Turmeric supplements and breastfeeding

Turmeric is a supplement recommended for the relief of inflammation in many chronic conditions. It is, of course, a spice used in curries.

When taken as a supplement levels are significantly higher than those used for culinary purposes.

This is the information on compatibility with breastfeeding that I found in LactMed https://www.ncbi.nlm.nih.gov/books/NBK501846/ (the emphasis is my own) :

Summary of Use during Lactation

Turmeric (Curcuma longa) rhizome contains curcuminoids such as curcumin. No data exist on the excretion of any components of turmeric into breastmilk or on the safety and efficacy of turmeric in nursing mothers or infants. Turmeric is “generally recognized as safe” (GRAS) as a food ingredient by the U.S. Food and Drug Administration. Turmeric is generally well tolerated even in high doses, but gastrointestinal side effects such as nausea and diarrhea, and rare allergic reactions have been reported, and it may increase the risk of bleeding in patients taking warfarin and antiplatelet drugs.

Because of a lack of data, turmeric in amounts higher than those found in foods as a flavoring should probably be avoided during breastfeeding.

Turmeric has been used as a galactogogue in India;[1][2] however, no scientific data support this use. In Thailand it is reportedly used as part of a topical herbal mixture to shorten the time to full lactation and also part of a topical herbal mixture used for breast engorgement.[3][4] Galactogogues should never replace evaluation and counseling on modifiable factors that affect milk production.[5] In India turmeric is a component of a paste applied to the breasts for sore nipples.[6] Contact dermatitis has been reported after contact of the skin with curcumin-containing products.[7]

References from LactMed https://www.ncbi.nlm.nih.gov/books/NBK501846/

1.Sayed NZ, Deo R, Mukundan U. Herbal remedies used by Warlis of Dahanu to induce lactation in nursing mothers. Indian J Tradit Knowl. 2007;6:602-5.2.Chaudhuri RN, Ghosh BN, Chatterjee BN. Diet intake patterns of non-Bengali Muslim mothers during pregnancy and lactation. Indian J Public Health. 1989;33:82-3. [PubMed]3.Dhippayom T, Kongkaew C, Chaiyakunapruk N et al. Clinical effects of Thai herbal compress: A systematic review and meta-analysis. Evid Based Complement Alternat Med. 2015;2015:942378. [PMC free article] [PubMed]4.Ketsuwan S, Baiya N, Paritakul P et al. Effect of herbal compresses for maternal breast engorgement at postpartum: A randomized controlled trial. Breastfeed Med. 2018;13:361-5. [PubMed]5.Brodribb W. ABM Clinical Protocol #9: Use of galactogogues in initiating or augmenting maternal milk production, second revision 2018. Breastfeed Med. 2018;13:307-14. [PubMed]6.Amuthavalluvan V, Devarapalli J. Indigenous knowledge and health seeking behavior among Kattunayakan: a tribe in transition. Glob J Human Soc Sci. 2011;11. http:​//socialscienceresearch​.org/index.php​/GJHSS/article/view/198/161.7.Chaudhari SP, Tam AY, Barr JA. Curcumin: A contact allergen. J Clin Aesthet Dermatol. 2015;8:43-8. [PMC free article] [PubMed]

Collagen and breastfeeding

Collagen seems to be another frequent supplement I get asked about . Collagen is found in connective tissue and can be used during exercise routines but also in the prevention and treatment of wrinkles as well as to strengthen hair I believe.

There are no studies on passage into breastmilk and it would therefore be unethical for me to comment.

Sorry – another of the increasing number of natural products which seem to be attracting attention during lockdown and as we emerge.

Retinoid beauty creams and breastfeeding

With the launch of a new beauty cream containing retinol advertised as reducing wrinkles, the questions about beauty products similar to it have increased. Or maybe we all just need something to cheer us up during Lockdown.

There is no research on the use of topical retinols and the best information I have sourced is “Because it is poorly absorbed after topical application, it is considered a low risk to the nursing infant” (Lactmed accessed June 2020 studies referenced below.)

Hale (Medications and Mother’s Milk accessed June 2020 states “Tretinoin is a retinoid derivative similar to Vitamin A. It is primarily used topically for acne and wrinkling and sometimes psoriasis. Used topically, tretinoin stimulates epithelial turnover and reduces cell cohesiveness.[1] Blood concentrations measured 2-48 hours following application are essentially zero.

