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

I am frequently asked about taking prochlorperazine (Buccastem® or Stemetil ®) to treat nausea due to labarynthitis, vertigo or dizziness. It is a drug I would be happy to prescribe and have used it myself as have my breastfeeding daughters. It seems a frequently asked question when the air pressure changes rapidly. Prochlorperazine may also be used for nausea

prochlorperazine and breastfeeding factsheet pdf

Brand names: Stemetil®, Buccastem®

Prochlorperazine is used to treat vertigo, labarynthitis or migraine particularly to treat nauseas caused by these conditions.

Its oral bio-availability is low due to high first-pass metabolism.  Long-term use should be avoided in breastfeeding where possible, particularly with very young babies where there is a potential risk of apnoea (breathing problems).

However short-term acute use for vertigo and labarynthitis probably poses few risks.  It is widely used for this purpose. It is licensed for use in children over 10 kg.

Compatible with use during breastfeeding if used short term. Avoid long term or where child is at risk of apnoea.

N.B This information is based on anecdote and experience as there are no research based studies on the amount passing into breastmilk.

see also https://breastfeeding-and-medication.co.uk/fact-sheet/betahistine-and-breastfeeding

It is not uncommon for breastfeeding mothers to need to take low dose aspirin, sometimes for reasons in pregnancy or after cardiac events. Whilst it isnt recommended regularly as a painkiller at a dose of 600mg four times a day it is compatible with breastfeeding in low dose of 75-150mg daily. There are no reported cases of Reye syndrome associated with the amount of low dose aspirin passing through breastmilk and it is widely used, particularly during pregnancy.

low dose aspirin and breastfeeding pdf

If accidentally taken at an analgesic dose see https://breastfeeding-and-medication.co.uk/fact-sheet/accidentally-taking-one-dose-of-aspirin-when-breastfeeding

Aspirin 75 -150mg acts by decreasing platelet adhesiveness irreversibly inhibiting aggregation. It is not used during treatment of thrombosis but may be used in cases of recurrent miscarriage or with risk of pre-eclampsia. In more serious conditions it is used post myocardial infarction (MI) and stroke or to decrease cardiovascular risk. There is little evidence that enteric-coated tablets are less likely to increase the risk of GI bleeds and may be less effective in their anti-platelet activity as well as more expensive. Although aspirin is not recommended during breastfeeding at analgesic doses of 600 mg four times a day, due to its association with Reye’s syndrome, use of the small dose in these circumstances may be considered to be acceptable. In the absence of the risk of association of Reye’s syndrome, aspirin would be a drug compatible with lactation due to its pharmacokinetic properties.

Before the link with Reye’s syndrome was identified, the children’s dose of aspirin was 75 mg four times a day. Relative infant dose is quoted as 2.5–10.8% (Hale 2017 online access). The BNF states that it should be avoided due to possible risk of Reye’s syndrome. Regular use of high doses could impair platelet function and produce hypo-prothrombinaemia in infant if neonatal vitamin K stores are low. After 2-4 hours there is virtually no aspirin in milk Compatible with breastfeeding if necessary at 75 -150mg mg daily, avoid as an analgesic Reye’s syndrome This is a rare syndrome, characterized by acute encephalopathy and fatty degeneration of the liver, usually after a viral illness or chickenpox. The incidence is falling but sporadic cases are still reported. It was often associated with the use of aspirin during the prodromal illness. Few cases occur in white children under 1 year although it is more common in black infants in this age group. Many children retrospectively examined show an underlying inborn error of metabolism.

The question as to the compatibility of high dose vitamin d supplements in the breastfeeding mother is a frequently asked question. We appear to monitor levels more frequently than we did in the past but research is difficult to source. I hope this information helps.

pdf of this information.

High dose vitamin d supplement for breastfeeding mothers factsheet

There has been an unexpected increase over the past 15 years in the number of babies found to be suffering from rickets or symptoms of decreased bone mass which demonstrate poor levels of vitamin D (NICE PH11). Vitamin D deficiency is unusual in babies born at term to mothers with adequate vitamin D status. Some women enter pregnancy with low vitamin D levels. This may be due to:

•             lack of exposure to sunlight due to wearing concealing clothing for cultural reasons;

•             inadequate consumption of foods containing vitamin D e.g. oily fish;

•             Inadequate consumption of dairy (prevalent particularly in adolescent girls)

•             BMI greater than 30;

•             Women who spend a lot of time indoors or use sun creams limiting the absorption of ultraviolet (UV) light;

•             living in the northern hemisphere where levels of UV light are only sufficient to stimulate vitamin D production in the summer months; and

•             having dark skin, which prevents absorption of available UV light in the UK climate.

