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It is not acceptable to leave any mother in pain because she is breastfeeding nor to suggest that she could have more effective pain relief if she stopped breastfeeding.
I’m often asked about the safety of opioids during breastfeeding so this is a really interesting study
Despite opioids being used first line in emergency settings to treat severe acute extremity pain, there is limited evidence available to inform this practice.
In a study in JAMA (7 November 2017), researchers randomly assigned 416 patients in the emergency department with moderate-to-severe acute extremity pain to one of the following groups: 400mg ibuprofen/1000mg paracetamol; 5mg oxycodone/325mg paracetamol; 5mg hydrocodone/300mg paracetamol; or 30mg codeine/300mg paracetamol.
I have written this powerpoint presentation which I hope explains the analgesic ladder and helps professionals to understand the compatibility of analgesics and breastfeeding
- Paracetamol or NSAID
- Paracetamol + NSAID
Paracetamol+NSAID+Opioid (at the lowest possible dose for the shortest possible time co prescribed with a laxative)
Non steroidal anti inflammatory drugs
- Compatible with breastfeeding: ibuprofen, diclofenac (Voltarol ™, Difene™), naproxen (Naprosyn™) https://breastfeeding-and-medication.co.uk/fact-sheet/naproxen-and-breastfeeding
- No data on compatibility with breastfeeding: etoricoxin (Arcoxia™), meloxicam (Mobic™)
- compatible with breastfeeding: oral morphine, dihydrocodeine
- use with caution as may cause drowsiness: oxycodone (Oxycontin™, Oxyfast™)
- avoid if possible as may cause drowsiness: codeine
All opioids can cause nausea and dizziness but almost invariably cause constipation so it is wise to commence stool softeners like lactulose and/or docusate both of which are compatible with breastfeeding as they don’t pass into milk.
Sharing a presentation which was given to GPs in the south west. Hopefully it is useful for professionals wanting to know more about prescribing for breastfeeding mothers
I sincerely hope this information is never needed but as of 6 june 2022 this is the recommendation on pregnancy and breastfeeding when a mother is suspected/proven to have monkeypox. This data is taken from the paper as below
RCOG 6 June 2022 New paper provides best practice for managing monkeypox in pregnancy (and breastfeeding) https://www.rcog.org.uk/news/new-paper-provides-best-practice-for-managing-monkeypox-in-pregnancy/
Highlights pasted from the paper below- basically we dont know about breastfeeding and the passage of monkeypox and need to protect the infant.
‘There is currently no evidence on the risk of viral transmission to the infant during breastfeeding, whether via the breast milk, direct contact with maternal skin lesions or via large droplet spread.
MVA-BN is considered safe in breastfeeding
There is little evidence to guide neonatal care following the birth of a baby to a woman with monkeypox infection. Apart from macroscopic examination, the baby should undergo viral PCR testing either by throat swab or any lesions that are present. The baby should be isolated at birth from its mother and others, in a single room, with carers wearing appropriate PPE. The baby should be carefully monitored for signs of compromise or monkeypox infection. If the baby tests positive, the mother and baby can be reunited. Ideally, both mother and baby should be tested in parallel thereafter; after the mother is de-isolated (e.g. two negative PCR tests), mother and baby should be reunited. If a mother has reached a threshold to warrant PCR testing for the monkeypox virus, the baby should be isolated pending her swab result.
The proposed strategy for neonatal care would preclude most women with active monkeypox infection from breastfeeding their newborn. The WHO advises against breastfeeding; this seems reasonable in high-income country settings, such as the UK, in order to minimize the risk of neonatal monkeypox infection”
Proposed management of suspected or confirmed monkeypox infection in labor or if urgent delivery is needed.
• Advise delivery via Cesarean section
• Assess need for steroids and magnesium sulfate
• Maternity and neonatal staff to wear PPE
• Mother and baby should be isolated separately; avoid NNU admission if possible
• Mother should not breastfeed
• Encourage expressing so mother has opportunity to breastfeed after de-isolation; follow
recommendations for pump cleaning after each use
• Milk should be discarded as infected waste*
• Discuss with virologist testing needed
• If mother is negative, these precautions can be lifted
• If maternal infection confirmed, baby to be isolated for 3 weeks
• If both mother and baby test positive, they can be reunited https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1002/uog.24968
Monkeypox is usually a mild self-limiting illness, spread by very close contact with someone with monkeypox and most people recover within a few weeks. https://www.gov.uk/government/news/monkeypox-cases-confirmed-in-england-latest-updates
Initial symptoms of monkeypox include fever, headache, muscle aches, backache, swollen lymph nodes, chills and exhaustion. A rash can develop, often beginning on the face, then spreading to other parts of the body including the genitals. The rash changes and goes through different stages – it can look like chickenpox or syphilis, before finally forming a scab which later falls off.
Because the virus spreads through close contact, we are urging everyone to be aware of any unusual rashes or lesions and to contact a sexual health service if they have any symptoms.
