Especially since the pandemic many more mothers have been asking about the compatibility of citalopram during breastfeeding. It has been a hard time for everyone with the incidence of anxiety and depression continuing to rise. As access to IAPT ( https://www.england.nhs.uk/mental-health/adults/iapt/) may be more difficult the prescription of medication is inevitable. Alternative CBT access may be available on line via and IESO (https://www.iesohealth.com/en-gb)

Citalopram is widely used and we have a high level of experience with it over many years. It is the drug of choice if it has been used by the mother in the past.

Unfortunately many doctors are, in my experience, still recommending that mothers should stop breastfeeding in order to take antidepressants. This may be that they think life would be easier if someone else could help with care of the baby or that the mother may get more sleep. Sadly, this doesnt always happen and the loss of oxytocin may also lower mood further.

There is often an assumption that pressure to breastfeed can lead to depression but in my experience pressure to stop breastfeeding in order to take medication may increase depression and may also stop mothers accessing professional help to avoid having that discussion.

This link to the RCGP perinatal mental health toolkit may be useful for professionals and parents

RCGP perinatal mental health toolkit

https://elearning.rcgp.org.uk/mod/book/view.php?id=13115

This factsheet contains information from my book Breastfeeding and Medication. Please message me for references used or with any questions.

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

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

https://bnf.nice.org.uk/drugs/citalopram/#breast-feeding

“Specialist sources indicate that sertraline and paroxetine are the SSRIs of choice in breast-feeding based on passage into milk, half-life, and published evidence of safety. However, all SSRIs can be used in breast-feeding with caution, and since there are risks with switching an SSRI, it may be more clinically appropriate to continue treatment with an SSRI that has been effective, or restart treatment with an SSRI that has previously been effective. With all SSRIs, infants should be monitored for drowsiness, poor feeding, adequate weight gain, gastro-intestinal disturbances, irritability, and restlessness.”

https://www.ncbi.nlm.nih.gov/books/NBK501185/

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

citalopram and breastfeeding factsheet pdf

Citalopram  is widely used by breastfeeding mothers.

It has a lower plasma protein binding than sertraline – less than 80% and the metabolite enters breastmilk in low levels. The manufacturer anecdotally reported cases of excessive somnolence, decreased feeding and weight loss in breastfed infants (Hale). However, more recent research suggests that symptoms are minimal and may not be associated with the use of this drug in lactation

There is one report of an infant exhibiting ‘uneasy’ sleep patterns on a maternal dose of 40 mg per day (Schmidt et al. 2000) that resolved when the mother’s dose was reduced and partial substitution with artificial formula undertaken.

Spigsett et al. (1997) studied two patients and estimated the absolute dose to the infant during steady-state conditions would be 0.7–5.9% of the weight-adjusted maternal dose.

Berle’s study (2004) of 25 women taking SSRI antidreprssants (nine taking citalopram) reported that  no adverse effects on the babies were noted. The infant serum levels of citalopram were undetectable in four infants and low in the remaining six.

Lee et al. (2004) conducted a prospective, observational study of 31 mothers suffering from depression and taking citalopram with 12 mothers with depression but not taking citalopram and 31 healthy control women and babies. Mothers were taking up to 60 mg citalopram daily. There were numerically more reports of adverse events in the trial group 3 per 31 (depressed and taking citalopram group) compared with 1 per 31 (control group) and 0 per 12 (depressed but not taking citalopram group) but this was not a statistically significant difference. Infants of the mothers in the group exposed to citalopram reported colic, decreased feeding and irritability.

Heikkinen et al. (2002) studied 11 mother and baby pairs with matched controls, for up to 2 months after delivery. The neurodevelopment of the children was monitored for up to 1 year. The levels in infant plasma were very low or undetectable. The delivery outcomes and development were normal. Relative infant dose quoted as 3.6% (Hale).

