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Botox for medical purposes and Breastfeeding
Botox injections are used for many medical purposes including migraine, anal fissures. The amount of botox getting into milk is low based on the research on one mother who caught botulism from eating fermented salmon eggs. She continued to breastfeed. No botulinum toxin or botulism was found in the breastmilk or the baby. The doses that are used medically are far lower than that which would have caused the mother’s botulism so the amount in breastmilk is assumed to be too low to produce adverse effects.
Hale also comments that when Botox is injected into the muscle, it produces a partial chemical denervation resulting in paralysis of the muscle. When injected properly, and directly into the muscle, the toxin does not enter the systemic circulation. Thus levels in maternal plasma, and milk are very unlikely. Waiting a few hours for dissipation of any toxin would all but eliminate any risk to the infant. Also, avoid use of generic or unknown sources of botulinum toxin, as some are known to produce significant plasma levels in humans. (Hale TW Medications and Mothers Milk online version accessed Feb 2024)
In February 2024 a study of 4 mothers was published https://www.liebertpub.com/doi/abs/10.1089/fpsam.2023.0326
Objective: To detect the presence of botulinum toxin in breast milk from lactating subjects treated with facial botulinum toxin injections, as measured by enzyme-linked immunosorbent assay (ELISA).
Methods: For this pilot study, lactating women were injected with standardized facial botulinum toxin type A (BTXA) (range 40–92 U). Collected breast milk samples over 5 days were analyzed for the presence of botulinum toxin. Exclusion criteria included (1) lactating women still using their breast milk for their infant, (2) muscular disorders, (3) any medication that could interfere with neuromuscular function, (4) uncontrolled systemic disease, (5) pregnant, and (6) neuromodulator injection in the past 90 days.
Results: Four lactating women were recruited. Eight samples had no BTXA detected, whereas 8 of the 16 total had detectable amounts, which were well below the reported lethal oral dose for an infant.
Conclusion of the authors: Although the exclusion of lactating women from receiving cosmetic botulinum toxin injections is out of an abundance of caution to the theoretical risk to the infant, this study helps support the notion that facial botulinum toxin injections do not warrant an interruption in breastfeeding. Further studies with larger sample sizes are needed.
Hudson C, Wilson P, Lieberman D, Mittelman H, and Parikh S. Analysis of Breast Milk Samples in Lactating Women After Undergoing Botulinum Toxin Injections for Facial Rejuvenation: A Pilot Study.Facial Plastic Surgery & Aesthetic Medicine.ahead of print
See also https://infantrisk.com/content/botox-injections-and-breastfeeding (April 2025)

Botox and Fillers and Breastfeeding
There is no published research that I have been able to find and trust on the passage of fillers into milk so I cant say that they are safe or unsafe. I just do not know.
However InfantRisk IN USA set up by Tom Hale my guru, published this in April 20205 https://infantrisk.com/content/botox-injections-and-breastfeeding
There is some information from one mother who caught botulism from eating fermented salmon eggs. She continued to breastfeed. No botulinum toxin or botulism was found in the breastmilk or the baby. The doses that are used medically are far lower than that which would have caused the mother’s botulism so the amount in breastmilk is assumed to be too low to produce adverse effects.
In February 2024 a study of 4 mothers was published https://www.liebertpub.com/doi/abs/10.1089/fpsam.2023.0326
Objective: To detect the presence of botulinum toxin in breast milk from lactating subjects treated with facial botulinum toxin injections, as measured by enzyme-linked immunosorbent assay (ELISA).
Methods: For this pilot study, lactating women were injected with standardized facial botulinum toxin type A (BTXA) (range 40–92 U). Collected breast milk samples over 5 days were analyzed for the presence of botulinum toxin. Exclusion criteria included (1) lactating women still using their breast milk for their infant, (2) muscular disorders, (3) any medication that could interfere with neuromuscular function, (4) uncontrolled systemic disease, (5) pregnant, and (6) neuromodulator injection in the past 90 days.
Results: Four lactating women were recruited. Eight samples had no BTXA detected, whereas 8 of the 16 total had detectable amounts, which were well below the reported lethal oral dose for an infant.
Conclusion of the authors: Although the exclusion of lactating women from receiving cosmetic botulinum toxin injections is out of an abundance of caution to the theoretical risk to the infant, this study helps support the notion that facial botulinum toxin injections do not warrant an interruption in breastfeeding. Further studies with larger sample sizes are needed.
Caroline Hudson, Parker Wilson, David Lieberman, Harry Mittelman, and Sachin Parikh.Analysis of Breast Milk Samples in Lactating Women After Undergoing Botulinum Toxin Injections for Facial Rejuvenation: A Pilot Study.Facial Plastic Surgery & Aesthetic Medicine.ahead of print
References
1. Lee KC, Korgavkar K, Dufresne RGJ et al. Safety of cosmetic dermatologic procedures during pregnancy. Dermatol Surg. 2013;39:1573-86.
2. Middaugh J. Botulism and breast milk. N Engl J Med. 1978;298:343.
Both these cosmetic procedures have to be undertaken with this limited information in mind. It is your choice .

Phenylephrine and Breastfeeding
I have written extensively about the use of decongestants in the past ( https://breastfeeding-and-medication.co.uk/fact-sheet/coughs-colds-flu-and-covid-when-breastfeeding and https://www.breastfeedingnetwork.org.uk/factsheet/decongestants/)
Pseudoephedrine has been shown to reduce milk supply in some women. The effect of phenylephrine on supply has not been demonstrated but use of oral decongestants is generally not advised for breastfeeding women.
I have always recommended the use of nasal sprays as decongestants together with the use of steam inhalation as being more effective than oral medication and with no potential impact on supply.
