Home » Thoughts
Category Archives: Thoughts
Just recently I have been contacted by several mothers who were told that they cant breastfeeding during the 24 hour period of bowel prep prior to a colonoscopy or for 24 hours following the procedure under sedation. This is not supported by research and understanding of the pharmacokinetics of the drugs used. It is also a potential risk in that the mother may develop blocked ducts or mastitis necessitating antibiotics if she is unable to express her milk, or in many cases hasn’t been advised to! Not all babies will drink from a bottle so may become dehydrated. Some babies are allergic to cow’s milk protein and may be compromised by 3 days of artificial formula. Hence this fact sheet on the bowel preparations generally used.
It is acceptable to breastfeed as normal during bowel prep. The mother should drink freely of the allowed clear fluids. Someone may be needed to look after the baby during rapid need to evacuate bowels – unless you have taken these products you cant begin to understand the urgency!
PDF of information available
An increasing number of breastfeeding mothers are having colonoscopies to investigate gut problems. The first stage of a colonoscopy is the use of a strong laxative and 24 hours of a fluid only diet to clear out the gut so that the professionals can see the gut in its entirety completely.
Many mothers worry that not eating for 24 hours will reduce their milk supply. Fasting does drop the supply a small amount for some women but frequent feeds seem to overcome problems. It is important to keep drinking the clear fluids which are allowed in order not to dehydrate.
From experience you may find that you need someone else in the house to take the baby urgently when you have to rush to the toilet – there is no waiting! You may find otherwise that you end up feeding whilst on the loo for practical reasons. The bowel washouts produce considerable urgency
One of the most commonly used laxative agents to clear the gut is Movicol ® otherwise known as polyethylene glycol- electrolyte solution. It is a saline laxative which is not absorbed from the gut but pulls water into the bowel to wash the contents out. Because it is not absorbed from the gut it cannot get into breastmilk and would not affect the baby.
This dual sachet product contains macrogol and electrolytes in 2 different sachets, Because it is not absorbed from the gut it cannot get into breastmilk and would not affect the baby.
Sodium picosulfate is not absorbed from the gastrointestinal tract, and its active metabolite, which is absorbed, is not detectable in breastmilk. Breastfeeding can continue as normal.
KleanPrep contains macrogol 3350 , an osmotic laxative with a high molecular weigh and zero oral bioavailabilty. Like Moviprep it accumulates water into the GI tract, where it acts as a laxative. It would be very unlikely to enter the plasma of the mother, or milk.
The ingredients magnesium carbonate and citric acid will form an osmotic laxative by pulling water into the bowel and stimulating the bowel to evacuate. Poor oral absorption of magnesium make it unlikely that any will be absorbed from milk to affect the breastfed baby.
Senna is a stimulant laxative. Its key ingredient (anthraquinone), is believed to increase bowel activity due to secretion into the colon. It may produce abdominal cramps. In one study of 23 women who received Senokot none was detectable in their milk. Of 15 mothers reporting loose stools, two infants had loose stools (Werthmann 1973). However, in a randomized, double-blind trial comparing Senokot tablets to placebo, of the women in the study, 126 breastfed their infants and took senna while 155 control mothers breastfed their infants. There was no difference in the percentages of infants in the active and control groups with loose stools or diarrhoea (Shelton 1980). In this study 8 doses were taken. In bowel preparation a single dose only is used.
Werthmann MW Jr, Krees SV. Quantitative excretion of Senokot in human breast milk. Med Ann Dist Columbia. 1973;42:4-5.
Shelton MG. Standardized senna in the management of constipation in the puerperium. A clinical trial. S Afr Med J. 1980;57:78-80.