References

• Berle JØ, Steen VM, Aamo TO, Breilid H, Zahlsen K, Spigset O, Breastfeeding during maternal anti-depressant treatment with serotonin reuptake inhibitors: infant exposure, clinical symptoms, and cytochrome P450 genotypes, J Clin Psychiatry, 2004;65:122834.
• Heikkinen T, Ekblad U, Kero P, Ekblad S, Laine K, Citalopram in pregnancy and lactation, Clin Pharmacol Ther, 2002;72: 184–91
• Lee A, Woo J, Ito S, Frequency of infant adverse events that are associated with citalopram use during breastfeeding, Am J Obstet Gynecol, 2004;190(1):21821.
• Schmidt K, Oleson OV, Jensen PN, Citalopram and breastfeeding: serum concentration and side effects in the infant, Biol Psychiatry, 2000;47:1645.
• Spigset O, Carieborg L, Ohman R, Norstrom A, Excretion of citalopram in breastmilk, Br J Clin Pharmacol, 1997;44(3):2958.

My book “Breastfeeding and chronic medical conditions” contains chapters on anxiety and depression

wendy@breastfeeding-and-medication.co.uk

I have recently written an article for ELACTA on a subject that causes so many problems. Just this week I received this question ” I have a 30 week prem baby, I didnt want to braestfeed so they gave me a single dose of cabergoline and the baby is having donor breastmilk. I’ve changed my mind and I would love to feed her. Can I give her the milk I have expressed today?” It is such a difficult question as we have so little data on the passage of cabergoline into braestmilk, the baby is very premature so has poor kidney and liver function and expressing to get a full supply is going to be a long hard journey. On the day of delivering such a tiny precious bundle, it is so hard to take in the implications of taking the drug

ELACTA is a European Journal for European Lactation Consultants. “Lactation & Breastfeeding” is also available in the UK as an electronic version for €8 per issue ( 4 annual editions) if you are not a member of ELACTA. Single Issues (elacta-magazine.eu)

PDF of the article can be downloaded

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/01/Pharmacological-methods-of-weaning-versus-conservative-weaning.pdf

There are several different reasons why a mother may wish to wean her baby from the breast if we accept that weaning for the purpose of this article means as the  cessation of breastfeeding rather than introduction of appropriate complimentary solid foods:

• Physiological natural weaning because the mother has decided that the time is right for them and their baby to stop breastfeeding and there is a natural reduction of milk supply.
• Unintentional weaning which may include ongoing supplementation or as a side effect of medication
• The prescription of medication to reduce lactation in the puerperium such as following a stillbirth or neonatal death, a baby to be adopted or where the mother has chosen not to breastfeed
• To rapidly cease lactation at a later period because of a medical diagnosis e.g., a diagnosis of cancer,  or more rarely because of initiation of a medication which is incompatible with breastfeeding initiation of long-term methotrexate or lithium
• The use of supplementary or complimentary products to reduce lactation which may include perceived over-supply
• To discourage an older nursling who is reluctant to stop breastfeeding
• To stop lactation following a stillbirth or baby loss

Physiological weaning

For the majority of women weaning from the breast occurs gradually over a period usually after the introduction of appropriate complimentary solid foods  (). As such under the influence of the Feedback Inhibitor of Lactation (FIL) supply diminishes slowly and without symptoms or discomfort or need for medication. As the baby breastfeeds less the feedback inhibitor lowers the production of milk.

Unintentional weaning

However, some 80% of lactations in the UK ceased before the baby was 6 months old and before the mother had planned to stop, usually because of lack of support and perceived low milk supply (McAndrew et al., 2012)  In this case usually breastmilk feeds have been replaced by formula milk feeds so that breastmilk supply has gradually reduced and ceased altogether. This sadly can happen because a mother has misunderstood the way that milk supply is stimulated or that a short-term feeding plan involving top ups of formula milk or replacement of breastfeeds has been continued longer than may have been anticipated by the professionals. Not reaching the goals of breastfeeding  been shown to be associated with feelings of loss and grief (Brown,2019) ⁽.

Suppression of lactation in the puerperium when mother has chosen not to breastfeed

Some mothers of course choose not to breastfeed from birth because of personal wishes or ill health of mother or baby. In the past many of them were prescribed medication to dry up their milk. Oladapo& Fawole ⁾  conducted a review of 46 controlled trials that randomised a total of 5164 mothers to receive the treatment under investigation, no treatment or another treatment (Oladapo & Fawole, 2019). The trials were generally of limited quality, and most were conducted among healthy women who chose not to breastfeed for personal reasons at hospitals in industrialized countries before 1980. Half of the trials involved bromocriptine which is no longer recommended for routine suppression of lactation and has indeed been withdrawn in USA by the FDA due to numerous maternal deaths.