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. Key Information about Nonprescription, Over-the-Counter (OTC), Oral Phenylephrine | FDA
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/drug-safety-update/pseudoephedrine-and-ephedrine-update-on-managing-risk-of-misuse#:~:text=Sales%20restrictions,-Since%20April%202008&text=It%20is%20illegal%20to%20sell,mg%20ephedrine%20without%20a%20prescription
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. Most of us have our own preferred remedies which we find effective and that remains a personal choice

What would women like professionals to understand? Breastfeeding an older baby whilst experiencing Hyperemesis.
PDF of this information is available at:
see also The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69)
https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.17739?fbclid=IwAR1c5ZE0_-AocuZ1bXuZSZGB9VCLHHCy4of4JkvxmYTTPWEzMAJVzTf1gQY
Thank you to everyone on the facebook group who shared their experiences and helped me to update this information.
More women are now breastfeeding their babies for longer and may still be feeding when they fall pregnant. For those who suffer from hyperemesis gravidarum (HG) this is a tough time. Sadly, some healthcare professionals do not understand that there is benefit to a child from being breastfed to the age of two years and beyond (WHO) alongside a normal weaning diet. Being asked to abruptly wean your older child in order to take medication is not an easy option and is not necessary. Sometimes sitting quietly to breastfeed whilst you fight the feeling of nausea is helpful. Some professionals remain concerned about the teratogenicity of drugs in pregnancy despite national guidance.
“ I had an absolutely awful time while still trying to breastfeed a toddler. The GP refused to prescribe anything other than cyclizine despite me calling them in desperation many times. Nothing else was made available and I was told that I just had to wait until it cleared up.”
Symptoms of NVP and HG
Nausea and vomiting of pregnancy (NVP) is common and usually settles by 12-14 weeks of pregnancy (although it may be longer and even last the full pregnancy). Often known as morning sickness it can occur at any time of the day or last all day.
Hyperemesis gravidarum is a severe form and can affect up to 1 to 3 in 100 pregnant women. Sadly, some women experience such extreme symptoms that they feel that they have no choice but to terminate the pregnancy even if it is a much longed for baby.
“I ended in termination of pregnancy after first hospital visit as I didn’t want to take from my child who was already here and after how badly I dealt with it last time, it being worse instantly I couldn’t do it”
Others decide that one child is sufficient to complete their family as they cannot contemplate symptoms again. There are medications but often primary care professionals do not appreciate the severity of symptoms or impact on mothers.
“I had HG with my daughter who will be 11 next month. Hyperemesis is the primary reason I only have one child. It was physically horrendous, and I had post-traumatic stress for years afterwards”.
“I had this with my daughter. It is the reason she will be an only child. She’s 4 now and I still suffer a lot of health issues as a direct result of hyperemesis. I had the best medical care. And was lucky to be given a lot of treatment. But it wasn’t enough, and my body still struggled. You can’t appreciate how difficult it is until you’ve experienced it.”
When asked in a facebook group (https://www.facebook.com/breastfeedingandmedication) for their experiences of suffering from morning sickness and hyperemesis, one of the overwhelming comments from women was about reluctance of GPs to prescribe medication in pregnancy, even when it had been prescribed whilst the mother was hospitalised!
“After one of my hospitalisations I was sent home with a prescription for cyclizine and when I went to my GP to renew the prescription she talked me out of it because “it wasn’t making enough of a difference for me to go back to work” so didn’t seem worth taking (mild relief from the symptoms of HG wasn’t considered a benefit.)”
Repeated comments from family, friends and professionals underestimated how the woman was feeling and she didn’t feel listened to.
“I didn’t feel I wasn’t listened to and also I didn’t feel dismissed. I just accepted this was part and parcel of my pregnancy as it was just relayed to me that it was normal.”
“It was awful. People (friends, family, healthcare workers) were quick to tell me what worked for them, and I felt very blamed that I was somehow not trying hard enough. All the admissions were almost a relief, just to lie there with fluid going in. I used to be admitted for several days each week, particularly in third trimester. I still have consequences from the prolonged malnutrition.”
For what should be a joyous family time there were repeated descriptions of an awful experience:
“ horrendous, hell on earth, pure hell, absolutely hell, housebound for months, nothing worked”.
“ I wasn’t taken seriously until my organs started to shut down and I needed to be induced, I spent 5 months in bed, couldn’t drink water or anything else, everything made me feel nauseous.”
“ I vomited so much and so hard that every time I wet myself and my nose bled. I was told when I was 5 weeks pregnant that if I didn’t want to be sick I shouldn’t be pregnant. I ended up hospitalized at 8 weeks.”
Should this be the experience of women in the UK in 2023?
Anti emetics in breastfeeding and pregnancy
Many of the drugs used to relieve nausea in pregnancy may be associated with lowering of milk supply. However, most women find that their supply very rapidly diminishes when they are pregnant. Many also develop aversion and very sensitive nipples and wish to limit feeding. Sadly, toddler nurslings don’t always understand the loss of their comfort! Many breastfeeding dyads continue to dry nurse throughout pregnancy and may go on to tandem feed. It is the decision which works for each family which matters, without judgement from family and professionals.
Hyperemesis may result in dehydration and subsequent admission to hospital. Signs of dehydration include feeling very thirsty, becoming drowsy or unwell, urine changing from a light yellow to a dark yellow or brown colour. Medical help should be sought if even sips of fluid produce vomiting. Weight loss can be excessive because of the restriction of quantity of food tolerated. Hyperemesis is diagnosed when there is prolonged nausea and vomiting with more than 5% pre pregnancy weight loss, dehydration and electrolyte imbalance. https://cks.nice.org.uk/topics/nausea-vomiting-in-pregnancy/background-information/definition/
Self-care
https://cks.nice.org.uk/topics/nausea-vomiting-in-pregnancy/management/management/
- Rest as needed and try to avoid sensory stimuli that may trigger symptoms, such as odours, heat, and noise.
- Try eating plain biscuits or crackers in the morning.
- Try eating bland, small, frequent protein-rich meals which are low in carbohydrate and fat.
- Cold meals may be more easily tolerated if nausea is smell-related.
