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Currently we are all anxious – Covid-19 is changing everything so rapidly and life is uncertain in so many aspects. On the drugs in breastmilk service we are receiving lots of queries about natural remedies for anxiety – Bach flower remedy, Kalms etc – and lots of supplements believed to have powers to protect. These queries are hard to deal with. Sometimes we have anecdotal information but rarely evidence that these are compatible with breastfeeding. It is hard for us to say we don’t know but we hope you understand why we can’t help.
Other ways to deal with anxiety
- Anxiety UK launched a You Tube on living with uncertainty – shorturl.at/qEIL8
- Headspace has a module on anxiety which may help you ground yourself by listening to your breathing.
- There are online CBT modules listed https://www.breastfeedingnetwork.org.uk/anxiety/ and much sensible information.
- Talk to others and share your anxiety but don’t dwell on it. Most people will develop only mild symptoms.
If I had one thing to share it would be – stay off social media which will probably fuel your anxiety. Listen to the news but not too often. We are in this situation for the long haul sadly and anxiety is exhausting. Enjoy every moment with your baby, value the oxytocin, watch your baby and not your phone. Sadly, there is no magic wand to relieve the anxiety and what-ifs just now. Life is changing daily.
- Do wash your hands with soap and water often –for at least 20 seconds
- Always wash your hands when you get home or into work or after going outside the house
- Use hand sanitiser gel if soap and water are not available
- Cover your mouth and nose with a tissue or your sleeve (not your hands) when you cough or sneeze or sneeze into your elbow (but change clothes as soon as possible).
- Dispose of used tissues in the bin immediately and wash your hands afterwards
- Avoid close contact with people who are unwell
- If you or a member of your family develop a fever or sudden onset cough self-isolate for 14 days and take paracetamol (ibuprofen currently not recommended although evidence of risk is low self help treatment coronovirus)
Keep an eye on the Public Health England information which us updated regularly.
That new title is going to take a lot of getting used to! I am very proud and delighted to have been nominated for an MBE for services to mothers and babies as a founder of the Breastfeeding Network Drugs in Breastmilk Service. I never thought this would happen to me following a path which I didnt really plan 22 years ago but has led me to this amazing place. I feel inspired to keep going and hopefully change some more professional attitudes that prescribing a medication doesnt mean that a mother needs to interrupt breastfeeding. Thank you to the many, many people who have sent messages of congratulations today – I appreciate them so much.
I also want to thank my wonderful family for their support – my husband Mike, my daughters Kerensa, Bethany and Tara, my son in laws Christian, Steve, Rich and Ian and of course my treasured grandchildren Stirling, Isaac, Beatrix and Elodie and the new bump due in 2019. I cant tell you how much I love you all
In a report today Public Health England have made recommendations on dental health and breastfeeding. Full information can be accessed at : www.gov.uk/government/publications/breastfeeding-and-dental-health/breastfeeding-and-dental-health#breastfeeding-and-dental-health
- dental teams should continue to support and encourage mothers to breastfeed
- not being breastfed is associated with an increased risk of infectious morbidity (for example gastroenteritis, respiratory infections, middle-ear infections)
- breastfeeding up to 12 months of age is associated with a decreased risk of tooth decay
- breast milk is the only food or drink babies need for around the first 6 months of their life, first formula milk is the only suitable alternative to breast milk
- bottle-fed babies should be introduced to drinking from a free-flow cup from the age of 6 months and bottle feeding should be discouraged from 12 months old
- only breast or formula milk or cooled, boiled water should be given in bottles
- only milk or water should be drunk between meals and adding sugar to foods or drinks should be avoided
Recent systematic reviews such as that by Tham and others (2015)6 included studies where children were breastfed beyond 12 months. When infants are no longer exclusively breast or formula fed, confounding factors, such as the consumption of potentially cariogenic drinks and foods and tooth brushing practices (with fluoride toothpaste), need to be taken into account when investigating the impact of infant feeding practices on caries development. Tham and others (2015) noted that several of the studies did not consider these factors and concluded that with regard to associations between breastfeeding over 12 months and dental caries “further research with careful control of pertinent confounding factors is needed to elucidate this issue and better inform infant feeding guidelines”. Good quality evidence on breastfeeding and oral health is an area with significant methodological challenges which have been outlined by Peres and others (2018)7.
Of course I would also have to highlight that dental procedures, including sedation, local and general anaesthetic and use of antibiotics and analgesics need not interrupt breastfeeding
We all know as parents how hard it is to comfort a baby who is teething and to witness their distress. As a pharmacist, mother and grandmother I know that the standard products often recommended in the past contained a local anaesthetic often lidocaine.