Phosphate enema (Fleet®)
Sodium phosphate is a saline laxative which sucks water into the lumen of the bowel. Whilst some phosphate may get into the plasma, it is very unlikely to change the levels in milk. The oral bioavailabilty is zero to 20%. Use of phosphate enemas should not require interruption of breastfeeding (LactMed)
Bisacodyl (Dulcolax ®)
Bisacodyl is poorly absorbed from the gut (oral bioavailabilty <5%) and so reaches low levels in breastmilk. It is a stimulant laxative. Breastfeeding can continue as normal
For information on sedatives (midazolam, fentanyl, pethidine) used in colonoscopies see separate fact sheet . These also do not preclude normal breastfeeding as soon as the mother is awake and alert.
Taken from Breastfeeding and Chronic Medical Conditions available from Amazon.
Most vaccinations can be undertaken during breastfeeding as they do not pass into breastmilk. For detailed information please check the Green Book which has sections for breastfeeding. https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book
- Chicken pox (varicella): compatible with normal breastfeeding
- Hepatitis A: compatible with normal breastfeeding
- Hepatitis B: Vaccinations are routinely offered to healthcare professionals who may come into contact with body fluids. Compatible with normal breastfeeding
- Influenza: compatible with normal breastfeeding
- Meningococcal C: Immunization of pregnant or lactating women with meningococcal vaccine increased the specific secretory IgA content of milk. compatible with normal breastfeeding
- MMR Injections: A breastfeeding mother can have an MMR injection if she is not rubella immune. Although live vaccines multiply within the mother’s body, the majority have not been demonstrated to be excreted in human milk (Bohlke K, Galil K, Jackson LA, et al. Postpartum varicella vaccination: is the vaccine virus excreted in breast milk? Obstet Gynecol 2003; 102:970–7). Although rubella vaccine virus might be excreted in human milk, the virus usually does not infect the infant. If infection does occur, it is well-tolerated because the virus is attenuated. Inactivated, recombinant, subunit, polysaccharide, conjugate vaccines, and toxoids pose no risk for mothers who are breast feeding or for their infants.
- Pneumonia: compatible with normal breastfeeding
- Polio: The injectable polio vaccine is inactivated and poses no risk when given to mothers who are breastfeeding. The oral vaccine may reduce the production of antibodies by the infant and immunisation of the mother before the infant reaches 6 weeks of age is not recommended.
- Tetanus Vaccination: One study of previously vaccinated infants found that at 21 to 40 months of age breastfed infants had higher IgG levels against diphtheria, higher secretory IgA levels in saliva against diphtheria and tetanus and higher faecal IgM against tetanus than formula-fed infants. There is no contra indication to a breastfeeding mother having this vaccination.
- Tuberculin and BCG: There is no reason to avoid tuberculin testing during breastfeeding nor to avoid use of the BCG vaccine unless the mother is immunocompromised.
- Typhoid Vaccination: One study of previously vaccinated infants found that at 21 to 40 months of age breastfed infants had higher IgG levels against diphtheria, higher secretory IgA levels in saliva against diphtheria and tetanus and higher faecal IgM against tetanus than formula-fed infants. There is no contra indication to having the vaccination and continuing to breastfeed.
- Whooping Cough: there is no evidence of risk of vaccinating breastfeeding mothers with the whooping cough (pertussis) vaccine as part of the campaign to protect new-born babies.
I keep being asked about strong analgesics in breastfeeding. Lots of people seem unaware that codeine and dihydrocodeine sound similar but do not have the same risk in breastfeeding. Although many babies dont exhibit drowsiness when exposed to codeine during breastfeeding, dihydrocodeine is preferred.
This explains why:
The analgesic effect of dihydrocodeine appears to be mainly due to the parent compound. The oral bio availability of dihydrocodeine is 20% due to substantial first pass metabolism. The half life is quoted as 3.5-5h . It is metabolised in the liver by CYP2D6 to dihydromorphine, which has potent analgesic activity. However, the CYP2D6 pathway only represents a minor route of metabolism, with other metabolic pathways being involved.
The metabolism of dihydrocodeine is not affected by individual metabolic capacity as the analgesic effect is produced by the parent drug compared to codeine which is a pro drug.