- Drinking little and often, rather than large amounts.
- Ginger (can be taken in fresh, tea, capsule, or syrup form).
- Acupressure (such as over the P6 point on the ventral aspect of the wrist using a wrist band or finger pressure).
Responses on the facebook group as to how helpful these suggestions were are exemplified by:
“Nausea and sickness with my first born I had such a heightened sense of smell. I couldn’t even open my fridge without feeling sick and running to the loo. I ended up using a cool bag instead of my fridge, and I had to call my mum to come and help me when my partner was away. I couldn’t brush my teeth without gagging and wanting to be sick.”
“I was asked what is had to eat and when I said an oat/raisin bar the doctor replied I shouldn’t be having anything sugary. That one doctor who knew her stuff had told me to eat anything I could keep down.”
Medical Treatment
The RCOG green top guidelines on treating are available https://www.rcog.org.uk/media/y3fen1x1/gtg69-hyperemesis.pdf
The UKTIS information on the use of drugs in pregnancy can be found at https://www.medicinesinpregnancy.org/leaflets-a-z/nausea–vomiting/
RCOG Recommended antiemetic therapies and dosages

In this fact sheet I have provided links to detailed information on the medication which can help prescribers to reach an evidence-based decision on the safety of the drug to the breastfeeding baby which is not available in standard reference texts like the British National Formulary (BNF). The linked pdf files contain information sourced from LACTMED February 2023
First Line treatments
- Cyclizine (Valoid™)
May possibly cause some drowsiness in the nursling but anecdotally appears to happen rarely . See https://www.ncbi.nlm.nih.gov/books/NBK501749/ and https://www.e-lactancia.org/breastfeeding/cyclizine/product/
Cyclizine is an anti-emetic used to treat nausea and vomiting including motion sickness, post-operative nausea and vomiting, after radiotherapy, in drug-induced situations, as well as for nausea in pregnancy. There are no reports of levels entering breastmilk (BNF) or data on which to base conclusions. There is an unlicenced dose for children aged over 6 years. It may be given orally, by IV or IM every 8 hours. Manufacturers advise to avoid in pregnancy, but there is no evidence of teratogenicity
·
Prochlorperazine (Buccastem, Stemetil)
Low levels of prochlorperazine are secreted into breastmilk and it can be used when breastfeeding. Side effects for the mother include drowsiness, restlessness and occasional extra pyramidal effects but babies seem to exhibit no adverse reactions. It is licensed to be given directly to babies weighing more than 10 kg. See https://www.ncbi.nlm.nih.gov/books/NBK501080/ and https://www.e-lactancia.org/breastfeeding/prochlorperazine/product/
Prochlorperazine is used to treat vertigo, labyrinthitis, migraine or drug-induced emesis if severe vomiting is a problem. Its oral bio-availability is low due to high first-pass metabolism but, like all phenothiazines, it has many metabolites, some active. It is not generally used in travel sickness prophylaxis. It is a member of the phenothiazine family to which children are particularly sensitive. Long-term use should be avoided in breastfeeding where possible, particularly with very young babies where there is a potential risk of apnoea. However, short-term acute use probably poses few risks as it is licenced for use in children over 10 kg. The dose is 5-10mg (one or two tablets) every 6-8 hours. It may also be given IV or IM.
- Promethazine (Avomine™ Phenergan™, Sominex™)
When used for hyperemesis in mother promethazine may possibly cause some drowsiness in the nursling but anecdotally appears to happen rarely. It also causes drowsiness in the mother so care should be taken with co sleeping.
See https://www.ncbi.nlm.nih.gov/books/NBK501081/ and https://www.e-lactancia.org/breastfeeding/promethazine/product/
Promethazine is widely used to reduce nausea particularly associated with travel sickness as well as symptomatic relief of urticaria and as an over-the-counter (OTC) hypnotic for short-term use. No data are available on transfer into breastmilk but it is believed that it does pass into breastmilk. It is licenced for use in children over 2 years.”
· Doxylamine/pyridoxine (Xonvea™, Cariban ™ )
This is the only licensed drug treatment for nausea and vomiting of pregnancy. It contains a combination of the antihistamine doxylamine and the vitamin pyridoxine. It became available in England in 2018. It has been widely used for pregnancy sickness in the US and Canada and studies have shown no link with birth defects in the baby. The antihistamine doxylamine might be more likely to cause drowsiness in nursling. https://www.ncbi.nlm.nih.gov/books/NBK500620/ and
https://www.e-lactancia.org/breastfeeding/doxylamine-succinate/product/. The 10mg of pyridoxine is unlikely to cause any disruption to breastfeed.
Second Line Treatments
· Metoclopramide (Maxolon™)
Metoclopramide has also been used to increase milk supply. It is associated with an increased risk of depression as well as other side effects if used long term. There are no reports of problems in the babies from the amount passing through breastmilk. https://www.ncbi.nlm.nih.gov/books/NBK501352/
Metoclopramide is a dopamine antagonist and can cause extra-pyramidal side effects, in particular acute dystonia. This adverse effect is most commonly seen in children and young adults, especially females, so it is not a drug of choice in lactating mothers who generally fall into this age group. It may also precipitate hypotension and depression. Other side effects reported include headache, diarrhoea, dry mouth and change in appetite (Ingram et al. 2011). It stimulates prolactin secretion and has been used as a galactogogue but has now been superseded by domperidone because of the latter does not cross the blood–brain barrier (Ingram et al. 2012). The bio-availability of oral metoclopramide is about 75% but varies widely between patients due to its hepatic first-pass metabolism. Concentrations higher than those in maternal plasma may be reached in breastmilk, particularly in the early puerperium, although these decrease with increased maturity. Metoclopramide has pro-kinetic and anti-emetic properties and acts directly on the gastrointestinal tract without altering acid secretion. It is more frequently used in the US where domperidone is not available. Relative infant dose is quoted as 4.7–14.3% (Hale online access). The BNF states that only a small amount is present in breastmilk but it should be avoided.