Adoption

In the past many women whose babies were to be placed for adoption were offered medication to suppress lactation presumably to diminish the grief of the separation. In some cases, where limited contact with the baby is being maintained under supervision, mothers may choose to provide some breastmilk which can either be given as expressed breastmilk by the carer or directly by the mother feeding during contact. Anecdotally there have been reports to social services (personal communications to the author) where foster mothers have reported concerns that following maternal breastfeeds the baby appeared to have loose bowel motions and that the mother may be passing unacceptable substances via breastmilk. This exemplifies a misunderstanding of the difference between the bowel motions of breast and formula milk fed babies. There appears to be little research on the subject suggesting that long term expression is rare for babies given up for fostering and adoption. Whilst breastfeeding a baby who is to be adopted seems to be more common (Gribble 2006)

Stillbirth or neonatal death

For some mothers the choice to donate their breastmilk, following loss of their baby is a comfort and seen as a tribute to the baby’s memory (Jones, 2018)  .

“When I gave birth to my stillborn daughter, I was given a dry up shot without them even mentioning donating to milk banks as an option. I would have LOVED donating my milk. ”

“It’s funny, no one told me about milk donation. I don’t know how I knew about it. I learned when I was planning the C-section, I knew donor milk was an option, but didn’t know who donated it, never suspected I would become one who would be a milk donor.”

The side effects of cabergoline, used to stop lactation are not insignificant and it can precipitate depression, already a high risk after baby death in the puerperium.

Some mothers (personal communication to the author) were encouraged to not express their milk after sick, pre-term birth “just in case” their baby didn’t survive. In each of the cases, although limited in number, the mothers expressed regret that they felt that they had been excluded from caring for their baby.

Unintentionally lowering of milk supply due to medication

Drugs known to lower milk production as a side effect of use as medication are the combined contraceptive pill and the decongestant pseudoephedrine. Use to deliberately lower supply is not supported by research and effects vary with individuals. There have been no clinical trials on use for this purpose. Side effects of the drugs may be to raise the blood pressure of the mother and cause restlessness and irritability in the baby.

In one study of eight mothers (Aljazaf et al., 2003) a single dose of 60 mg pseudoephedrine was found to reduce the breastmilk supply by 24%. The reduction appeared to be more pronounced in those with later stage lactation defined as more than 60 weeks. The authors proposed that this may be due to a reduction in the production of prolactin although the reduction did not reach statistical significance with this small study population. Theoretically the reduction is also possible with the more frequently used phenylephrine although this hasn’t been reported in studies (Hale & Krutsch 2022, ) .

Dr Jack Newman has reported that bromocriptine and cabergoline are prescribed to overcome the symptoms of engorgement and mastitis sometimes on a routine basis (Newman, 2014)  without the mother being aware of the potential effect on her long-term chances of successful breastfeeding.

Early post-partum use of the combined oral contraceptive pill has been shown to decrease milk supply in some women due to the oestrogenic activity. However, the reduction seen is not consistent and seems to vary from woman to woman. The studies available are very dated and evidence relies on anecdotal reporting by mothers and lactation specialists.

Other non-prescribed products used to reduce lactation

The herb sage has been reported to lower milk supply although without clinical research. In 2014 Eglash  stated that “Sage is the most common herb used to reduce milk supply. Sage tea or extract made from the leaves is typically recommended, although there are no studies on the use of sage for hypergalactia and very few on its effect on the nursing baby. Sage tea may be prepared by steeping 1–3 g of dried sage leaves in a cup of hot water. The mother should be advised to just use one dose of the extract or 1 cup of tea and to observe the effect on her supply, as well as any behavioural change in the baby, over the next several hours. If she does not notice a difference in supply in 8–12 hours, then she can try another, stronger dose. Once she sees a response, she should just use it as needed. Often women will use one dose every 12 hours for 3 days to keep their supply down. Sage is known to have several side effects in high doses, including nausea, vomiting, and dizziness. It can induce wheezing, lower the blood sugar, and induce seizures, so high doses should be avoided in asthmatics, diabetics, and people prone to seizures. It is considered safe when used as a food.