In 2014 the FDA in USA first raised concerns stating that “Topical pain relievers and medications that are rubbed on the gums are not necessary or even useful because they wash out of the baby’s mouth within minutes, and they can be harmful”.
Today the MHRA have announced that parents and caregivers are being advised that products containing lidocaine used for teething in babies and children will be sold only in pharmacies, under the supervision of a pharmacist from the beginning of 2019. The MHRA review concluded there is a lack of evidence of benefit to using products containing lidocaine for teething before non-medicinal options. Evidence of any risk associated with these products is very small given the wide usage of these medicines. A pharmacist or healthcare professional can provide appropriate guidance. Teething is a natural process and lidocaine containing teething products such as teething gels should only be used as a second line of treatment after discussion with and guidance of a healthcare professional.
It is suggested that parents try non-medicine options such as rubbing or massaging the gums or a teething ring before considering teething gels after discussion with a pharmacist.
Further information can be found :
And a patient information leaflet: https://assets.publishing.service.gov.uk/media/5c0fd7cbed915d0c736a1e64/Lidocaine-patient-sheet.pdf
La Leche League GB have produced an excellent article on teething which can be accessed www.laleche.org.uk/breastfeeding-and-teething/#Pain.
The NHS also has sound information: https://www.nhs.uk/conditions/pregnancy-and-baby/teething-tips/
Products include Dentinox gel ®, Calgel ®, Bonjela ®, Anbesol gel ®
I spend on average 4 full hours across every day providing info to mums told they HAVE to stop breastfeeding to take medicines. Do more people know about the drugs in breastmilk service or are professionals less willing to take risks so stopping breastfeeding seen as best option? How can we change the conversation ?
Where does it make sense to tell mothers stop breastfeeding to take medicines when we have specialist support texts and services? Breastfeeding has HUGE advantages for mums, babies and the economy. We need to listen, support and provide evidence based info for all mums breastfeeding and formula feeding not rely on manufacturers
There are economic savings for the health economy. Renfrew (2012) provided a detailed cost analysis of potential savings, reductions in hospital admissions and GP appointments:
Assuming a moderate increase in breastfeeding rates, if 45% of women exclusively breastfed for four months, and if 75% of babies in neonatal units were breastfed at discharge, every year there could be an estimated:
- 3,285 fewer gastrointestinal infection-related hospital admissions and 10,637 fewer GP consultations, with over £3.6 million saved in treatment costs annually
- 5,916 fewer lower respiratory tract infection related hospital admissions and 22,248 fewer GP consultations, with around £6.7 million saved in treatment costs annually
- 21,045 fewer acute otitis media (AOM) related GP consultations, with over £750,000 saved in treatment costs annually
- 361 fewer cases of NEC, with over £6 million saved in treatment costs annually.
In total, over £17 million could be gained annually by avoiding the costs of treating four acute diseases in infants. Increasing breastfeeding prevalence further would result in even greater cost savings”
In addition, if half those mothers who currently do not breastfeed were to breastfeed for up to 18 months in their lifetime, for each annual cohort of around 313,000 first-time mothers there could be:
- 865 fewer breast cancer cases with cost savings to the health service of over £21 million, 512 breast cancer-related quality adjusted life years (QALYs) would be gained, equating to a value of over £10 million.
This could result in an incremental benefit of more than £31 million, over the lifetime of each annual cohort of first-time mothers.
This is my blog written for the Breastfeeding Network for maternal mental health awareness week. Perinatal mental health and its impact on breastfeeding and vice versa is becoming a specific passion of mine. So sad that women are repeatedly told you cant have medication UNLESS you stop breastfeeding. Incorrect and unhelpful
Raynaud’s phenomenon affects up to 10% of otherwise healthy women aged 21-50 years of age. It is 9 times more common in women than men.
Yet many doctors are unaware that Raynaud’s can affect breastfeeding. It produces deep pain after feeds with a mother often automatically covering her nipples or massaging them to restore the blood flow. Symptoms are often mis-diagnosed as thrush when in fact the use of fluconazole can make the symptoms worse by causing further vasoconstriction.
Most mothers who experience problems with Raynaud’s during breastfeeding, have a history of cold hands and feet or a close relative who has. It may be that in a family it is routine to wear thick socks and gloves, maybe a vest without realising that they may be “unusual” in their response to the cold.