· Domperidone (Motilium™)
Domperidone has widely been used to increase milk supply in the past. Concerns were raised by the MHRA in 2014 about use in patients with heart defects, there has been some reticence by doctors to prescribe it. There are no reports of problems in the amounts passing through breastmilk
See https://www.ncbi.nlm.nih.gov/books/NBK501371/ and https://www.e-lactancia.org/breastfeeding/domperidone/product/
Domperidone acts at the chemoreceptor trigger zone. It stimulates gastric emptying. It causes fewer central effects such as sedation and dystonia (although there are still reports of these) because it does not cross the blood–brain barrier as metoclopramide does. Its dopamine antagonist activity stimulates prolactin release, which makes it useful as a galactagogue (see section on drugs to increase lactation, pages 285–288). Domperidone is metabolised by cytochrome P450 so care should be taken with potential interactions. It is more than 90% bound to plasma proteins and has a low bioavailability on an empty stomach (15%) when taking orally due to first-pass hepatic and intestinal metabolism. Mean serum levels of domperidone measured in babies through maternal use of 10 mg three times daily was only 1.2 ng per millilitre. The total amount of the drug that would be ingested by the infant (Da Silva et al. 2001) would be extremely small (about 180 ng per kilogramme daily, assuming a daily milk intake of 150 ml per kilogramme). Relative infant dose quoted as 0.01– 0.04% (Hale 2017 online access). The BNF states that the amount secreted into breastmilk is probably too small to be harmful.
· Ondansetron (Zofran™)
This is an anti-emetic originally used to treat people who have severe sickness when being treated with chemotherapy for cancer. Ondansetron is frequently used for nausea during and after caesarean section, usually in doses of 4 to 8 mg intravenously. Use during and after caesarean section appears to not affect the onset of breastfeeding. No adverse infant effects have been reported or among women who received ondansetron postpartum in a pharmacokinetic study. Use of ondansetron in nursing mothers beyond the immediate postpartum setting has not been studied well, but the drug is licensed for use in infants as young as 1 month of age. See https://www.ncbi.nlm.nih.gov/books/NBK500798/ and https://www.e-lactancia.org/breastfeeding/ondansetron/product/
This drug is a 5-HT3 antagonist with antiemetic activity. It is also for the prevention and treatment of post-operative nausea and vomiting that have not responded to other antiemetic agents. Ondansetron may also be used for nausea in pregnancy. It is licenced for use in children It is 60% orally bio-available and 70–75% plasma protein bound. The terminal half-life is three hours after oral doses. There are no studies on transfer into breastmilk although it has been found in animal studies (BNF).
A large, well-designed study found that the vast majority of babies exposed to ondansetron in the womb (at least 998 out of every 1,000) are born without cleft lip and/or palate Ondansetron https://www.medicinesinpregnancy.org/leaflets-a-z/ondansetron/
Third Line
Corticosteroids
Corticosteroids are sometimes prescribed for women with hyperemesis gravidarum that has not responded to other treatments including rehydration together with anti-emetics. There is no strong evidence that use of corticosteroids in early pregnancy increases the chance of cleft lip and palate or heart defects in the baby. Use in pregnancy also does not appear to increase the chance of the baby having a low birth weight. Some studies have shown that pregnant women taking corticosteroids have a higher chance of preterm delivery. However, it is thought that this is likely caused by the underlying illnesses that steroids are commonly used to treat rather than a direct effect of steroids themselves. https://www.medicinesinpregnancy.org/Medicine–pregnancy/Corticosteroids—systemic/
Pregnancy Sickness Support in the UK found that many women seeking terminations in desperation had not been offered the full range of treatments available and fewer than 10% had been offered steroids
Other non-medical treatments
· Ginger
The conclusion from 6 randomised controlled trials with a total of 675 participants was that ginger extract at 1000 mgs per day may be effective treatment for NVP. However , the small number of patients in these studies allocated to receive ginger (n=303) may have been insufficient to properly test the safety of ginger with regards to pregnancy outcome. ( Viljoen, E., Visser, J., Koen, N. et al. A systematic review and meta-analysis of the effect and safety of ginger in the treatment of pregnancy-associated nausea and vomiting. Nutr J 13, 20 (2014).) The authors found that Ginger did not significantly reduce the number of vomiting episodes during NVP, when compared to placebo, although there was a trend towards improvement. Many mothers have reported feeling angry and frustrated that this is recommended so frequently but that they found it caused side effects as well as not being effective. It is definitely not the answer to all NVP!
· Acupressure
Stimulation of the acupressure point, located three fingers breadth above the wrist, has been used for many years to treat nausea from a variety of causes. Mohd Nafiah et al (2022) concluded that the use of acupressure wristbands at the P6 point was also able to decrease the frequency of antiemetics and increase the rate of urine ketone clearance. The implication of the trial was the reported as the existence of an effective adjunct to alleviate the severity of nausea and vomiting in pregnant women with hyperemesis gravidarum, thereby improving their quality of life. There are no concerns about the safety of acupressure in pregnancy ( Mohd Nafiah, N.A.; Chieng, W.K.; Zainuddin, A.A.; Chew, K.T.; Kalok, A.; Abu, M.A.; Ng, B.K.; Mohamed Ismail, N.A.; Nur Azurah, A.G. Effect of Acupressure at P6 on Nausea and Vomiting in Women with Hyperemesis Gravidarum: A Randomized Controlled Trial. Int. J. Environ. Res. Public Health 2022, 19, 10886.)
Conclusion
We should not underestimate how NVP and HG affect pregnant women. We should listen to how they are feeling and ask how we can help. Untreated symptoms can lead to lifetime mental health issues.