I have been unable to access the full papers and so would recommend caution

They

  • Leachman SA, Reed BR. The use of dermatologic drugs in pregnancy and lactation. Dermatol Clin. 2006;24:167-97. [PubMed]
  • Zip C. Common sense dermatological drug suggestions for women who are breast-feeding. Skin Therapy Lett. 2002;7:5-7. [PubMed]
  • Butler DC, Heller MM, Murase JE. Safety of dermatologic medications in pregnancy and lactation: Part II Lactation. J Am Acad Dermatol. 2014;70:417.e1-417.e10. [PubMed].
  • Zbinden G. Investigation on the toxicity of tretinoin administered systemically to animals. Acta Derm Verereol Suppl(Stockh) 1975; 74:36-40.
  • Lucek RW, Colburn WA. Clinical pharmacokinetics of the retinoids. Clin Pharmacokinet 1985; 10(1):38-62

Betahistine and Breastfeeding

Betahistine (Serc ) is prescribed for dizzines and vestibular problems. There is little research available on it, because it isnt marketed in USA where most of the research studies are conducted. Anecdotally it is quite widely used without apparent problems. Observe the nursing baby for signs of drowsiness/ poor feeding in case

This is the entry I made for Breastfeeding and Medication 2018

“Betahistine is prescribed for vertigo, tinnitus and hearing loss associated with Ménière’s disease. There is no data on the amount that passes into breastmilk . It is an analogue of histamine and is believed to work by improving the microcirculationn of the labarynth. Side effects are reported to include gastro-intestinal disturbances, headache,  pruritus and rashes. Prochlorperazine or cinnarazine would be the preferred to drug to treat dizziness. If betahistine use is perceived as essential the baby should be observed for drowsiness, GI disturbance and rash. There are no animal studies on use during lactation. Plasma levels of betahistine are very low. Plasma protein binding <5% (manufacturer SPC) Anecdotally it has been used without problems in breastfed babies “

The BNF entry (online access May 2020 is ” Use only if potential benefit outweighs risk—no information available”.

Botox for medical purposes

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 May 2020)

Products to support hair growth/ thickness

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

Protein Shakes and Breastfeeding

During the “lockdown” I have had more questions than usual about using protein shakes as part of a return to fitness/ exercise programme. Great to see so many people getting fit but sadly I cant help on the use of protein shakes as there is no research that I have found to prove safety. I’m not happy to comment without evidence to back what I say which I am sure you understand.

Live vaccinations and Immunosuppressant medication taken by breastfeeding mothers

To finish the posts on immunosuppresant medications the final most frequently asked question is about the administration of live vaccinations to the baby. This is particularly a problem with the rotavirus vaccine.

The Torento consensus statement also suggested that live vaccinations are not recommended within the first 6 months of life in the offspring of women who were on anti-TNF therapy during pregnancy. The babies of mothers taking immunosupressant drugs eg azathioprine and infliximab have not been shown to be immunocompromised because of the limited passage of medication through breastmilk.

However, if live vaccinations, particularly rotavirus are used then the mother with IBD should use precautions like wearing gloves when changing the baby’s nappy for 2 weeks after the vaccination to avoid picking up the particles of live virus shed in faeces.

The Rotavirus Vaccination Programme Public Health England

” There is a potential for transmission of the live attenuated virus in Rotarix vaccine from the infant to severely immunocompromised contacts through faecal material for at least 14 days. However, vaccination of the infant will offer protection to household contacts from wild-type rotavirus disease and outweigh any risk from transmission of vaccine virus to any immunocompromised close contacts. Those in close contact with recently immunised infants should, as always, observe good personal hygiene which should include handwashing after changing the infant’s nappy”

” Rotavirus vaccine should not be given to infants of mothers that used immunosuppressive biological therapy during their pregnancy because of the potential that these will have a postnatal influence on the infants’ immune status. It is recommended that immunisation with live vaccines should be delayed for 6 months in children born to mothers who were on immunosuppressive biological therapy (TNFα antagonists and other biological medicines such as Infliximab) during pregnancy. As Rotarix vaccine is contraindicated in infants presenting for the first dose after 15
weeks of age (beyond 14 weeks and 6 days), infants whose mothers received such treatment during pregnancy will therefore not be eligible to receive Rotarix vaccine, but they should benefit from herd (indirect) protection.”

” Infants born to mothers who received non-biological immunosuppressive therapy such as steroids, cyclosporine, tacrolimus or azathioprine at any time during their pregnancy can safely have the rotavirus vaccine at the appropriate age.


A recent review of the literature concluded that it is safe for mothers to breastfeed while on immune suppression that includes steroids, cyclosporine, tacrolimus or azathioprine. Breastfed infants of mothers taking immunosuppressive therapy can receive rotavirus vaccine at the appropriate age. Rotarix vaccine should not be administered to breastfeeding infants whose mothers are using biological medicines such as Infliximab.”

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770826/Rotavirus_vaccination_programme__information_document_Nov_2018.pdf

  • Sameh M, Mohsen EK, Jon JK, Halawa A, Sharma Al. Safety of Breastfeeding by Mothers on Immunosuppressive
    Medication for Renal Transplantation: Obsession, Myth and Truth. JOJ Uro & Nephron. 2017; 3(3): 555612. Available at
    www.juniperpublishers.com/jojun/pdf/JOJUN.MS.ID.555612.pdf
  • Public Health England. Immunisation against infectious disease. Contraindications and Special Considerations. Chapter 6.
    www.gov.uk/government/publications/contraindications-and-special-considerations-the-green-book-chapter-6

Infliximab and breastfeeding

Following on from the page on Azathioprine I thought it would be useful to add data on infliximab which is also widely used by breastfeeding mothers. Like most of the biologicals the molecules are too large to pass into milk.

