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Breastfeeding and Oestrogen cream or pessary

Oestrogen creams and pessaries seem to be prescribed with increasing frequency to breastfeeding women to help with healing of sutures, prolapses or for ongoing vaginal dryness. There is little research evidence to guide a discussion of compatibility with breastfeeding.

Breastfeeding does seem to have an effect on natural vaginal lubrication for some and basics products such as KY Jelly®, Replens®, Sylk® and other products may help.

But for others oestrogen creams may be prescribed by the GP or an obs and gynae consultant.

It is known that vaginal absorption of oestrogen results in measurable amounts in milk (LactMed, Hale).

In Nielson’s study 6 lactating mothers were given vaginal suppositories (pessaries) containing 50 or 100 mcg of oestradiol. Levels of oestradiol were measurable in milk whilst before application of the pessaries the levels was below that of detection. According to Nielson a ratio of transfer of estradiol from plasma to milk during physiologic conditions is calculated to be less than 100:10. Peak levels were found in milk between 3 and 11 hours after application but was inconsistent and irrelevant with ongoing use. Outcome data is not given in the data that I have been able to access.

Nilsson S, Nygren KG, Johansson ED. Transfer of estradiol to human milk. Am J Obstet Gynecol. 1978;132:653-7.

Hale says vaginal absorption is greater than oral and quotes Chollet who studied atrophic vaginitis in post menopausal women. It is unclear what relevance this has to brestfeeding

Chollett J. A., G. Carter, et al. (2009). “Efficacy and safety of vaginal estriol and progesterone in postmenopausal women with atrophic vaginitis.” Menopause 16(5): 978-983.

Levels of oestradiol in the 2 most commonly used products are:

Ovestin – One applicator-dose contains 0.5 mg estriol.

Vagifem contains 10 mcg estradiol per vaginal tablet

neither product is licensed to be used in lactation.

Anecdotally some mothers have reported that their supply has dropped but by no means everyone.

Hypertension (raised blood pressure) and Breastfeeding

Many mothers experience raised blood pressure it seems. Is this due to our busy lifestyles, more mums giving birth at an older age? Who knows but it causes a lot of confusion. The drug normally initiated if a mother has symptoms of pre-eclampsia is labetolol. It is usually continued after delivery until the BP has settled. Virtually none passes into breastmilk. However, some mothers with poor circulation may notice sore, white nipples where the supply to the tip is decreased . If this happens the drug may need to be changed. Prolonged high BP in pregnancy can lead to restricted growth of the baby who may be born sleepy. Rather than just monitoring blood glucose levels the baby should be helped to attach to the breast and feed regularly or be given colostrum by spoon or syringe. A drop of colostrum can work magic.

Later blood pressure rises can be treated with enalapril, amlodipine and felodipine which are all compatible with breastfeeding according to expert sources. The NICE Guidelines NG 133 (2019) can also guide good practice.

The data for this fact sheet is taken from my book Breastfeeding and Medication which provides more detail and references to studies. Please consider buying a copy for future reference.

Hypertension and breastfeeding factsheet

Breastfeeding after VQ scans

One of the questions that frustrates me is “Can I continue to breastfeed immediately after a VQ scan, they think I may have a clot on my lungs? I’ve been told I have to stop feeding for 12 hours”. Most of these mothers have very young babies – often under 2 weeks so to dump that precious milk for 12 hours is really tough. There hasnt been enough time to build up expressed milk so necessitates the use of formula and a very premature end, against mum’s wishes usually, to exclusive breastfeeding.

The evidence is really hard to find. One option is to request a CT scan after which breastfeeding can continue as normal. The #dontsaystoplookitup poster refers just to CT and MRI scans and not to VQ scans

This information is from my book “Why Mother’s Medication Matters”

Breastfeeding and VQ scan

Timing of breastfeeds if taking medication

I’ve recently had several emails/ Facebook messages that mothers have been advised to pump and dump their breastmilk for a period of time after taking medication in order to minimise / prevent exposure of the baby to the drug. This has often been undertaken when the drug is compatible with breastfeeding and resulted in the unnecessary exposure of the baby to formula milk.

For most drugs taken for more than 3 days the amount in milk is constant across 24 hours. So timing feeds with respect to breastfeeding or dumping of the breastmilk is pointless. The half life of a drug is very important but just one of the factors in determining the compatability with normal breastfeeding. If you want to know more please consider buying “Breastfeeding and Medication”

Timing of medication and breastfeeds

Pain relief after birth and breastfeeding

I was recently asked for input in a guideline on pain relief for new mothers after birth. I was surprised to see it almost seemed to penalise breastfeeding mothers suggesting that if you are breastfeeding you cant have effective pain relief for more than 3 days even if you have had a c section. With a new grandchild due in June I decided to put together this information. It includes pain relief, laxatives, haemorrhoidal treatment and iron supplements

Pain relief after birth

Codeine and breastfeeding

Botox and Fillers and Breastfeeding

From my aged viewpoint having botox and fillers whilst breastfeeding feels odd. It would never have occurred to me but I’m trying not to sound old fashioned!

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.

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.

Both these cosmetic procedures have to be undertaken with this limited information in mind. It is your choice and I am not making any recommendations.

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.

Breastfeeding and multivitamin and mineral supplements

Breastfeeding specific multi vitamin supplements are expensive and many mothers want to purchase standard multivitamin and mineral supplements. The standard products such as Sanatogen and Centrium are suitable for use. It is important not to take products which claim to be high dose and where the recommended daily amount is reported as in excess of 100% on the label.

The only vitamins needed by breastfeeding mothers are vitamin d 10 mcg/day and folic acid 400mcg/day if no active contraception is being used. Normal diets should provide everything your body needs. Remember babies need vitamin d supplements too according to UK recommendations https://breastfeedingnetwork.org.uk/wp-content/dibm/vitamin%20D%20and%20breastfeeding.pdf

However, we do know that as a new mum finding time to eat properly can be a challenge and a multivitamin is a safety net.

AVOID dose of vitamin A above 700 mcg/day and vitamin B6 above 20-50 mcg/day. Iodine can concentrate in breastmilk so do not take levels in excess of 100% RDA.

Omega fatty acids are safe in breastfeeding

Accidental dose of codeine when breastfeeding

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

Anti epilepsy medication and breastfeeding

A brief introduction to the information on the safety of anti epilepsy medication during breastfeeding. It does not include full information but you can find more in my book or by emailing me.

There is no reason why women who have taken anti-epileptic medication throughout their pregnancy should not be encouraged to breastfeed their baby (Veiby 2013). However, women should be counselled on the signs of risk to be aware of, in particular excessive somnolence and poor weight gain. The risks increase with multiple drug regimens.

Epilepsy and breastfeeding

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!

Bowel prep and breastfeeding factsheet

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