“I had morning sickness (not hyperemesis). The first 4 months I went from bed to the sofa, my husband did everything. I couldn’t look at food, walk into the kitchen to get a drink etc. I wasn’t physically that sick but the nausea was absolutely horrendous. Constantly, nothing stopping it, the minute I woke to the second I fell asleep for 4 months. I lost 6kg by my first scan. Although it got better I still felt slightly sick through the whole pregnancy. I was refused anti nausea meds by multiple doctors, even the midwife shrugged it off. The effect it has had on me even now (my daughter is 2.5) is horrible. I still can’t eat certain foods, put too much food in my mouth and the slightest nausea (which I get often due to anxiety, migraines etc) sends me into complete panic.”
“What would you like professionals to understand? The struggle and how debilitating it is.”
“Medically, only one doctor seemed to have any awareness of what I was suffering from. Others told me “I’d be better in a couple of weeks” every two weeks.”
Resources
Pregnancy Sickness Support https://www.pregnancysicknesssupport.org.uk/
RCOG Green Top Guidelines https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/the-management-of-nausea-and-vomiting-of-pregnancy-and-hyperemesis-gravidarum-green-top-guideline-no-69/
UKTIS Medicines in Pregnancy https://www.medicinesinpregnancy.org/About-Us/

Bowel cleansing before colonoscopy and breastfeeding
Just recently I have been contacted by several mothers who were told that they cant breastfeeding during the 24 hour period of bowel prep prior to a colonoscopy or for 24 hours following the procedure under sedation. This is not supported by research and understanding of the pharmacokinetics of the drugs used. It is also a potential risk in that the mother may develop blocked ducts or mastitis necessitating antibiotics if she is unable to express her milk, or in many cases hasn’t been advised to! Not all babies will drink from a bottle so may become dehydrated. Some babies are allergic to cow’s milk protein and may be compromised by 3 days of artificial formula. Hence this fact sheet on the bowel preparations generally used.
It is acceptable to breastfeed as normal during bowel prep. The mother should drink freely of the allowed clear fluids. Someone may be needed to look after the baby during rapid need to evacuate bowels – unless you have taken these products you cant begin to understand the urgency!
PDF of information available
https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/08/Moviprep-and-breastfeeding-1.pdf
An increasing number of breastfeeding mothers are having colonoscopies to investigate gut problems. The first stage of a colonoscopy is the use of a strong laxative and 24 hours of a fluid only diet to clear out the gut so that the professionals can see the gut in its entirety completely.
Many mothers worry that not eating for 24 hours will reduce their milk supply. Fasting does drop the supply a small amount for some women but frequent feeds seem to overcome problems. It is important to keep drinking the clear fluids which are allowed in order not to dehydrate.
From experience you may find that you need someone else in the house to take the baby urgently when you have to rush to the toilet – there is no waiting! You may find otherwise that you end up feeding whilst on the loo for practical reasons. The bowel washouts produce considerable urgency
Movicol®
One of the most commonly used laxative agents to clear the gut is Movicol ® otherwise known as polyethylene glycol- electrolyte solution. It is a saline laxative which is not absorbed from the gut but pulls 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. The movicol website says that it can be used during pregnancy and breastfeeding. https://www.movicol.co.uk/
MoviPrep®
This dual sachet product contains macrogol and electrolytes in 2 different sachets, Because it is not absorbed from the gut it cannot get into breastmilk and would not affect the baby.
Plenvu ®
This powder contains macrogol and electrolytes in sachets, Because it is not absorbed from the gut it cannot get into breastmilk and would not affect the baby.
Picolax®
Sodium picosulfate is not absorbed from the gastrointestinal tract, and its active metabolite, which is absorbed, is not detectable in breastmilk. Breastfeeding can continue as normal.
KleanPrep ®
KleanPrep contains macrogol 3350 , an osmotic laxative with a high molecular weigh and zero oral bioavailabilty. 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.
Citramag®
The ingredients magnesium carbonate and citric acid will form an osmotic laxative by pulling water into the bowel and stimulating the bowel to evacuate. Poor oral absorption of magnesium make it unlikely that any will be absorbed from milk to affect the breastfed baby.
Senna
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.
Werthmann MW Jr, Krees SV. Quantitative excretion of Senokot in human breast milk. Med Ann Dist Columbia. 1973;42:4-5.
Shelton MG. Standardized senna in the management of constipation in the puerperium. A clinical trial. S Afr Med J. 1980;57:78-80.
Phosphate enema (Fleet®)
Sodium phosphate 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 bioavailabilty is zero to 20%. Use of phosphate enemas should not require interruption of breastfeeding (LactMed)
Bisacodyl (Dulcolax ®)
Bisacodyl is poorly absorbed from the gut (oral bioavailabilty <5%) and so reaches low levels in breastmilk. It is a stimulant laxative. Breastfeeding can continue as normal
For information on sedatives (midazolam, fentanyl, pethidine) used in colonoscopies see separate fact sheet . These also do not preclude normal breastfeeding as soon as the mother is awake and alert.

Constipation, laxatives and breastfeeding
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
Movicol now says that it can be used during pregnancy and breastfeeding! https://www.movicol.co.uk/
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.


Levonorgestrel as emergency hormonal contraception (morning after pill) and breastfeeding
Levonelle™ (levonorgestrel), when originally marketed was licensed to be given to women during breastfeeding. However, the patient information leaflet in the packet now suggests that women should not breastfeed for 8 hours. This is not supported by research and breastfeeding can continue as normal.
The tablet should be taken as soon as possible after unprotected intercourse – up to 72 hours after. The longer the interval between intercourse and taking the tablet the greater is the chance that it will not be effective. No contraception has a 100% success rate. If vomiting occurs soon after taking the tablet medical advice should be sought as soon as possible.
The next period may be early or late and barrier contraception should be continued until the next period. Levonorgestrel can be purchased over the counter from a pharmacist as well as being prescribed by a GP, pharmacies, family planning clinic or accident and emergency departments.
Should the next period be delayed more than 5 days further medical advice should be sought. Levonelle™ is reported by the manufacturers not to show evidence of teratogenicity even if it fails to prevent pregnancy. However emergency hormonal contraception should not be used if there is any possibility that the woman is already pregnant.