Babies born to mothers with low vitamin D levels may be born deficient. In turn this will be exacerbated by being breastfed as the vitamin D levels in breastmilk will be sub-optimal.

In 2016 SACN amended recommendations so that breastfed babies from birth to one year of age should be given a daily supplement containing 8.5 to 10mcg of vitamin D as a precaution and breastfeeding mothers should also take a daily Vitamin D supplement of 10 µg (400IU) per day

This in no way suggests that the breastmilk of a mother with low levels of vitamin D, does not have all the other health advantages but is a reflection of current awareness of the risk of sun damage in sunlight balanced with the UK climate and poor levels of sunshine for the majority of the year. Breastfeeding alone cannot redress the deficiency resulting from low levels in pregnancy. Vitamin D is a fat-soluble vitamin that is found in food and can also be made in the body after exposure to UV rays from the sun. Fortified foods are common sources of vitamin D but without sunshine exposure it is difficult to achieve maximal intake. Supplements can be taken as part of multi-vitamin products or with calcium.

Sources of vitamin D

•             More than 90% of mankind’s vitamin D supply is derived from UVB sunlight exposure

•             Oily fish including trout, salmon, mackerel, herring, sardines, anchovies, pilchards and fresh tuna

•             Cod liver oil and other fish oils

•             Egg yolk – 0.5 µg (20 IU) per yolk

•             Mushrooms

•             Supplemented breakfast cereals, mainly supermarket ‘own brands’ in the UK. Typically contain between 2 and 8 µg (80-320 IU) per 100 g

•             Margarine

In a fair-skinned individual, exposure of the face and forearms to 20–30 minutes of sunlight at midday is estimated to generate the equivalent of 2000 IU vitamin D. Between April and October all of Scandinavia, much of western Europe, including 90% of the UK (roughly north of Birmingham) and 50% of USA is above the latitude where exposure to sufficient UVB is possible (Pearce 2010).

High dose vitamin d supplements

Many breastfeeding mothers appear to be being diagnosed as vitamin D deficient and prescribed high doses daily or weekly. Hollis et al 2015 reported that “Maternal vitamin D supplementation with 6400 IU/day safely supplies breast milk with adequate vitamin D to satisfy her nursing infant’s requirement and offers an alternate strategy to direct infant supplementation. With the use of higher dose supplements the mother should observe the baby for signs of hyper calcaemia (nausea, vomiting, weight loss, thirst, muscle weakness and confusion) and if observed blood test the baby.

Hollis and Wagner (2004) studied 18 women exclusively breastfeeding one month after delivery, and gave half 1600 IU vitamin D2 and 400 IU vitamin D3 and the others 3600 IU vitamin D2 and 400 IU vitamin D for 3 months. Blood, urine, and milk samples were obtained from the mothers at months 1, 2, 3, and 4 of lactation. Infant blood was collected at months 1 and 4 (beginning and end of the study). Maternal blood was monitored for total calcium, vitamin D2, vitamin D3, 25(OH)D2, and 25(OH)D3 concentrations. Infant serum was monitored for vitamin D2, vitamin D3, 25(OH)D2, 25(OH)D3, calcium, and phosphorus concentrations. The conclusion of the study was that the 400iu per day has been recommended arbitrarily and needs further research. In the study maternal vitamin D intakes of ≥4000 IU/d appear to be safe and to provide sufficient vitamin D to ensure adequate nutritional vitamin D status for both mothers and nursing infants.

• Hollis BW, Wagner CL, Vitamin D requirements during lactation: high-dose maternal supplementation as therapy to prevent hypovitaminosis D for both the mother and the nursing infant, Am J Clin Nutr, 2004;80(6 Suppl.):1752S–8S. (https://academic.oup.com/ajcn/article/80/6/1752S/4690524)

Hollis et al (2015) randomised 3 groups of exclusively breastfeeding women to 400 IU vitamin D3 per day 2400 IU or 6400 IU vitamin D3 per day, The infants of the mothers in group one were given a vitamin d supplement but those in the higher dose groups received placebo drops. 148 mothers completed the full study still exclusively breastfeeding. The conclusion of the study was that maternal vitamin D supplementation with 6400 IU/day safely supplies breast milk with adequate vitamin D to satisfy her nursing infant’s requirement and offers an alternate strategy to direct infant supplementation. This was not achieved with lower doses.