In a 1998 Shrivastavet al  studied  the use of topical application of jasmine flowers was compared to bromocriptine to suppress lactation immediately after birth⁽. They reported that “The efficacy of jasmine flowers applied to the breasts to suppress puerperal lactation was compared to that of Bromocriptine. Effectiveness of both regimens was monitored by serum prolactin levels, clinical evaluation of the degree of breast engorgement and milk production and the analgesic intake. While both bromocriptine and jasmine flowers brought about a significant reduction in serum prolactin, the decrease was significantly greater with bromocriptine. However, clinical parameters such as breast engorgement, milk production and analgesic intake showed the two modes of therapy to be equally effective. The failure rates of the two regimens to suppress lactation were similar; however, rebound lactation occurred in a small proportion of women treated with bromocriptine. Jasmine flowers seem to be an effective and inexpensive method of suppressing puerperal lactation and can be used as an alternative in situations where cost and nonavailability restrict the use of bromocriptine.”

KellyMom reports that other herbs can be used to decrease supply but no evidence from research is supplied to support the statement. The herbs include Peppermint, Spearmint, Parsley, Chickweed, Black Walnut, stinging nettles, Yarrow, Herb Robert Lemon Balm, Oregano, Periwinkle Herb, Sorrel (KellyMom, 2018).

Normal consumption of the herbs as foodstuffs or drinking peppermint tea would not be likely to decrease supply.

Medication to reduce lactation

Bromocriptine

In 2015, the French pharmacovigilance program( Bernard) published a review of the adverse events associated with bromocriptine use to cease lactation. This group reported 105 serious adverse reactions including cardiovascular (70.5%), neurological (14.4%) and psychiatric (8.6%) events. There were also two fatalities: one 32-year-old female had a myocardial infarction with an arrhythmia, and a 21-year-old female had an ischemic stroke. (Hale & Kutsch 2022)⁽⁸⁾

Cabergoline

If a dopamine-receptor agonist is required to suppress lactation, cabergoline is preferred at a dose one mg, to be taken as a single dose on the first day postpartum. For the suppression of established lactation, a dose of 0.25mg is taken every 12 hours for two days for a total of 1mg (BNF 2022). However, this drug also has significant side effects, including headache, dizziness, fatigue or insomnia, orthostatic hypotension, oedema, nosebleed, dry mouth, inhibition of lactation, nausea, constipation, anorexia and weakness.

The manufacturer’s summary of product characteristics (Electronics Medicines Compendium SPC) ⁽ states that:

“As with other ergot derivatives, cabergoline should not be used in women with pregnancy-induced hypertension, for example, preeclampsia or post-partum hypertension, unless the potential benefit is judged to outweigh the possible risk.

Serious adverse events including hypertension, myocardial infarction, seizures, stroke or psychiatric disorders have been reported in postpartum women treated with cabergoline for inhibition of lactation. In some patients the development of seizures or stroke was preceded by severe headache and/or transient visual disturbances. Blood pressure should be carefully monitored after the treatment. If hypertension, suggestive chest pain, severe, progressive, or unremitting headache (with or without visual disturbances), or evidence of central nervous system toxicity develop, cabergoline should be discontinued and the patient should be evaluated promptly.

In post-partum studies with cabergoline, blood pressure decreases were mostly asymptomatic and were frequently observed on a single occasion 2 to 4 days after treatment. Since decreases in blood pressure are frequently noted during the puerperium, independently of drug therapy, it is likely that many of the observed decreases in blood pressure after cabergoline administration were not drug-induced. However, periodic monitoring of blood pressure, particularly during the first few days after cabergoline administration, is advised”.

Cabergoline can also cause depression. They should be avoided if the mother has experienced pre-eclampsia. Both drugs can produce sudden onset sleep or excessive daytime drowsiness and driving should be avoided.

Although bromocriptine and cabergoline are licensed to suppress lactation, they are not recommended for routine suppression when women have decided not to breastfeed, or for the relief of symptoms of postpartum pain and engorgement that can be adequately treated with simple analgesics and breast support. Should the mother decide that she wants to continue to breastfeed after taking cabergoline caution is recommended as there are no studies on the effects on babies of the dose used to suppress lactation (Hale and Krutsh 2022). Elactancia suggests that “No untoward effects have been reported in breastfed infants of mothers who were treated (or erroneously had received medication) and decided to resume breastfeeding” whilst recommending waiting 3-7 half lives. The half life of cabergoline is 63-69 hours.