In a cohort study of 71 women who took levonorgestrel as a postcoital contraceptive no obvious decrease in milk supply was found after the drug was used according to maternal reports. 75% of mothers re-initiated breastfeeding before 8 hours after the dose. None noticed any adverse effect in their infants (Polakow-Farkash 2013). One study demonstrated that levonorgestrel passes into breastmilk but in minimal quantities (Jatlaoui 2016). Polakow-Farkash reports that the study findings support the safety of using levonorgestrel as an emergency contraceptive during lactation without the need for withholding breastfeeding.
The recommendation to avoid breastfeeding for 8 hours comes from a study by Gainer (2007) where 12 exclusively breastfeeding mothers received a single 1.5 mg dose. Levonorgestrel concentrations were found to peak in milk 2-4 hours after the dose was taken. Milk/plasma ratios averaged 0.28. The estimated infant dose of levonorgestrel was only 1.6 µg during the first 24 hours. If the mother interrupts breastfeeding for 8 hours, this dose was reduced to only 1 µg. The authors recommended that to limit exposure, the mother should not breastfeed for the first 8 hours, or at most 24 hours. However, the amount in milk after 24 hours was only 0.09% of the total dose which is insignificant.
For other options of emergency contraception
A copper intra-uterine contraceptive can be inserted up to 5 days after intercourse as an alternative method of emergency contraception.
Women who do not wish to expose their baby to any medication may wish to consider how frequently they are breastfeeding and therefore the likelihood of ovulation. Factors which can be taken into consideration are whether she is still exclusively breastfeeding or has introduced solids or complimentary feeds which make it more likely that she is ovulating. She and her partner also need to consider the consequences of a subsequent pregnancy for them.
References
Hale TW and Krutsch K. Medications and Mothers Milk
Jatlaoui, Tara C. Riley H,. Curtis KM 2016 Contraception ,2016;93(2): 93 – 112Safety data for levonorgestrel, ulipristal acetate and Yuzpe regimens for emergency contraception
Polakow-Farkash S, Gilad O, Merlob P et al. Levonorgestrel used for emergency contraception during lactation-A prospective observational cohort study on maternal and infant safety. J Matern Fetal Neonatal Med. 2013;26:219
World Health Organization . Medical Eligibility Criteria For Contraceptive Use: Fifth Ed. 2015. www.who.int/reproductivehealth/publications/family_planning/MEC-5/en/
Gainer E, Massai R, Lillo S, Reyes V, Forcelledo ML, Caviedes R, Villarroel C, Bouyer J. Levonorgestrel pharmacokinetics in plasma and milk of lactating women who take 1.5 mg for emergency contraception. Hum Reprod 2007; 22(6):1578-1584.Highlight
E lactancia https://e-lactancia.org/breastfeeding/levonorgestrel-emergency-contraceptive/product/
SPS https://www.sps.nhs.uk/articles/levonorgestrel-1500-microgram-tablets-for-emergency-contraception/

Lactose in medication and lactose intolerance
Over the years I have had many questions from mothers about the lactose content of their medication and how this might affect their CMPA babies by passage through breastmilk.
If a breastfeeding mother is taking a tablet which contains lactose it is unlikely to affect the levels of lactose in her milk and therefore produce symptoms in her baby.
Lactose intolerance is very different to CMPA. Lactose is the sugar in breastmilk which varies little with maternal consumption. Lactose intolerance is usually identified soon after birth with failure to thrive (Savilahti).
Lactose intolerance occurs when a person does not produce the enzyme lactase, or does not produce enough of it, and is therefore unable to digest lactose. If it is not digested and broken down, lactose cannot be absorbed. The undigested lactose passes rapidly through the gut until it is broken down by bacteria, producing gastric pain, bloating and diarrhoea.
See https://www.breastfeedingnetwork.org.uk/factsheet/lactose-intolerance-and-breastfeeding/
The production of lactase decreases in most humans from the age of two years although symptoms of intolerance are rare before the age of six. Lactose intolerance in adults is very common. This is probably a throwback to early dietary consumption in pre-historic humans. Production of lactase also varies between cultures. It is most common in people of African, Asian, Hispanic and American Indian descent. One article I found suggests that 100% of the residents of Ghana, Malawi, South Korea, and Yemen are believed to be lactose intolerant.
CMPA is due to an allergy to the protein in dairy products (not the same as the sugar). Cows’ Milk Protein Allergy (CMPA) and Breastfeeding – The Breastfeeding Network
Savilahti et al identified only 16 cases of congenital lactase deficiency over 17 years despite the fact that the gene for lactose intolerance is very common in Finland. In each case the mother reported watery diarrhoea usually after the first breastfeed but up to 10 days after birth. Poor absorption of lactose was confirmed between 3 and 90 days after delivery at which time all infants were dehydrated and 15 of the 16 weighed less than at birth. On a lactose feed diet the children all caught up with their growth.
Temporary lactose intolerance
Some premature babies are temporarily lactose intolerant due to their immaturity. Babies may also show temporary secondary lactose intolerance following exposure to maternal antibiotics passing through breastmilk. There is no need to alter feeding or add probiotics as all factors to restore the gut are in breastmilk. It is self-limiting.
Lactose in maternal medication
So, if a breastfeeding mother is taking a tablet which contains lactose it is unlikely to affect the levels of lactose in her milk and therefore produce symptoms in her baby.