Dihydrocodeine may be the preferred weak opioid for postoperative use in the breastfeeding woman, because of its cleaner metabolism compared with codeine and wide experience of use after caesarean section. As with any strong painkillers the baby should be monitored for drowsiness and changes in feeding pattern. Dihydrocodeine may be combined with paracetamol as co-dydramol.
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.
The reason I write these factsheets is in response to the questions which are posed to me on social media. I have included the use of midazolam in fact sheets on colonoscopy, endoscopy and dental sedation on information on the Breastfeeding Network but still mothers are told that they need to delay procedures, are only allowed gas and air during the procedure or must stop breastfeeding for 24 hours. The latter is recommended by the manufacturers but since the half life is 3 hours it is all gone from the mother’s body and therefore her milk within 15 hours. However, looking at the pharmacokinetics of midazolam use as a single dose sedative is not a contra indication to normal breastfeeding as confirmed
Guideline on anaesthesia and sedation in breastfeeding:
“Midazolam: extensive first-pass metabolism results in low systemic bioavailability after oral doses, so blood levels in the infant after breastfeeding can be expected to be low . Breastfeeding can be resumed after a single dose of midazolam as soon as the woman has recovered from the procedure.”
This factsheet contains information taken from my book Breastfeeding and Medication 2018. I hope it helps breastfeeding mums and professionals
Endometriosis is a condition where tissue similar to that lining the womb, starts to grow in other places, such as the ovaries and fallopian tubes. Endometriosis can affect women of any age. The exact number of women who develop endometriosis is unknown. This is because many women have endometriosis without symptoms, or with mild symptoms, and are never diagnosed. Estimates vary, from 1 to 5 in 10 of all women having some degree of endometriosis. Symptoms typically develop between the ages of 25-40 but can begin in teenage years. The condition can run in families.
It can be incredibly painful and hard to live with as evidenced by the mothers in this factsheet who shared their stories. Sadly it is often poorly recognised
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
Mothers have been reporting that they have been advised to interrupt breastfeeding or even stop altogether in order to have skin and patch allergy testing. This doesn’t seem based on evidence but possibly without national guidelines.
The allergens do not pass into the blood stream let alone breastmilk so there is no reason to interrupt breastfeeding.
Should you react severely to an allergen test and require administration of an antihistamine, an adrenaline injection (e.g. EpiPen) or a steroid that does not stop you breastfeeding as normal
Adrenaline/epinephrine injection e/g/ EpiPen ™. Ingredient present in milk but unlikely to be harmful as poor oral bioavailability . Half life 2 minutes so all gone from the body in 10 minutes.
Antihistamine – https://www.breastfeedingnetwork.org.uk/antihistamines/
Prednisolone – https://www.breastfeedingnetwork.org.uk/prednisolone/
Recently whilst writing the planned book (hopefully coming soon) I decided to update the section on the website about “Who Am I?” It is about how I came to have this passion and to write my books and the inspiration and support of my husband, my girls and my grandchildren.
I hope it explains a little more about what drives me to do this 18 hours a day 365 days a year.
Do you want to buy a copy of one of my books? They are all available on Amazon which is probably easiest. Or direct from the publishers Routledge, Pinter and Martin, Praeclarus Press or Kindle . I’m not going to available as much in the future to answer questions so maybe now is the time to buy the books so you have answers 24/7 365 days a year.
Several questions have come up recently about caffeine intake and breastfeeding. With spending more time indoors we are probably all drinking more caffeinated beverages.
Most of us drink caffeine in one form or another. Women who drink a significant amount of caffeinated drinks who notice that their babies are jittery and restless, may find reduction in caffeine consumption leads to resolution of symptoms. This does not mean that all breastfeeding women need to restrict their consumption of tea and coffee A baby who appears restless may benefit from lowered caffeine intake by the mother but for the average consumption there is little evidence to support restricting intake. From research maternal consumption below 300 milligrammes a day should not cause issues for breastfed babies.
Extract reproduced from Breastfeeding and Medication 2018 by Jones W (Routledge, London)