Babies of mothers with Raynaud’s may be born early and / or smaller because of restriction of blood flow to the placenta. It is not uncommon for there to be a maternal (or close family) history of migraines.
Symptoms which differentiate Raynaud’s phenomenon with other causes of breast pain are:
- Pain in both breasts after feeds
- Pain which may be precipitated by being cold or for example going down the freezer aisle in a supermarket
- Rapid 3 colour change in the nipples after feeds
- Pain that is resolved by warmth or gentle massage
- A history or close family history of poor circulation
Treatment of Raynaud’s during breastfeeding
- Don’t ignore the fact that pain after breastfeeds may be due to less than perfect attachment of the baby at the breast. A white tip to the nipple after feeds is not the same as the tri colour change typical of Raynaud’s
- Nifedipine 30mg a day (either as 10mg three times a day or long acting 30mg once daily. The amount in breastmilk is too small to affect babies although it may give the mother hot flushes and / or headaches. The following extract is taken from Breastfeeding and Medication 2nd Ed to be published May 2018
- High doses of vitamin B6 (Newman 2012), magnesium (Smith 1960, Turlapaty Leppert1994), calcium (DiGiacomo 1989), fatty acids (Belch 1985) and fish oil supplementation (DiGiacomo 1989) have also been suggested but take a minimum of 6 weeks to be effective. Ginger 2000mg-4000mg daily. Capsules usually contain 500mg. It may also be beneficial to add ginger to your diet, to drink ginger tea, or to put a spoonful of ground ginger in your bathing water (Royal Free hospital www.royalfree.nhs.uk/pip_admin/docs/Raynaudsnatural_186.pdf)
Nifedipine relaxes vascular smooth muscle and dilates coronary and peripheral arteries. It has activity in reducing blood pressure and in the treatment of Reynaud’s syndrome
Nifedipine is almost completely absorbed from the GI tract but undergoes extensive first-pass metabolism. It is up to 98% bound to plasma proteins. It is used to treat hypertension (Penny and Lewis 1989; Ehrenkranz et al. 1989) and also to improve circulation in Reynaud’s disease (cold extremities and nipple vasospasm) in doses up to 30 mg daily (Lawlor-Smith and Lawlor-Smith 1996; Garrison 2002; Anderson et al. 2004). Side effects for the mother include flushing and headache, which may limit its usefulness. It is present in breastmilk but in levels too small to be harmful and there have been no reports of adverse effects in babies (see Chapter 5).
In Taddio et al’s study (1996) of 21 women taking 40 mg daily the babies were estimated to be exposed to 0.1% of the maternal weight adjusted dose via breastmilk. Nifedipine is widely used to treat pre-eclampsia and eclampsia in the mother together with methyldopa or a beta blocker. Ehrenkranz et al. (1989) studied one woman who took 10, 20 or 30 mg three times daily on different days. Using the maximum dose transferred by the 30 mg regimen, the authors estimated that the baby would be exposed to the authors estimated that an exclusively breastfed infant would receive an estimated maximum of 7.5 µg per kilogramme of nifedipine daily. Its relative infant dose is quoted as 2.3–3.4% (Hale 2017 online access).
The BNF reports that the amount secreted into breastmilk is too small to be harmful but that manufacturer advises it should be avoided.
Compatible with breastfeeding.
- Anderson JE, Held N, Wright K, Raynaud’s phenomenon of the nipple: a treatable cause of painful breastfeeding, Pediatrics, 2004;113(4):e360–4.
- Ehrenkranz RA, Ackerman BA, Hulse JD, Nifedipine transfer into human milk, J Pediatr, 1989;114:478–80.
- Garrison CP, Nipple vasospasm, Raynaud’s syndrome, and nifedipine, J Hum Lact, 2002;18(4):382–5.
- Lawlor-Smith LS, Lawlor-Smith CL, Raynaud’s phenomenon of the nipple: a preventable cause of breastfeeding failure?, Med J Aust, 1996;166:448. Letter.
- Penny WJ, Lewis MJ, Nifedipine is excreted in human milk, Eur J Clin Pharmacol, 1989;36:427–8.
- Taddio A; Oskamp M; Ito S; Bryan H; Farine D; Ryan D; Koren G,. Is nifedipine use during labour and breastfeeding safe for the neonate?, Clin Invest Med, 1996;19(4 Suppl.):S11. Abstract.