SPS also provided information on the absorption of lactose from medication in January 2024. https://www.sps.nhs.uk/articles/assessing-the-clinical-impact-of-lactose-in-medicines/
“Lactose in medicines
Lactose is widely used as an excipient in pharmaceutical manufacturing. Although anecdotal reports of drug-induced lactose intolerance exist, when used as an excipient the lactose content in most medicines is too small to cause problems. Daily lactose exposure from medicines is unlikely to exceed 2g per day. Whereas the threshold for lactose intolerance symptoms is approximately 12g (equivalent to 250ml of milk). Therefore, it is unlikely that severe gastrointestinal (GI) symptoms will be due to lactose in medicines, especially in adults without a diagnosis of severe intolerance. “
References
- Anderson J Lactose intolerance and the breastfed baby. www.breastfeeding.asn.au/bf-info/lactose
- BfN Lactose intolerance and Breastfeeding https://www.breastfeedingnetwork.org.uk/factsheet/lactose-intolerance-and-breastfeeding/
- Jones W Breastfeeding and Medication Routledge 2018
- Savilahti E, Launiala K, Kuitunen P. Congenital lactase deficiency. A clinical study on 16 patients. Arch Dis Child 1983;58:246-252
- Shulman R, Feste A, Ou C (1995). Absorption of lactose, glucose polymers or combination in premature infants. Journal of Pediatrics, 127, 626-631.
- SPS Assessing the clinical impact of lactose in medicines https://www.sps.nhs.uk/articles/assessing-the-clinical-impact-of-lactose-in-medicines/
Tirzepatide (Mounjaro™) and Breastfeeding
Tirzepatide is a long-acting GIP (glucose-dependent insulinotropic polypeptide) receptor and GLP-1 (glucagon-like peptide-1) receptor agonist that increases insulin sensitivity and secretion, suppresses glucagon secretion, and slows gastric emptying.
Tirzepatide is used to treat Type 2 diabetes mellitus as monotherapy (if metformin is inappropriate), or in combination with other antidiabetic drugs (including insulin) if existing treatment fails to achieve adequate glycaemic control. It is also used in the treatment of obesity by weekly subcutaneous administration.
No information is available on the clinical use of tirzepatide during breastfeeding. Because tirzepatide is a large peptide molecule with a molecular weight of 4814 Da, the amount in milk is likely to be low and absorption is unlikely because it is probably partially destroyed in the infant’s gastrointestinal tract. Until more data become available, tirzepatide should be used with caution during breastfeeding, especially while nursing a newborn or preterm infant. (LactMed).
Due to its protein nature, it is inactivated in the gastrointestinal tract and is not absorbed (oral bioavailability is practically nil), which makes it difficult or impossible for it to pass into the infant’s plasma from ingested breast milk, except in premature infants and in the immediate neonatal period, where there may be greater intestinal permeability. (E-lactancia).
While caution is still necessary without confirmatory data, it is unlikely to be present in large quantities in the milk compartment (Hale )
See also https://www.infantrisk.com/content/weight-loss-lactation
https://www.springerpub.com/blog/weight-loss-drugs-breastfeeding
Hale and Krutsch (Infantrisk pharmacists express concern on the use of weight loss medications and breastfeeding due to inadequate consumption of nutrients.
“Concerns have been expressed about how the pharmacodynamics of GLP-1 agonists such as tirzepatide or semaglutide could impact the nutritional constituents of milk. These drugs are analogs of natural GLP-1 with small modifications to slow their degradation by the DPP-4 enzyme. However, lactation, in general, is expected to occur during a catabolic physiological state – GLP-1 agonists catalyze the catabolism to encourage weight loss. As long as the mother has sufficient weight to lose, the nutrient profile of milk would likely be similar if compared to a diet producing equivalent weight loss. If a mother is reducing caloric intake for any reason, we recommend a postnatal vitamin and attention to consuming enough calories to meet the elevated nutrient needs required during lactation”.
Other sources of information
NICE TA 1026 Tirzepatide for managing overweight and obesity . https://www.nice.org.uk/guidance/ta1026
See also Semaglutide and Breastfeeding https://breastfeeding-and-medication.co.uk/fact-sheet/semaglutide-and-breastfeeding
Liraglutide and Breastfeeding https://breastfeeding-and-medication.co.uk/fact-sheet/liraglutide-saxenda-and-breastfeeding
ADHD and Breastfeeding
I have shared the chapter on ADHD from my book Breastfeeding and Chronic Medical Conditions multiple times this week. Many mothers seem to be diagnosed in later life and are concerned about breastfeeding. Hope this is a useful link.
More information
ADHD and Breastfeeding Factsheet
If this is useful maybe you need the book available on Amazon. I published on Kindle to try to make this more affordable and available to mothers and breastfeeding supporters as well as professionals
https://infantrisk.com/content/adhd-medications-and-breastfeeding
I came off my medication to conceive and my baby is now 6 months old. I am really struggling to think straight now and getting really overwhelmed by the smallest of things.
Description
ADHD is a disorder that includes symptoms such as inattentiveness, hyperactivity, and impulsiveness. It is normally diagnosed in childhood, but some parents have found themselves being diagnosed when seeking a diagnosis for their children. The cause is unknown, but it seems to at least in part, genetic. It has been suggested that being born prematurely (before the 37th week of pregnancy), having a low birth weight or maternal smoking or alcohol or drug abuse during pregnancy may be linked. Attention deficit hyperactivity disorder (ADHD) is thought to affect about 1 in 20 children in the UK with incidence being three times higher in boys.
Symptoms fall into 2 categories:
inattentiveness main symptoms of which are:
- having a short attention span and being easily distracted
- making careless mistakes
- appearing forgetful or losing things
- being unable to stick to tasks that are tedious
- appearing to be unable to listen to or carry out instructions
- constantly changing activity or task
- having difficulty organising tasks
hyperactivity and impulsiveness main symptoms of which are:
- being unable to sit still and constantly fidgeting
- being unable to concentrate on tasks
- excessive physical movement
- excessive talking
- being unable to wait turn
- acting without thinking
- interrupting conversations
- little or no sense of danger
- ADHD may be linked with anxiety, autism, and several other conditions. By the age of 25, an estimated 15% of people diagnosed with ADHD as children still have a full range of symptoms, and 65% still have some symptoms that affect their daily lives. ( https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/symptoms/)
Treatment
- Methylphenidate (Ritalin ™, Concerta ™); works by increasing the amount of a dopamine in the parts of the brain responsible for self-control and attention. It is usually the first line treatment. There are side effects of loss of appetite and difficulty sleeping and mood swings. Limited evidence indicates that methylphenidate levels in milk are very low and not detectable in infant serum. The effects of methylphenidate in milk on the neurological development of the infant have not been well studied. Monitor the baby for agitation, irritability, poor sleeping patterns, changes in feeding and poor weight gain.
