month period February – August 2016 were analysed. All 19 mothers were already diagnosed with Inflammatory Bowel Disease (Ulcerative Colitis or Crohns Disease). Details of the duration advised to interrupt breastfeeding were noted together with comments made by the mothers about their care.

Quotes From Mothers

• My daughter will not take anything from a bottle or cup at the moment
• I am very worried that if I do not feed him for 2 days that my already tenuous supply will dwindle. (Baby 20 weeks)
• Their imaging department have been quite adamant that I cannot breastfeed for at least 24 hours but cannot explain to me why
• I also co-sleep with my baby at night and am concerned to only do this safely, this is currently the only way my baby will sleep at night.
• I am not sure I want to express that much as I do not want to mess with my supply
• The consultant I see is not very sympathetic to me wanting to continue breastfeeding and just told me I need to choose between feeding my baby or being well.
• I will proceed without any pain relief but wondered if there might be an alternative?
• I am worried I should try and cancel the procedure
• It has been suggested maybe I delay it until not breastfeeding, but I want to continue
• I had a colonoscopy today after switching hospital. It was wonderful to be treated with care and respect. I feel so much happier. I would recommend asking your GP for a referral for a different hospital if you are not happy with your care.
• It took us 8 weeks to latch and now at 15 weeks I am not going to go back to pumping all day when it is not essential.
• I know I can breast feed but not keen to starve myself for 24 hours and dehydrate myself. She then said as my little girl has turned one it is probably me feeding her that is caused this.
• Starting to doubt myself as some family members not happy

Summary Of Mother’s Comments

There are recurrent themes of:

• feeling that their breastfeeding is dismissed as unimportant by the specialist team
• concerns about supply or impact on risk of engorgement/mastitis
• Worries about how they will cope on liquid diet only when breastfeeding and caring for a baby
• That the mothers will endure pain and discomfort by coping without pain relief or just with gas and air rather than interrupt breastfeeding
• Concern from other family members about risk to the baby

There is no research to support the belittling of the importance in a breastfeeding an older baby and may represent a need to improve the education of medical professionals to the importance of breastmilk to protect mother and baby (Walters 2019). Indeed, WHO guidance supports the use of breastmilk as part of the diet of a child to 2 years and beyond. There is a link between formula feeding and IBD (Whorwell 1979, Xu 2017)

Midazolam

Matheson (1990) studied 12 women prescribed midazolam orally for sleep in the first 5 days after delivery. In 11 of the mothers the midazolam was undetectable in breastmilk 7 hours after the dose ((<3 mcg/L). However, in the first 5 days after delivery the gaps between cells are wide open to allow passage of immunoglobulins to pass through into milk with ease. This inevitably means that all other medication administered at this time will similarly pass readily into milk. That levels were below the level of detection after 7 hours at this stage supports the hypothesis that the drug does not readily transfer to the baby.

Nitsum (2006) studied 5 women 6-15 weeks post-partum given 2 mg pre- operatively (IV). The researchers estimated that the infants would receive an average of 0.016 mcg/kg in the 24 hours after a single dose of midazolam (0.06% of the maternal weight-adjusted dosage) and that this would be unlikely to affect a healthy, term baby.

Lee (1993), Spigsett (1994) and Nitsum (2006) recommend that after a single dose of midazolam that the mother may resume breastfeeding as soon as she is awake and alert following anaesthesia (LactMed).

Midazolam is extensively plasma-protein bound (97%) and poorly bioavailable (40-50%). (Brown 2019). Half life 3 hours so all removed from the body in 15 hours (5 half-lives).

Fentanyl

In Nitsum (2006) study the 5 the median amount of fentanyl recovered in milk within 24 hours post dose was 0.024 µg or 0.024% of the maternal dose women undergoing surgery and he recommended that mothers could breastfeed as normal thereafter. Oral bio availability 50-75% (Brown 2019).

Meperidine/Pethidine

Meperidine/ Pethidine has historically widely been used in labour. In a neonate the metabolite normeperidine it has a prolonged half-life (63 hours) but after 6 weeks returns to that of the adult (15-30 hours). Borgatta (1997) studied 9 women undergoing surgery for tubal ligation and concluded that a single dose for anaesthesia or conscious sedation usually does not cause problems in older breastfed infants. Meperidine/pethidine is only 50% orally bio-available (Brown 2019).

Propofol

Mitchell et al (2020) minimal amounts (0.025%) of propofol are transferred to breast milk. This is not a concern even when propofol is used by infusion for maintenance of anaesthesia. Breastfeeding may be resumed as soon as the woman has recovered sufficiently from general anaesthesia (Allegaert 2015).