Weaning the reluctant nursling

Social media posts often have posts from mothers who are experiencing aversion to breastfeeding, sometimes around the time of menstruation, or because their babies are “nipple twiddling”. They report that they are desperate to stop breastfeeding whilst their nursling remains bonded and even reliant on breastfeeding. Discussions that they have felt unable to convince their little ones that milk has dried up are undermined when the nursling latches on and finds there is milk. They often question whether taking a medication to suppress lactation would be an option as a strategy of last resort!

“So, unless I can come up with a better plan, I need to dry my milk up. I bedshare with my 23-month-old (no other options), am a solo parent, and night nurse all night long (her choice, not mine). I planned to keep breastfeeding for as long as she wanted but I can’t nurse her at night anymore. I have no clue how to night wean her because I’m literally lying next to her all night long. So, I figured the easiest thing to do would be to dry my milk up with drug. “

Conclusion

In an ideal world it is better to allow the breastmilk supply to dwindle slowly, by dropping one feed at a time or expressing/feeding only when the breasts become uncomfortably full. It may however be necessary to speed up this process up, but it is still important to avoid blocked ducts and mastitis. It is possible to treat the breasts as in the early days of engorgement, using simple analgesics and cold savoy cabbage leaves in a firm but well-fitting bra. Or the mother can express just enough milk to remain comfortable, frequently changing breast pads, which may become soaked as milk leaks from the breasts. Restricting the fluids which the mother is drinking will not help the milk to dry up; nor will the use of laxatives to remove water from the body.

Whose choice should it be?

The choice should ultimately be that of the lactating mother having been provided with full information about the side effects of the drug, alternative methods of reducing supply and that this should be a final decision. So many times, mothers say that they have taken cabergoline but regret the decision and wish to return to breastfeeding, for example that formula isn’t suiting their baby. As with so many aspects of parenthood it isn’t always as easy a professionals might suggest.

References

• Aljazaf K, Hale TW, Ilett KF, et al. (2003) Pseudoephedrine: effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin Pharmacol. 56(1):18-24  
• Bernard N, Jantzem H, Pecriaux C, et al. Severe adverse effects of bromocriptine in lactation inhibition: a pharmacovigilance survey. BJOG. 2015;122:1244-1251.
• Brown A, Why Breastfeeding Grief and Trauma Matter Pinter and Martin 2019
• Dr Jack Newman Facebook social media https://www.facebook.com/DrJackNewman/posts/the-use-of-cabergoline-dostinex-and-bromocriptine-parlodel-in-breastfeeding-wome/311003792384007/
• Eglash A.  (2014)Treatment of maternal hypergalactia. Breastfeed Med. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216483/pdf/bfm.2014.0133.pdf
• Elactancia online database https://www.halesmeds.com/monographs/60947?q=cabergoline
• Electronics Medicines Compendium SPC  bromocriptine https://www.medicines.org.uk/emc/product/1202
• Cabergoline https://www.medicines.org.uk/emc/product/1691/smpc (accessed December 2022)
• Gribble, K.D.  (2006) Mental health, attachment and breastfeeding: implications for adopted children and their mothers. Int Breastfeed J 1: 5
• Hale TW and Krutsch K Medications and Mothers Milk online access December 2022).
• Joint Formulary Committee. (2022). British national formulary. Accessed  December 2022, fromhttps://www.medicinescomplete.com/#/browse/bnf
• Jones W Breastfeeding and Medication website lowering or stopping breastmilk supply https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-lowering-stopping-milk-supply
• KellyMom Herbs that may decrease milk supply https://kellymom.com/bf/got-milk/herbs_to_avoid/ Accessed December 2022
• McAndrew F, Thompson J, Fellows L, Large A, Speed M, Renfrew MJ (2012) Infant Feeding Survey 2010, Health and Social Care Information Centre
• Oladapo, O.T.; Fawole, B. (2009) Treatments for suppression of lactation. Cochrane Database of Systematic Reviews
• Shrivastav P, George K, Balasubramaniam N, Jasper MP, Thomas M, Kanagasabhapathy AS. Suppression of puerperal lactation using jasmine flowers (Jasminum sambac). Aust N Z J Obstet Gynaecol. 1988 Feb;28(1):68-71

So many mums seem to injure their backs – maybe we need antenatal classes on how to lift your baby (and equipment!) or more assessment of post-natal damage. When pain has not resolved with simple painkillers (paracetamol and ibuprofen (taken regularly and at full dose) sometimes further treatment is necessary from professionals. This may help the mother access physiotherapy or other mobility treatment.