This information is taken from Breastfeeding and Medication

In 2002, the NICE (NICE 2002) recommended that this drug be only used for the treatment of severe, active CD when treatment with immunosuppressant drugs and corticosteroids is not tolerated or has failed.

It is now much more commonly prescribed to pregnant and breastfeeding women.

Infliximab is a large molecular weight antibody and preliminary results suggest it is too large to pass into breastmilk and it is not orally bio-available. It is distributed primarily in the vascular compartment and has a terminal elimination half-life of 8 to 9.5 days.

It is suggested that use by a mother should not preclude breastfeeding based on this data (Peltier 2001; Forger 2004; Mahadevan 2005; Basilisks 2006).

The BNF states that the amount in breastmilk is too small to be harmful.

Compatible with breastfeeding due to poor bio-availability and hence low-level absorption by the infant.

Infliximab is usually either not detectable in breastmilk or detectable at very low levels. Absorption of the drug from milk by the infant is minimal. Follow-up of infants exposed in utero and breastfed during maternal infliximab therapy have found no adverse effects and normal development. The measurement of minute concentrations in the milk of some women raises the possibility of local immune suppression in the gastrointestinal tact, but levels were not high enough to be of concern for systemic immunosuppression (LactMed)

References

  • Forger F, Matthias T, Oppermann M Becker H, Helmke KInfliximab in breastmilk, Lupus, 2004;13:753. Abstract NICE Crohns Disease – infliximab 2002
  • Mahadevan U, Kane S, Intentional infliximab use during pregnancy for induction or maintenance of remission in Crohn’s disease, Aliment Pharmacol Ther, 2005;21:733–8.
  • Peltier M, James D, Ford J, Wagner C, Davis H, Hanauer S Infliximab levels in breastmilk of a nursing Crohn’s patient, Am J Gastroenterol, 2001;96(9 Suppl. 1):S312. Abstract.
  • Vasiliauskas EA, Church JA, Silverman N, Barry M, Targan SR, Dubinsky MC, Case report: evidence for transplacental transfer of maternally administered infliximab to the new born, Clin Gastroenterol Hepatol, 2006;4:1255–8.

Any queries please contact me on wendy@breastfeeding-and-medication.co.uk

If you have IBD or have an interest in it please join the facebook page https://www.facebook.com/groups/BreastfeedingIBD/

Azathioprine and breastfeeding

I frequently get asked about the compatibility of azathioprine during breastfeeding . It is used for several auto-immune diseases including inflammatory bowel disease and sometimes rheumatoid arthritis. It is actually quite widely taken by breastfeeding mothers from the questions I receive.

This information is taken from Breastfeeding and Medication

“Azathioprine is an immunosuppressive anti-metabolite. It is converted to mercaptopurine in the body. It has a corticosteroid-sparing effect and is widely used to produce and maintain remission in IBD, as well as conditions such as lupus and rheumatoid arthritis.

Traditionally, breastfeeding by mothers have been discouraged from continuing to breastfeed if taking azathioprine because of the theoretical risks of infant bone marrow suppression, susceptibility to infection, growth retardation and pancreatitis.

According to recent research (Gardiner et al. 2007) breastfeeding need not be withheld in infants whose mothers are taking azathioprine. Gardiner et al. studied four mothers taking azathioprine. The metabolites 6-MP and 6-TGN were undetectable in neonatal blood and no clinical signs of immunosuppression were observed in the infants. Similarly Moretti et al. (2006) studied four babies and measured levels of 6-MP in breastmilk and neonatal blood for drug levels, white cell and platelet counts. Levels of metabolites were below the level of detection in the neonates and no clinical signs of immunosuppression were observed. Sau et al. (2007) studied ten women and similarly found no immunosuppression. Women taking azathioprine should therefore not be discouraged from breastfeeding.

It is licensed to be given to children over the age of 2 years at a dose of 2 mg per day initially for severe UC and CD. Relative infant dose is quoted as 0.07% to 0.3% (Hale 2017 online access).

The BNF states that it is present in milk in low concentrations, that there is no evidence of harm in small studies and the drug may be considered if the potential benefit outweighs the risk.

Compatible with breastfeeding according to more recent studies; metabolites undetectable in infant’s blood and no signs of immunosupression in studies.

  • Gardiner SK, Gearry RB, Roberts RL, Zhang M, Barclay ML, Begg EJ, Exposure to thiopurine drugs through breastmilk is low based on metabolite concentrations in mother-infant pairs, Br J Obstet Gynecol, 2007;114:498–501.
  • Sau A, Clarke S, Bass J, Kaiser A, Marinaki A, Nelson-Piercy C, Azathioprine and breastfeeding – is it safe?, BJOG, 2007;114:498–501.
  • Moretti ME, Verjee Z, Ito S, Koren G, Breastfeeding during maternal use of azathioprine, Ann Pharmacother, 2006;40:2269–72.
  • Hale TW Medications and Mother’s Milk”

Any queries please contact me on wendy@ breastfeeding-and-medication.co.uk

For mothers with IBD, or professionals with an interest please join our Facebook page https://www.facebook.com/groups/BreastfeedingIBD/