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Bismuth subsalicylate (Pepto Bismol®) and Breastfeeding

Another of the frequently asked questions is the use of Pepto Bismol™ for indigestion or nausea

Pepto Bismol™ is marketed to relieve symptoms of upset stomach and diarrhoea. It’s active ingredient is bismuth subsalicylate, so it is related to aspirin which we avoid during breastfeeding at painkilling doses.

We are unsure if bismuth subsalicylate passes into a mother’s breast milk. Although bismuth salts are poorly absorbed from the maternal GI tract, significant levels of salicylate could be absorbed in theory. There are currently no reports of Reye’s syndrome in babies exposed to bismuth subsalicylate and it is normally only used very short term for stomach upset.

Breastfeeding mothers would be well advised to use alternative products to treat acute diarrhoea E.g. loperamide (Imodium®) if possible. However, In my experience of queries Pepto Bismol may be the only product available late at night and at weekends. The risk of short term use is probably low although this cannot be proved. The decision remains with the mother as to whether she wants to take it. Continuing to breastfeed during a stomach upset transfers antibodies to the baby to offer protection from the bacterial or viral condition.

It is also advertised to treat heartburn and indigestion for which there are many alternative remedies which are safe in breastfeeding, containing aluminium, calcium and magnesium carbonate.

See also https://www.e-lactancia.org/breastfeeding/bismuth-sub-oxysalicylate-2/synonym/

A very small amount of bismuth is absorbed from the gut: ≈ 0.1% (Tora 2020, Chen 2010, Boertz 2009, Dresow 1992, Nwokolo 1990: Bismuth is not absorbed into the systemic circulation of the mother, so it cannot be excreted in breast milk.

Salicylate is well absorbed (Nwokolo 1990), but is excreted in breast milk in negligible amounts, and the infant receives a relative dose of 1% (see Aspirin) and no cases of Reye’s syndrome have been reported after taking bismuth salicylate or other non-acetylated salicylate compounds.

Due to the otherwise minimum risk of Reye’s syndrome and the indiscriminate use of bismuth subsalicylate for treatment of gastroenteritis cannot be justifiable since most of gastroenteritis do not require medication instead a simply adequate hydration, a safer alternative should be desirable while breastfeeding. (Chen 2010, Nice 2000) 

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