Information here on how to treat the pain of acute back injury and relieve the spasm. I hope that it aids mothers and professionals.

Breastfeeding and pain relief for acute back injury

Non- steroidal analgesia

Normally mothers have taken ibuprofen along with paracetamol and may have found the pain has not resolved. I would suggest changing ibuprofen to naproxen or diclofenac to see if that helps. Both are compatible with breastfeeding. They should be taken with food and may be co-prescribed with omeprazole to protect the mother’s stomach from gastric bleed. The omeprazole is largely destroyed in the maternal gut and does not impact on breastfeeding. See https://www.sps.nhs.uk/articles/using-nsaids-during-breastfeeding

Muscle spasm

Muscle spasm relief can be achieved by the use of cold packs or heat packs. Topical rubs containing NSAIDS (Volatrol ®, Ibuleve®, PhorPain ®, Fenbid® etc) can be used with paracetamol. Ribs which produce warming or cooling can also provide relief along with massage to the area (Deep Heat ®, Tiger Balm®, Algesal® etc)

Up to a maximum of three days of diazepam 2mg 2-3 times a day to relive the spasm is also regularly used. It doesn’t seem to cause any problems used short term like this despite the long half-life. This is normally long enough to access some physio or other exercise regime. The evidence for this is largely anecdotal and based on my professional experience over the past 20 years. (Hale TW Medications and Mother’s Milk “Some reports of lethargy, sedation, and poor suckling have been found. The acute use such as in surgical procedures is not likely to lead to significant accumulation.”

Opiate pain relief

If greater pain relief is required, tramadol, Oramorph or dihydrocodeine are all breastfeeding compatible options.

• Dihydrocodeine or co dydramol is widely used post c section and is now the opiate analgesic of choice due to the fact that it has a cleaner metabolism.
• Morphine has extensive first pass metabolism so actually reaches low levels in milk. Oramorph is widely used
• Tramadol reaches low levels in babies but can make mum very sleepy. Watch the baby for signs of drowsiness too.

Constipation

If you take co-dydramol or oramorph or any opioid you will need a laxative like lactulose, bisacodyl or dioctyl all of which you can buy from a pharmacy, See https://breastfeeding-and-medication.co.uk/fact-sheet/constipation-laxatives-and-breastfeeding

The following data is extracted from my book Breastfeeding and Medication 2018

Co-dydramol – paracetamol 500 mg and dihydrocodeine 10 mg.

Preferred compound analgesic due to cleaner metabolism than codeine. Use for as short a time as possible. Observe baby for drowsiness. If baby becomes drowsy stop drug immediately and seek medical advice.

Tramadol

Tramadol is an opiate analgesic used for moderate to severe pain. Its use would appear to have increased as a result of concern over codeine preparations. It is subject to first-pass metabolism. It has an elimination half-life of six hours. Tramadol inhibits the reuptake of noradrenaline and serotonin and may potentiate the action of other drugs with similar action, e.g. SSRI anti-depressants.

Ilett et al. (2008) studied 75 breastfeeding mothers who were given 100 mg tramadol post-caesarean section on days two–four. They collected milk and plasma samples of four or more doses to reflect steady state. Additionally, he observed the infants together with matched controls not exposed to tramadol. He determined a relative infant dose quoted as 2.24% for tramadol and 0.64% for its metabolite. No difference was noted in the behaviours of the infants exposed compared with the controls and the authors therefore concluded that short-term maternal use of tramadol is compatible with breastfeeding.

In 2015 the FDA recommended that tramadol is not used in breastfeeding mothers. When tramadol is taken, it is changed in the liver to O-desmethyltramadol (known as M1). Both tramadol and M1 relieve pain and are responsible for side effects that some people may experience, but M1 has stronger opioid effects than the tramadol. Tramadol is metabolised in the liver by enzyme cytochrome P450 isoenzyme 2D6 (CYP2D6). Some people have a variation of this enzyme that changes codeine to morphine and tramadol to M1 faster and to a greater extent than in other people. These individuals are called CYP2D6 ultra-rapid metabolisers. Just as in codeine, this can produce an accumulation of the drug in breastmilk. This genotype is present in up to 10% of the white population in Europe and North America, but only 4% of black African Americans (FDA 2015).

