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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/
This week I posted a link to a recently published paper which concluded that poor pain relief after a C section affected breastfeeding. https://consultqd.clevelandclinic.org/following-cesarean-delivery-postoperative-pain-affects-likelihood-of-in-hospital-breastfeeding/
I was saddened that we even had to think that pain would not be managed well for any mother, let alone when she was trying to initiate breastfeeding. It isn’t always easy to life a baby from a cot side crib when you have had surgery, let alone try to position a baby to achieve the perfect latch.
What surprised and horrified me was the mother’s who replied that they hadnt been given good pain relief when in hospital. They mentioned:
- not being told that more than paracetamol was available
- being offered only paracetamol and ibuprofen even when they needed more
- being forgotten on medication rounds,
- being discharged without sufficient pain relief.
This just isnt good enough and I would hope that everyone to whom this applies contacts the ward directly or through PALS that pain management plans are essential.
Pain relief which should be given to a breastfeeding mum in my opinion:
- In theatre a non steroidal anti inflammatory eg diclofenac as a suppository
- On the ward there should be available oramorph (subject to extensive first pass metabolism so little in milk)
- Regular use of an NSAID – ibuprofen, diclofenac or naproxen (low levels in milk) plus paracetamol
- Codeine is no longer recommended but dihydrocodeine can be offered https://breastfeeding-and-medication.co.uk/thoughts/breastfeeding-and-codeine
- Discharge packs should include the NSAID offered in hospital plus limited number of dihydrocodeine and if necessary oramorph. This may challenge the formulary in the hospital but can be overcome simply with care and thought for the patient.
NO WOMAN SHOULD BE LEFT IN PAIN BECAUSE SHE IS BREASTFEEDING
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.
It is normal during lactation to notice that your hair becomes thinner or may even appear to drop out in significant levels. In pregnancy we grow more hair and the apparent loss is usually just a return to normal.
It may however, be a sign of thyroid deficiency so always worth checking with your doctor and requesting a blood test to check levels, just in case.
Most of the commercially available products which claim to thicken, strengthen, promote growth of hair contain biotin in addition to the normal vitamins and minerals.
Symptoms of biotin deficiency include thinning hair, skin rash, and depression. The recommended daily dose of biotin for a lactating woman is 35 µg/day. Levels of biotin in human milk range from 5 to 9 µg/L, indicating that there is active transport of biotin into milk. No adverse effects have been found. (Hale Medications and Mother’s Milk)
Biotin (vitamin B7) is needed in very small amounts to help the body break down fat. The bacteria that live naturally in the bowel synthesise biotin, so it’s unclear whether supplements are necessary if a varied and balanced diet is eaten.. Biotin is also found in a wide range of foods, but only at very low levels. There’s not enough evidence to know what the effects might be of taking high daily doses of biotin supplements. Taking 0.9mg or less a day of biotin in supplements is unlikely to cause any harm. ( NHS Vitamin B https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-b/)
Vitamin and Mineral content compatible with breastfeeding https://breastfeeding-and-medication.co.uk/fact-sheet/breastfeeding-and-multivitamin-and-mineral-supplements
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
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)
Certolizumab pegol is anti TNF alpha drug used to treat rheumatoid arthritis, Crohn’s disease, psoriatic arthritis, and ankylosing spondylitis. What makes it different is that it is the first drug I can remember which has been licensed for use in pregnancy and in breastfeeding. This means that the manufacturer in applying for marketing authority has accepted that it is safe. www.medicines.org.uk/emc/product/7387/smpc
Recently I have found myself suggesting it to mothers who are at the point of needing methotrexate to control their symptoms and therefore needing to stop breastfeeding.
I have to congratulate the manufacturer UCB Pharma on taking this very positive step and hope others follow suite. Please note I have no links financial or otherwise with them.
This is the study