Medications in Breastfeeding.

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Medications in Breastfeeding

26 June 2021|Breastfeeding and medications

 Many mothers find themselves in a position where they need to take medication during their breastfeeding
journey, and it is common and normal to have some concerns about the safety of those medications in
breastmilk and the potential impact on milk supply. And when prescribing practitioners are unsure about the
safety of the medication in breastfeeding, they may just advise to delay or cease breastfeeding in an attempt to
be extra cautious. In most cases, interrupting breastfeeding is not necessary. It is important that your
prescribing health professional is aware of where to seek further information in making decisions regarding
your treatment while protecting your breastfeeding journey. Always let your doctor know that you are
breastfeeding when planning medication management.
Good Sources of further information
Lactmed
Wendy Jones Factsheets
Thomas Hale Publications and Hale's Medications and Mothers' Milk app.
Women's and Children's Hospital (SA) Medicines Information 08 8161 7555 (9-5 weekdays)
NPS Medicines hotline 1300 633 424
MotherSafe (NSW) Royal Hospital for Women, Randwick 1800 647 848
Rodney Whyte at Monash Medical Centre (Vic) 03 9594 2361
Poisons Information is available 24 hours a day 7 days a week on 13 11 26 (all states & territories)

How are medications determined to be safe in breastfeeding?

There are a number of factors which help determine whether a medication is safe in breastfeeding or not.
These factors can be used to calculate the potential dose that a breastfed infant may receive via breastmilk.
- protein binding- A medication which binds at a high percentage to proteins is less likely to enter breastmilk.
- size of the drug molecule- large molecules pass less easily into breastmilk than small molecules.
- fat solubility- drugs which are highly lipid soluble will more easily pass into breastmilk due to the fat content in
milk.
- pH- weak organic bases (higher pH) are attracted to milk, whereas weak organic acids are held in maternal
plasma (less likely to enter breastmilk).
Also for consideration is if the medication is used routinely in infants and children, how the medication is
metabolised by the mother and the infant, impact on milk supply and potential side e"ects.
Always consider the risk versus the benefit. Interrupting breastfeeding to take medications may result in
challenges with breastfeeding and introducing the risks of formula, however, sometimes it is necessary to treat
the mother with a medication that may pose a risk to the infant and the best decision may be to cease or
interrupt breastfeeding for a period of time. In the majority of cases, breastfeeding should be able to continue
uninterrupted, but perhaps with some closer monitoring of the infant for potential side e"ects.
The following is a summary of medications commonly used and some considerations for use in breastfeeding
mothers. This information is not intended as a replacement for the advice of your prescribing professional.
Analgesics- Pain relief

Paracetamol L1- Paracetamol is considered a safe option for pain relief. There may be links to an increased risk
of the development of asthma in early childhood.
Ibuprofen (NSAID) L1- highly protein bound, Ibuprofen enters the milk in only tiny amounts. Ibuprofen is
considered a safe option and an analgesic of choice in lactating women.
Diclofenac (NSAID)L2- Levels found in milk are too low to be of concern, however as there is limited data
available, Diclofenac is considered an L2 classed medication.
Naproxen (NSAID) L3- Low amounts are found in milk, but Naproxen has a long half life and has been
associated with some symptoms in breastfed infants of drowsiness and vomiting (x2). It is 99% protein bound.
The amount presenting in breastmilk is considered too low to be harmful. Ibuprofen is a preferred alternative.
Codeine L3 - Codeine is no longer recommended for breastfeeding mums. Although Hale classes codeine as an
L3 (limited data, probably compatible), some people are ultra-rapid metabolisers, and can result in much higher
concentrations of the medication's metabolites (morphine) in the breastmilk. If a single, accidental dose is
taken, Wendy Jones recommends to continue breastfeeding if the baby is term, fit and well, and closely observe
the infant for signs of drowsiness and respiratory problems (apnoea- stopping breathing, cyanosis- blue tinged
skin, slow or shallow breathing). Please seek immediate and urgent medical attention if you are noticing any of
these symptoms. It takes 15 hours to clear from the body and the breastmilk.
Asprin L2- Asprin is not a preferred choice of analgesic in breastfeeding mothers due to its links to Reye
syndrome in infants and children. High doses in lactation when the infant has a virus should be avoided. Due
to Asprin being the drug of choice for treatment in rheumatic fever patients, a risk versus benefit assessment
should be considered.
Morphine L3- High doses over prolonged periods could lead to sedation and respiratory problems in newborn
infants, due to the decreased ability to metabolise and clear morphine. Adult rates of clearing Morphine is
achieved at around 2 months of age. Oral absorption of Morphine is very poor and levels absorbed from
breastmilk is likely to be not of concern in the stable breastfeeding infant.
Fentanyl L2- levels in milk are low to undetectable. Fentanyl has low oral bioavailability and has a short half life,
clearing from the maternal system quickly.
Mental Health (antidepressants, anxiolytics, antipsychotics)