“A notable proportion of recent cases in the UK and Europe have been found in gay and bisexual men so we are particularly encouraging these men to be alert to the symptoms” Dr Susan Hopkins, Chief Medical Adviser, UKHSA
UKHSA health protection teams are contacting people considered to be high-risk contacts of confirmed cases and are advising those who have been risk assessed and remain well to isolate at home for up to 21 days. In addition, UKHSA has purchased supplies of a safe smallpox vaccine (called Imvanex) and this is being offered to identified close contacts of someone diagnosed with monkeypox to reduce the risk of symptomatic infection and severe illness.
It’s very uncommon to get monkeypox from a person with the infection because it does not spread easily between people. But it can be spread through:
- touching clothing, bedding or towels used by someone with the monkeypox rash
- touching monkeypox skin blisters or scabs
- the coughs or sneezes of a person with the monkeypox rash
For full information from the UK Government and WHO see:
- The epidemiology, symptoms, diagnosis and management of monkeypox virus infections. https://www.gov.uk/guidance/monkeypox (May 2022)
The incubation period is the duration/time between contact with the infected person and the time that the first symptoms appear. The incubation period for monkeypox is between 5 and 21 days.
- World Health Organisation Monkeypox (May 2022) https://www.who.int/news-room/fact-sheets/detail/monkeypox
Transmission can occur via the placenta from mother to fetus (which can lead to congenital monkeypox) or during close contact during and after birth.
Vaccination with smallpox vaccine during breastfeeding
MVA-BN is not contraindicated if breast-feeding. It is not known whether MVA-BN is excreted in human milk, but this is unlikely as the vaccine virus does not replicate effectively in humans. Individuals who are breast feeding and have a significant exposure to monkeypox should therefore be offered vaccination, after discussion about the risks of monkeypox to themselves and to the breast-fed child. UKHSA Recommendations for the use of pre and post exposure vaccination during a monkeypox incident May 22 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1077678/Recommendations-for-use-of-pre-and-post-exposure-vaccination-during-a-monkeypox-incident.pdf?fbclid=IwAR2mS-bJgP3LLvvzNUS5aQf4SR3ZIdvg1Fn7XAxHTe7Vpm3KTDt0JPauNbg
Further information on monkeypox infection in pregnancy
- Kisalu NK, Mokili JL. Toward Understanding the Outcomes of Monkeypox Infection in Human Pregnancy. J Infect Dis. 2017;216(7):795-797. doi:10.1093/infdis/jix342 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279131/?fbclid=IwAR1MVfVw9dQLR5ITTLEod3xhJAsvkdtLFkycDeIdIbBk-zja5CL4rlxNnFw
- Placide K Mbala, John W Huggins, Therese Riu-Rovira, Steve M Ahuka, Prime Mulembakani, Anne W Rimoin, James W Martin, Jean-Jacques T Muyembe, Maternal and Fetal Outcomes Among Pregnant Women With Human Monkeypox Infection in the Democratic Republic of Congo, The Journal of Infectious Diseases, 2017: 216 (7): 824–828, https://doi.org/10.1093/infdis/jix260 https://academic.oup.com/jid/article/216/7/824/4348689?fbclid=IwAR1MVfVw9dQLR5ITTLEod3xhJAsvkdtLFkycDeIdIbBk-zja5CL4rlxNnFw&login=false
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.
There is much information in this factsheet.
Back long ago before books and training material, let alone the website, I wrote a training pack for professionals with support from Roberta Roulstone from Peterborough Hospital. She inspired me to share my knowledge and changed my life. Another person who helped with the IT was Sarah Saunby a very great friend who I miss seeing.
This is an up to date version of that training which I have been picking up and putting down for a while. I hope it helps professionals to protect and support breastfeeding whilst adding to their own CPD.
For once I got round to recording it! But have included a link to the powerpoint as some links got covered up in my recording
This is an adapted version of a training powerpoint I gave some time ago. I plan to record it over the next few weeks and will upload it to my You Tube channel.
But hope it helpsin the meantime. Happy to answer any questions email@example.com
I was only involved in preparing one table of this article but it deserves to be widely shared as an excellent model of support for breastfeeding by all in primary care – doctors, nurses and pharmacists
so proud and delighted to have worked with Lisa, Carmella and Jane over the past year to have this published in the BMJ today. To find out different practices across the world has been fascinating but I so hope this informs clinical practice
I have recorded the presentation which I have frequently given about perinatal mental health and breastfeeding. It should be used after listening to ” How drugs get into milk”
as it contains the pharmacokinetic data of drugs prescribed for perinatal mental health including SSRIs, anti anxiety medication and anti psychotics. It also includes research studies about the links between mental health and breastfeeding.
I hope this may increase prescriber’s knowledge as well as empower peer supporters and parents.
I have been working with a small team of anaesthetists for some time to develop guidelines so that breastfeeding mothers can have surgery, pain relief etc and continue to breastfeed as normal. The guideline also recommends support for the mother in terms of pumps, information and her baby nearby – not necessarily in that order.
World Breastfeeding Week 2020 I was proud to share this guideline and infographic
Guideline on anaesthesia and sedation in breastfeeding mothers is available in full at