• Hollis BW, Wagner CL, Howard CR, Ebeling M, Shary JR, Smith PG,Taylor SN,  Morella K, Lawrence RA,Hulsey TC, Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial. Pediatrics 2015;136 (4): 625-634 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586731/pdf/peds.2015-1669.pdf

Some mothers are prescribed 20,000 or 40,000 units once weekly which approximate to a similar dosage. There is limited research to support this level being compatible with breastfeeding so the baby should be monitored for hypercalcaemia as described above – nausea, vomiting, weight loss, thirst, muscle weakness and confusion

See also: https://www.ncbi.nlm.nih.gov/books/NBK500914/

https://www.sps.nhs.uk/articles/using-vitamin-d-during-breastfeeding (December 2023)

For full references see Breastfeeding and Medication 2018

When paracetamol plus a non steroidal drug (ibuprofen, naproxen, diclofenac or celecoxib) are insufficient to control pain opioid drugs may need to be used. They cause constipation so should be co prescribed with a stool softener). They are also addictive so should be used for the shortest possible time, in the lowest possible dose.

Codeine is not recomemnded for breastfeeding https://breastfeeding-and-medication.co.uk/thoughts/breastfeeding-and-codeine but one accidental dose or short term use, maybe overnight when no other pain relief is available does not mean that breastfeeding needs to be interrupted.

No breastfeeding mother should ever be asked to choose between adequate pain relief and breastfeeding

Opioids and breastfeeding factsheet

Another medication used during breastfeeding for anxiety and depression is mirtazapine. It may be used where other SSRIs have not been effective or tolerated. Mirtazapine may be also be seen as an option where insomnia is a symptom of  anxiety or depression.

The baby should be observed for signs of drowsiness and ineffective feeding.

Care should be taken with co sleeping because it is likely to cause drowsiness in the lactating mother. Falling asleep in chairs or on sofas should be regarded as an even greater risk https://www.basisonline.org.uk/

LactMed summarises that “Limited information indicates that maternal doses of up to 120 mg daily produce low levels in milk and would not be expected to cause any adverse effects in breastfed infants, especially if the infant is older than 2 months.” In practice the normal dose is 15mg taken at night.

Professionals may find the RCGP Perinatal mental health toolkit a useful resource https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/perinatal-mental-health-toolkit.aspx

See also https://www.sps.nhs.uk/articles/using-duloxetine-mirtazapine-trazodone-or-venlafaxine-during-breastfeeding

The information in this factsheet is taken from my book Breastfeeding and Medication. Please message me with queries or the references used. wendy@breastfeeding-and-medication.co.uk

Mirtazapine and Breastfeeding Factsheet

There are so many reasons that we need to apply creams, lotions, ointments and pastes to our bodies when breastfeeding. There is poor absorption of most products applied topically and most can be used without interrupting breastfeeding. These include:

• Moisturizers/emollients used to soothe skin e.g Diprobase ® , Dermol ® , E45 ® , Aveeno ® , Cetraben
• Topical steroids to soothe eczema should be applied sparingly regardless of breastfeeding and accompanied by emollients to keep skin supple eg Betnovate ®, Eumovate ® , Elocon ® , Hydrocortisone. They can be applied to the nipple very sparingly for short periods of time after feeds without needing to wash off as this may further damage skin. Moisturisers should be used to keep the skin supple but not soggy.
• Bath emollients and shower gels to soothe irritated skin e.g Oilatum ®, E45 ® , Aveeno ®
• Creams to treat cold sores e.g anti viral acyclovir (Zovirax ®), Compeed patches ®
• Antiseptic creams e.g Savlon ®, Germolene ®, Dettol ® for minor wounds.
• Antibacterial creams e.g fucidic acid (Fucidin ®), muciprocin (Bactroban) can be applied sparingly after feeds without need to wash off
• Preparations to treat corns, warts and veruccas e.g Bazuka ® , Scholl products, Wartner ®
• Creams to treat athletes food e.g terbinafine (Lamisil ® ), clotrimazole (Canesten ® ), Mycota ® , Mycil ®, Daktarin ®, Scholl products
• Anti inflammatory gels and creams eg ibuprofen (Ibugel ® ), Diclofenac (Voltarol ® ), Deep Heat ® , Tiger Balm® , taking care not to use these where baby can rub into eyes
• Medicated shampoos and lotions eg BetaCap ® , Selsun ®, Polytar ®
• Head lice treatment https://breastfeeding-and-medication.co.uk/fact-sheet/head-lice-and-breastfeeding