We know that breastfeeding can be protective of mental health and that weaning can cause further
complications in mental health in some circumstances due to breastfeeding grief and changes in hormones.
Having parents that are feeling emotionally well enough to engage in their babies needs is important to infant
development. Sometimes medication is required for optimal feelings of wellbeing. There are medications
which are safe to take for mental health conditions while breastfeeding. Discuss the best options for your
situation with your prescribing doctor.
Amitriptyline L2- antidepressant compatible with breastfeeding with very small amounts entering breastmilk.
Amoxapine L2- antidepressant compatible with breastfeeding with very small amounts entering breastmilk.
Citalopram L2- drug of choice for anxiety and depressive disorders during pregnancy and lactation.
Duloxetine L3- Used as an antidepressant and for neuropathic pain, it is an option for patients with major
depressive disorder who have responded poorly to other medications. Transfer into milk of Duloxetine is low
compared to some other commonly used medications such as Venlafaxine, Desvenlafaxine, Citalopram,
Mirtazepine and Fluoxetine.
Escitalopram (Lexapro) L2- This medication can have a number of unpleasant side e"ects in the adult patient
such as cardiac issues, sedation, headache, nausea and insomnia but studies have found the drug to be
undetectable in breastfed infants of mothers taking the medication and nil adverse e"ects noted.
Fluoxetine (Prozac) L2- Sertraline and Escitalopram are preferred over Fluoxetine, however, if Fluoxetine is the
most e!ective medication for the breastfeeding individual, then it is not contraindicated to breastfeed, but the
infant should be observed for potential side e!ects. Colic behaviours, fussiness and crying have been observed
in one case study. potential sedation, irritability, not demanding feeds and growth should be monitored
Fluvoxamine L2- Miniscule amounts are transferred to infants via breastmilk and no adverse e!ects have been
noted.
Mirtazapine L3- Found in milk in low levels but considered safe in breastfeeding.
Nortriptyline L2- Studies suggest that breastfed infants exposed to Nortriptyline are unlikely to develop
detectable concentrations in plasma, and therefore breastfeeding is not contraindicated during its use.
Paroxetine (Aropax 20, Paxil) L2- Detected in breastfed infants in levels low to undetectable and considered
relatively safe in breastfeeding.
Sertraline (Zoloft) L2- Antidepressant drug of choice for breastfeeding mothers. low levels in breastmilk
Venlafaxine (E!exor) L2- Infants exposed in utero may have adverse e!ects immediately upon delivery, but it is
not clear whether this is due to the e!ect of the medication on the fetus or withdrawal symptoms after birth.
adverse e!ects from use in pregnancy may be relieved by exposure to the medication in breastfeeding.
Diazepam L3- Avoid if possible. Breastfeeding can continue as normal with single doses used for anxiety
provoking situations such as pre-surgery or fear of flying. Observe baby for drowsiness. Do not bed-share.
Lorazepam L3- Avoid if possible. Lorazepam is preferred over Diazepam. Low levels in breastmilk and short half
life. Do not bed-share
Alprazolam L3- Avoid if possible, but is the preferred benzodiazepine if required due to its short half life.
Antibiotics

Antibiotic use in breastfeeding mothers may cause a change in breastfed infants gut flora, diarrhoea, rash and
sometimes vomiting. The benefit of treating infection while continuing breastfeeding usually outweigh the mild
side e!ects noted in the infant. Discuss any concerns with your prescribing practitioner.
These commonly used antibiotics are considered compatible in breastfeeding:
Amoxicillin L1
Amoxicillin and Clavulanate (Augmentin) L1
Ampicillin L1
Cefazolin L1
Cephalexin L1
Clindamycin L2
Flucloxacillin L1 (commonly used to treat mastitis)
Gentamycin L2
Metronidazole L2 (found in high levels in breastfed infants of mothers taking the medication, but is a drug
considered safe to administer in pregnancy, premature neonates, infants and children)
Penicillin G L1
Trimethoprim L2 (long term use should be avoided due to interference with folate metabolism)
Vancomycin L1
These antibiotics should be used with caution
Azithromycin L2 (rare but serious toxicities have been associated with administration direct to infants, but no
documented side e!ects from exposure via breastmilk)
These antibiotics should be avoided in breastfeeding, or other alternative antibiotics are preferred.
Ciprofloxacin L3 (eye drops are considered to be safe)
Erythromycin L3 (associated with infantile hypertrophic pyloric stenosis)