As with other opiates, exposure of premature infants should be undertaken with caution because of the risk of apnoea and sedation. Amount probably too small to be harmful, but manufacturer advises avoidance (BNF).

Avoid if possible although the amount in breastmilk is probably too small to be harmful. Use for as short a time as possible. Observe baby for drowsiness. If baby becomes drowsy stop drug immediately and seek medical advice.

• FDA, Use of Codeine and Tramadol Products in Breastfeeding Women, FDA, 2015.
• Ilett KF, Paech MJ, Page-Sharp M, Sy SK, Kristensen JH, Goy R, Chua S, Christmas T, Scott KL, Use of a sparse sampling study design to assess transfer of tramadol and its o-desmethyl metabolite into transitional breastmilk, Br J Clin Pharmacol, 2008;65(5):661–6.

Morphine

Therapeutic doses of morphine in the breastfeeding mother are unlikely to be harmful to baby in the short term, e.g. post-operatively. Infants under 4 weeks of age have a prolonged elimination half-life and clearance does not approach adult levels until 2 months of age. Respiratory difficulties may be important to be aware of with premature babies or others at risk of apnoea. The oral absorption of morphine is very poor and first-pass metabolism is high. It is therefore frequently used post-caesarean section as Oramorph solution.

Robieux et al. (1990) reported a single case of an infant who was breastfed while his mother was receiving low doses of morphine. Morphine concentration in his serum was in the analgesic range (4 ng per millilitre), while concentrations in the milk varied substantially from 10–100 ng per millilitre. The authors calculated that the baby had received 0.8–12% of the maternal dose. Oberlander et al. (2000) studied one baby born to a mother who received morphine intrathecally during and after pregnancy. Minimal levels were determined in breastmilk over seven weeks and the infant’s development and feeding up to seven months were normal. Baka et al. (2002) also studied women receiving patient-controlled analgesia post-caesarean section and noted that the concentrations of morphine in breastmilk were very small (<1 to 274 ng per millilitre) with a m/p ratio <1. Relative infant dose is quoted as 9.1% (Hale 2017 online access). Therapeutic doses unlikely to affect infant (BNF).

Compatible with use short term during breastfeeding. Observe baby for sedation and poor feeding.

References

• Baka NE, Bayoumeu F, Boutroy MJ, Lexenaire MC, Colostrum morphine concentrations during postcesarean intravenous patient-controlled analgesia, Anesth Analog, 2002;94:184–7.
• Ilett KF, Paech MJ, Page-Sharp M, Sy SK, Kristensen JH, Goy R, Chua S, Christmas T, Scott KL, Colostrum morphine concentrations during postcesarean intravenous patient-controlled analgesia, Anesth Analg, 2002;94:184–7.
• Oberlander TF, Robeson P, Ward V, Huckin RS, Kamani A, Harpur A, McDonald W, Prenatal and breastmilk morphine exposure following maternal intrathecal morphine treatment, J Hum Lact, 2000;16:137–42.
• Robieux I, Koren G, Vandenbergh H, Schneiderman J, Morphine excretion in breastmilk and resultant exposure of a nursing infant, J Toxicol Clin Toxicol, 1990;28:365–70.
• Naproxen  
• Naproxen is more than 99% bound to plasma proteins. Davies and Anderson (1997) reported that although naproxen is excreted into breastmilk, the amount of drug transferred comprises only a small fraction of the maternal exposure. In Jamali and Stevens’ study (1983) only 0.26% of the mother’s dose was recovered from the infant and adverse effect reports are low. However, this drug has a longer half-life than other NSAIDs, normally being taken only twice a day. The BNF considers that the amount of naproxen distributed into breastmilk is too small to be harmful to a breastfed infant; however, some manufacturers recommend that breastfeeding should be avoided during naproxen therapy, due to licencing considerations rather than potential risk. Relative infant dose is quoted as 3.3% (Hale 2017 online access). The BNF states that the amount in breastmilk is too small to be harmful but that the manufacturer advises use should be avoided.
• Compatible with use during breastfeeding due to limited transfer into breastmilk.
• References
• Davies NM, Anderson KE, Clinical pharmacokinetics of naproxen, Clin Pharmacokinet, 1997;32:268–93.
• Jamali F, Stevens DRS, Naproxen excretion in milk and its uptake by the infant, Drug Intell Clin Pharm, 1983;17:910–11.
• Diclofenac  
• Research studies are not widely documented as it is used less frequently in the USA than in the UK. However, the lack of reports of adverse effects suggests that there is little cause for concern. It has been one of the most widely used drugs in the immediate postpartum period in the UK but is now being replaced by naproxen because of the risk of cardio-vascular effects.
• Oral diclofenac is almost completely absorbed but it is subject to first-pass metabolism so less reached the systemic circulation. Its high plasma protein binding (in excess of 99%) limits its passage into breastmilk. It is widely used on post-natal wards. Relative infant dose is quoted as 1% (Hale 2017 online access). The BNF states that the amount present in breastmilk is too small to be harmful.