Bowel preparations

Macrogols: the most commonly used laxative agents to clear the gut are Movicol ™and Laxido ™ otherwise known as polyethylene glycol- electrolyte solution. They are saline laxative which are not absorbed from the gut but pull water into the bowel to wash the contents out. Because it is not absorbed from the gut it cannot get into breastmilk and would not affect the baby. They are licensed to be used during breastfeeding

Sodium picosulfate (Picolax ™):  is not absorbed from the gastrointestinal tract, and its active metabolite, which is absorbed, is not detectable in breastmilk. Breastfeeding can continue as normal.

Macrogol 3350 (KleanPrep ™): contains, an osmotic laxative with a high molecular weight and zero oral bioavailability. Like Moviprep it accumulates water into the GI tract, where it acts as a laxative. It would be very unlikely to enter the plasma of the mother, or milk. Senna: is a stimulant laxative. Its key ingredient (anthraquinone), is believed to increase bowel activity due to secretion into the colon. It may produce abdominal cramps. In one study of 23 women who received Senokot none was detectable in their milk.[1] Of 15 mothers reporting loose

stools, two infants had loose stools (Werthmann 1973). However, in a randomized, double-blind trial comparing Senokot tablets to placebo, of the women in the study, 126 breastfed their infants and took senna while 155 control mothers breastfed their infants. There was no difference in the percentages of infants in the active and control groups with loose stools or diarrhoea (Shelton 1980). In this study 8 doses were taken. In bowel preparation a single dose only is used.

Sodium phosphate enema (Fleet™): is a saline laxative which sucks water into the lumen of the bowel. Whilst some phosphate may get into the plasma, it is very unlikely to change the levels in milk. The oral bioavailability is zero to 20%. Use of phosphate enemas should not require interruption of breastfeeding (LactMed)

Bisacodyl (Dulcolax ®): is poorly absorbed from the gut (oral bioavailability <5%) and so reaches low levels in breastmilk. It is a stimulant laxative. Breastfeeding can continue as normal

Conclusion

There is no evidence to support the recommendation to delay breastfeeding after endoscopy or colonoscopy or after bowel cleansing for colonoscopy in a healthy, term infant.

References

• Allegaert K, van den Anker JN. Maternal analgosedation and breastfeeding: guidance for the pediatrician. Journal of Pediatric and Neonatal Individualized Medicine 2015; 4: e040117.
• Borgatta L, Jenny RW, Gruss L, et al. Clinical significance of methohexital, meperidine, and diazepam in breast milk. J Clin Pharmacol. 1997; 37:186–92.
• LactMed National Library of Medicine, Drugs and Lactation Database
• Lee JJ, Rubin AP. Breast feeding and anaesthesia. Anaesthesia. 1993; 48:616–25.
• Matheson I, Lunde PKM, Bredesen JE. Midazolam and nitrazepam in the maternity ward: milk concentrations and clinical effects. Br J Clin Pharmacol. 1990; 30:787–93.
• Mitchell J, Jones W, Winkley E, Kinsella. S.M Guideline on anaesthesia and sedation in breastfeeding women 2020. Guideline from the Association of Anaesthetists. First published: 01 August 2020 https://doi.org/10.1111/anae.15179
• Nitsun M, Szokol JW, Saleh HJ, et al. Pharmacokinetics of midazolam, propofol, and fentanyl transfer to human breast milk. Clin Pharmacol Ther. 2006; 79:549–57. [PubMed]
• Shelton MG. Standardized senna in the management of constipation in the puerperium. A clinical trial. S Afr Med J. 1980; 57:78-80. Brown A and Jones W A guide to supporting breastfeeding for the medical profession Routledge (2019)
• Shergill AK, Ben-Menachem T, Chandrasekhara V, et al. Guidelines for endoscopy in pregnant and lactating women GASTROINTESTINAL ENDOSCOPY 2012;76 (1): 18-24)
• Sidhu R, Turnbull D, Haboubi H, et al British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy Gut Published Online First: 10 October 2023. doi: 10.1136/gutjnl-2023-330396
• SPC Hypnovel https://www.medicines.org.uk/emc/product/10948/smpc
• Spigset O. Anaesthetic agents and excretion in breast milk. Acta Anaesthesiol Scand. 1994; 38:94–103.
• Walters, D, Phan, LTH, & Mathisen, R, (2019). The cost of not breastfeeding global results from a new tool, Health Policy and Planning, doi.org/10.1093/heapol/czz050
• Werthmann MW Jr, Krees SV. Quantitative excretion of Senokot in human breast milk. Med Ann Dist Columbia. 1973; 42:4-5.