- Atomexatine is a selective noradrenaline reuptake inhibitor (SNRI), increasing levels of noradrenaline rather than dopamine. It can aid concentration and help control impulses. Side effects include rise in blood pressure and heart rate, nausea and vomiting, gastric pain, difficulty sleeping, dizziness, headaches, and irritability. More importantly it has been associated with suicidal thoughts and liver damage. There is no published experience with atomoxetine during breastfeeding, although reports from the manufacturer found no serious adverse effects in two breastfed infants (Besag 2014).
- Dexamphetamine. Side effects include decreased appetite, mood swings, agitation and aggression, dizziness, headaches, nausea, vomiting and diarrhoea. Only used if lisdexamphetamine is helpful but not tolerated. In dosages prescribed for medical indications, some evidence indicates that dextroamphetamine might not affect nursing infants adversely. The effect of dextroamphetamine in milk on the neurological development of the infant has not been well studied. It is possible that large dosages of dextroamphetamine might interfere with milk production. Infant Monitoring for agitation, hyperactivity, insomnia, decreased appetite, weight gain, and tremor.
- Lisdexamphetamine (Vyvance ™) may be offered as first line treatment in adults. Side effects include decreased appetite, aggression or drowsiness, dizziness, headaches, nausea, vomiting and diarrhoea. Lisdexamfetamine is a prodrug of dextroamphetamine. In medicinal dosages, some evidence (5 mothers studied) indicates that dextroamphetamine might not affect nursing infants adversely. The effect of dextroamphetamine in milk on the neurological development of the infant has not been well studied. Infant Monitoring should be for agitation, irritability, poor sleeping patterns and poor weight gain.
- The NHS website suggests that for adults with ADHD if you find it hard to stay organised, then make lists, keep diaries, stick up reminders and set aside some time to plan what you need to do
- let off steam by exercising regularly
- find ways to help you relax, such as listening to music or learning relaxation techniques
- if you have a job, speak to your employer about your condition, and discuss anything they can do to help you work better
- talk to your doctor about your suitability to drive, as you will need to tell the Driver and Vehicle Licensing Agency (DVLA) if your ADHD affects your driving
- contact or join a local or national support group – these organisations can put you in touch with other people in a similar situation, and can be a good source of support, information, and advice
References
- Attention deficit hyperactivity disorder: diagnosis and management; NICE guideline (March 2018, updated September 2019)
- Attention deficit hyperactivity disorder; NICE CKS, May 2018
- Besag FM. ADHD treatment and pregnancy. Drug Saf. 2014; 37:397-40
- NHS ADHD https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/living-with/
- Further Information
- AADUK https://aadduk.org/
Can women with ADHD stay on medication while they breastfeed?
Anecdotally there are many mothers who take medication for ADHD during their breastfeeding journey despite a lack of published studies on the effect of the level of medication passing through breastmilk to babies. It is a topic regularly raised on social media discussions from which many parents take their information. Since the pandemic the increase in diagnoses of adults has driven the discussions too.
As with many drugs we rely on the pharmacokinetics of the products: that is the way that the drugs are handled by the body. Drugs used to treat ADHD are not recommended during breastfeeding as the manufacturers are not required to take responsibility as they cannot ethically conduct clinical trials during the development of the medication. This is true of virtually all products used by breastfeeding women – they are used outside of the product licence and prescribed with the professionals being required to take responsibility.
For example methylphenidate (Concerta™ and Ritalin™) was studied in 3 women taking between 35 and 80mg daily. The average milk levels measured were very low. The infants had no drug-related adverse reactions and were developing normally for their ages which averaged 4.4 months. No adverse events have been identified according to specialist sources although it would be wise to monitor changes in sleep patters and feeding including weight gain.
What ones are safest?
It is difficult to say which one is “safest” as this is a relative term. No drug is absolutely safe, but all of the drugs used to treat ADHD are recognised as compatible with breastfeeding by expert, specialist sources. The drug which would generally be chosen is the one that has proven to be most effective for the mother. Methylphenidate could perhaps be said to have the best evidence but as has already been discussed, the data published is limited. The decision to prescribe should be agreed between the mother and her professionals with full, accessible information so that she can make an informed choice in the risks and benefits for her and her nursling. Ongoing breastfeeding has many health advantages but if the mother has concerns about exposing her child to the medication (in however low a level) that may influence her choice as to whether to take the drug and continue to breastfeed, breastfeed but delay the drug or take the medication and choose to formula feed. We all have individual feelings as to the risks and benefits of each choice.
Is there a risk to the baby at all?
In the first 6 weeks after birth a baby has immature kidney and liver function and is at greater risk of not being able to metabolise the levels of drug passing through breastmilk. This in turn makes it more likely that side effects such as changes in sleep and feeding patters may occur but are difficult to identify from normal neonatal behaviour.
Individual reactions are always possible although reporting in specialist expert sources suggest these are limited.
Is it advised to stay on rather than coping without it?
That is very much an individual decision depending on how well the mother is coping with her symptoms alongside the complexity of life with a newborn which will all be associated with loss of routine and long periods sitting to breastfeed. Most mothers stop medication during pregnancy and may be desperate to re start. A fully informed discussion with appropriate, accessible data puts the decision with the mother on what she feels comfortable with.
Specialist sources of information
https://www.ncbi.nlm.nih.gov/books/NBK501922
https://www.sps.nhs.uk/articles/safety-in-lactation-drugs-for-adhd