Compatible with use during breastfeeding due to limited transfer into breastmilk.

Omeprazole  

Omeprazole is rapidly destroyed in acid conditions of the stomach below pH 4. It is also given to infants to treat severe gastric reflux. It is 95% bound to plasma proteins. It is not licenced for use in children below 1 year but is used outside of its licence application at a dose of 700 µg per kilogramme per day for reflux compared with an estimated dose through breastmilk of 3 µg per kilogramme per day passing through breastmilk in the study of one mother (Marshall et al. 1998). Hale 2017 (online access) quotes the relative infant dose as 0.02%.

Omeprazole suspension (unlicenced) is the only proton pump inhibitor liquid preparation available for administration to infants. This preparation is a ‘special’ and needs to be ordered by the pharmacy from a specials laboratory. However, it is not licenced for children under 1 year of age. It is metabolised by the cytochrome P450 system so potential interactions are possible. The BNF reports that it is present in milk but that it is not known to be harmful.

Compatible with breastfeeding as destroyed at pH <4. Used directly in children with severe gastro oesophageal reflux disease.

References

• Marshall JK, Thompson AB, Armstrong D, Omeprazole for refractory gastroesophageal reflux disease during pregnancy and lactation, Can J Gastroenterol, 1998;12:225–7.
• National Institute for Health and Care Excellence (NICE), Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people (cks.nice.org.uk/gord-in-children).

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. I decided to put together this information. It includes pain relief, laxatives, haemorrhoidal treatment and iron supplements

After birth you may need pain relief for stitches, after pains as the womb contracts or if you need a caesarean section.

Standard pain relief which you might find useful to take regularly is paracetamol (2 tablets 4 times a day) and ibuprofen (400mg three times a day).

If this isn’t sufficient you can take:

• co-dydramol – paracetamol and dihydrocodeine (latter available over the counter as Paramol although it will say don’t take if you are breastfeeding because the manufacturer doesn’t take responsibility). It can also be prescribed in combination or separately
• naproxen or diclofenac which are stronger than ibuprofen – virtually none gets into breastmilk. These will need to be prescribed. See https://www.sps.nhs.uk/articles/using-nsaids-during-breastfeeding
• You may be given morphine if you have a caesarean section and can feed as normal
• oramorph – morphine liquid which will be prescribed in hospital after a c section
• AVOID codeine as it may make your baby drowsy. Some people concentrate codeine in their milk. Most find that it makes them feel sick or dizzy themselves. See https://breastfeeding-and-medication.co.uk/thoughts/breastfeeding-and-codeine

Constipation

If you take co-dydramol or oramorph you will need a laxative like lactulose, bisacodyl or dioctyl all of which you can buy from a pharmacy, See https://breastfeeding-and-medication.co.uk/fact-sheet/constipation-laxatives-and-breastfeeding

Piles

IF you experience haemorrhoids (piles) after birth you can use suppositories and creams e.g. Anusol, Anusol HC, Preparation H, Germaloids, pharmacy own brands

Anaemia

You can take iron supplements after birth – ferrous sulphate or fumerate or gluconate.

PDF of this information is available at:

https://breastfeeding-and-medication.co.uk/wp-content/uploads/2023/02/hyperemesis-and-breastfeeding-feb-2023-.pdf

See also https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.17739?fbclid=IwAR1c5ZE0_-AocuZ1bXuZSZGB9VCLHHCy4of4JkvxmYTTPWEzMAJVzTf1gQY

The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69) Feb 2024

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/Medicine–pregnancy/NV/

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™)

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 (https://www.medicinesinpregnancy.org/Medicine–pregnancy/Morning-Sickness/)

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/

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