Cold and Flu

Decongestants such as Pseudoephedrine (Sudafed) L3 should be avoided due to the potential to decrease milk
supply. Local nasal sprays such as Vicks Vapor Inhaler (Levmetamfetamine) L3 has no data available on use in
breastfeeding women but it is suspected that infant side e!ects would be minimal.
Oseltamivir Phosphate (Tamiflu) L2 is recommended for use in breastfeeding mothers by the CDC for treatment
of influenza a and B infections.
Antihistamine

There are safe option antihistamines available for breastfeeding mums. The preferred options are the non-
sedating medications.
Loratadine (Claratyne) L1 and Cetirizine (Zyrtec) L2 are considered safe options, as well as nasal sprays such as
Beclomethasone (Beconase) L2, Fluticasone L3, Mometasone (Nasonex) L3, Triamcinolone (Nasacort) L3.
Diphenhydramine (Benadryl) L2 can be used with caution, although other antihistamines are preferred. (can
cause drowsiness in some people).
Avoid Promethazine (Phenergen) and Chlorpheniramine as these can cause sedation and lower milk supply.
Nausea and Vomiting- antiemetics

Prochlorperazine (Stemetil) L3- Compatible with breastfeeding with short term use, but avoid long term use or if
the breastfeeding child is at risk of apnoea.
Domperidone (Motilium) L3- Compatible with breastfeeding and used as a galactagogue (medication to increase
milk supply)
Metoclopramide (Maxalon) L2- Compatible with breastfeeding, but due to side e!ects- extrapyramidal (muscle
spasms, dystonia, movement problems) and depression, Domperidone is preferred. Metoclopramide was
historically used a a galactagogue and also has the side e!ect of increasing milk supply.
Ondansetron (Zofran) L2- Avoid if possible as there is no information on its transfer via human milk.
Laxatives
Bisacodyl L2- limited secretion into breastmilk due to poor gastric absorption with little/no harmful e!ects
noted in infants.
Docusate L2- transfer of the medication into breastmilk is expected to be minimal. monitor for loose stools in
the infant
Lactulose L3- poorly absorbed and likely to not transfer into breastmilk
Senna L3- recommended for only short term use. one study showed none of the medication present in the
breastmilk of mothers taking it.
GoLytely L3- used for bowel prep prior to procedures. It is not absorbed in the adult gut and unlikely to enter
breastmilk.
When considering medication use:
- Drugs with published data are preferred over newer drugs.
- Caution should be taken with premature infants or medically complex infants.
- Is drug therapy necessary? Other options may be available.
- The safest drug should be chosen. Consultations between the infant's doctor and the prescribing doctor can
be helpful.
- If there is a possibility that a drug may present a risk to the infant, consideration should be given to
measurement of blood concentrations in the nursing infant.
- The safest medications are those which have short half lives (excreted quickly), high protein binding, low oral
bioavailablity or high molecular weight, and present in the breastmilk for a relative infant dose at less than 10%
of the maternal dose.
Hale's risk categories
L1- Compatible. A drug which has been taken by a large number of breastfeeding mothers without adverse
e"ects in the infant.
L2- Probably Compatible. A drug which has been studied in a limited number of breastfeeding women, without
an increase in adverse e"ects in the infant.
L3- Probably Compatible. No controlled studies available or controlled studies show only minimal non-
threatening adverse e"ects.
L4- Potentially Hazardous. There is known risk to the breastfed infant or to breastmilk production, but the
benefits from use in breastfeeding mothers may be acceptable despite the risk to the infant.
L5- Hazardous. Studies have shown significant and documented risk to the infant. The risk of using the drug in
breastfeeding women clearly outweighs the possible benefit from breastfeeding. These drugs are
contraindicated in breastfeeding.
Information sourced from Hale, Medications and Mother's Milk; Wendy Jones; NCBI; Lactmed, American
Academy of Pediatrics, Lactation Education Resources.

Josie Plant RN IBCLC

Thrive Lactation Consultants
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