Too many breastfeeding women suffer symptoms of anxiety and depression and dont seek treatment because’
- they are ashamed
- they are frightened they may be seen as not a good enough mother and at risk of having their baby taken into care
- because healthcare professionals may not support ongoing breastfeeding
- they are worried that medication passing through milk may affect their baby
- they just find asking for help too hard
Our mental health varies every day and within every day – we move up and down just like a petrol guage. And that is normal. Every day thousands of mothers are worried, anxious, depressed and tired. We need to support them and admit that we can all be affected at some time in our lives.
Support Heads Together www.headstogether.org.uk/about-heads-together/ and check the information sheets for drugs which can be used by breastfeeding mothers with:
and bi-polar www.breastfeedingnetwork.org.uk/bipolar-disorder/
or email me firstname.lastname@example.org for information
Fathers and grandmothers of the baby may be the first to notice that a mother may not be her normal cheery self. Dont ignore it, talk about it as a family, help the special mum in your life get help whether it be medication or talking therapy. Life with a newborn is a precious time, be honest about feelings as you will not be alone. Dads can also feel depressed and anxious – you dont have to pretend to be strong.
Let’s talk about mental health and make it normal – then we can move forward stronger www.headstogether.org.uk/about-heads-together/
71% of 500 women who responded to a PHE study, think breastfeeding will limit the medication which can be taken! So lots of work for me still to do then. Could professionals buy a copy of Breastfeeding and Medication to reassure women?
Statements like this on the NHS site arent going to help – more about manufacturer protecting themselves? Not taking risks? Could be better worded as it just isnt true. Breastfeeding mothers with depression get treated every day and their babies are fine!
“Breastfeeding: As a precaution, the use of antidepressants if you’re breastfeeding isn’t usually recommended. However, there are circumstances when both the benefits of treatment for depression (or other mental health conditions) and the benefits of breastfeeding your baby outweigh the potential risks. If you’re treated with antidepressants when breastfeeding, then paroxetine or sertraline is normally recommended.”
The Start for life page https://www.nhs.uk/start4life/breastfeedingto which the chat box https://www.messenger.com/t/Start4LifeBreastFeedingFriend/ links identifies the BfN Drugs in breastmilk helpine which I run as a resource. But they dont fund it – it is run on a voluntary basis and they didnt ask permission to see if I can deal with additional work. But I will keep doing my best to support mothers who need medication whilst breastfeeding
” Almost three-quarters of women in England start breastfeeding after giving birth but less than half are still doing so two months later, according to NHS and Public Health England data.
PHE recommends exclusive breastfeeding for the first six months, as does the World Health Organisation, because it boosts a baby’s ability to fight illness and infection. But a comparison of initial breastfeeding rates and those after six to eight weeks in the final quarter of 2015 found that they were 40% lower for the latter (44% compared with 73%).
A survey of 500 mothers commissioned by PHE found that fears about breastfeeding among women included that it could be painful (74%), prevent them taking medication (71%) and be embarrassing in front of strangers (63%).
The PHE’s chief nurse, Viv Bennett, said: “We can all help women feel comfortable breastfeeding their baby wherever they are. Creating a wider culture of encouragement and support will help make a mother’s experience all the more positive.”
PHE has launched an interactive breastfeeding friend chatbot, accessed through Facebook messenger, to provide personal support for breastfeeding 24 hours a day. Bennett said it would help women through the “crucial” initial period, after which things generally became easier.
A study published in the Lancet last year found the UK had the lowest rate of breastfeeding in the world, with only one in 200 women breastfeeding their children after they reach their first birthday.
The WHO recommends that breastfeeding form part of a baby’s diet up to two years of age. As well as reducing the likelihood of babies getting diarrhoea and respiratory infections, breastfeeding also lowers a mother’s risk of ovarian and breast cancer and burns about 500 calories a day.
The results, published on Thursday, suggested high-profile figures who promote breastfeeding can have a positive influence on other mothers. Just under half of respondents said the example of household names such as The Only Way is Essex star Sam Faiers, broadcaster Fearne Cotton and actor Blake Lively, who have recently championed breastfeeding on social media, had inspired them to do so themselves. About two-thirds (64%) said they felt more confident to breastfeed in public because of celebrity mums.
Other concerns raised by more than half of women were not being able to tell if their baby was getting enough or too much milk and that it could potentially place restrictions on the mother.
Jacque Gerrard, the director for England at the Royal College of Midwives, said: “Any initiative that goes towards helping mothers start and sustain breastfeeding for longer is positive as we know the health benefits from being breastfed last a lifetime.”
If you see breastfeeding mothers who need medication maybe you need to buy this book