Medication and breastfeeding

Can I take medication and still breastfeed?

Breastfeeding mothers who need to take medication are generally encouraged to keep breastfeeding. Most medications are considered compatible (pose little or no risk to the baby) with breastfeeding because only a small amount generally gets into the baby’s blood and tissues. Before starting any medication, mothers should ask whether it is needed, whether it’s the best medication for their condition, and if this is the safest medication for the baby. The risk of exposing a baby to a small amount of medication must be weighed against the need for mothers to be healthy and the benefits of breastfeeding for mother and baby. Expressing and throwing away milk can result in unnecessary weaning. Mothers can minimize risk by taking the minimum effective dosage of medication for the shortest time. Various sources can provide current and accurate information to guide decisions.

A) Describing medication use while breastfeeding

Most medications taken by mothers are compatible (pose little or no risk to the baby) with breastfeeding as only a small amount enters the baby’s blood and tissues. Mothers on medication are generally encouraged to keep breastfeeding (Sachs 2013). However information can be limited, especially for newer medication and about possible long-term effects.

Mothers having dental work or surgery, including some types of breast surgery, can usually continue to breastfeed. Medicated skin products are generally compatible with breastfeeding.

A very small number of medications should not be used by mothers while breastfeeding as the risk to the baby outweighs the benefits of breastfeeding.

Rarely, medication use can indirectly affect the baby by:

  • Accidentally making the mother’s health worse because of side-effects or allergic reactions, which can then decrease her milk supply.
  • Reducing the levels of vitamins or minerals in the mother’s body and breast milk.

B) Resources for information about medication use while breastfeeding

Research frequently challenges what we assume to be true. Please discuss medication use with your health-care providers and ensure that you have current, accurate information about the use of a particular medication.

1) The lack of research

Unfortunately, drug companies are often not be interested in studying the risks of medication used by pregnant and breastfeeding mothers as this only represents a very small part of their market (Byrne 2020). To protect themselves from legal action, they often put blanket restrictions on the use of the medication (Arguello 2015).

It is therefore necessary to use other resources to make informed choices.

2) Resources

a) LactMed

LactMed (NIH) is an excellent free online source of information about medication use while breastfeeding. The database is created by the U.S. National Library of Medicine. It has information on a huge number of medications and herbal preparations as well as suggestions for alternative medications.

b) MotherToBaby 

MotherToBaby is a service of the non-profit Organization of Teratology Information Specialists (OTIS) and is a leading authority of evidence-based information on the safety of medications and other exposures during pregnancy and while breastfeeding. They have online information and a no-cost information service is available via chat, text, phone, and email in both English and Spanish. They also conduct research on the safety of medications. The MotherToBaby network consists of 15 affiliates housed at universities and hospitals across the United States and Canada. 

c) Infant Risk Center

The Infant Risk Center is a research centre at the Texas Tech University School of Medicine and offers advice on medication use in breastfeeding and pregnancy. They have information available on their website and on their app, Mommymeds. 

d) E-lactancia

E-lactancia (e-lactancia), a large online database similar to LactMed, is a project of the Association for the Promotion of Scientific and Cultural Research Into Breastfeeding (APILAM). The information is compiled by European pediatricians and pharmacists, and the project is supported by commercial sponsors and donations. The database is especially useful for finding information on herbal and non-prescription products.

e) The Academy of Breastfeeding Medicine

The website of the Academy of Breastfeeding Medicine has guidelines on the following subjects (ABM):

  • Contraception and Breastfeeding
  • Pain medication and drugs for surgery (Analgesia and Anesthesia for the Breastfeeding Mother)
  • Use of Antidepressants in Nursing Mothers
  • Substance Use and Breastfeeding
  • Pain medication and drug for surgery around the time of delivery (Peripartum Analgesia and Anesthesia for the Breastfeeding Mother)

f) Others

Natural Medicines is a database about dietary supplements and herbal medicines. It requires a subscription.

C) Why most medication is compatible with breastfeeding

Most medication is compatible with breastfeeding. There are a number of reasons for this.

1) The barriers to medication entering the mother’s milk

In general, only a small amount of a mother’s medication gets into the baby’s blood and tissues, because it has to pass through several barriers:

  • From the mother’s digestive system into her blood if she takes the medication by mouth.
  • From the mother’s blood into breast milk.
  • Through the baby’s digestive system.
  • From the baby’s digestive system into the baby’s blood and tissues.

2) The medication’s properties

Medications have different physical and chemical properties. Some can pass through these barriers and others can’t (Sachs 2013). In general, less than 3% of a mother’s medication enters the breast milk (Rowe 2015).

Less medication will enter breast milk if it (Rowe 2013):

  • Is acidic, not basic.
  • Is a large molecule.
  • Is mostly attached to protein instead of floating freely in the blood.
  • Is destroyed in significant amounts in the digestive system.
  • Does not stay in the body for long.

3) Medication may be broken down in the gut

Some medication is destroyed when passing through the stomach or bowels. It must be given by injection to avoid the digestive system. Similarly, any of the medication that gets into breast milk and ends up in the baby’s digestive system would be destroyed there and could not enter the baby’s blood and tissues. In general, medications that cannot be given by mouth are compatible with breastfeeding.

D) Deciding about medication use

1) Choosing the right medication

Before starting any medication, consider the following:

  • Is it needed for your condition or are there non-drug alternatives?
  • Is this the best medication to use for your condition?
  • Are there safer alternative medications?
  • What are the risks to the baby if exposed to the medication?

The risk of exposing the baby to a small amount of medication must be weighed against:

2) Try to avoid medication that may decrease milk supply

A few medications may decrease milk supply and result in poor growth of the baby.

Instead of estrogen-containing contraceptives, mothers may consider progesterone-only birth control, barrier methods, or depending on breastfeeding to keep periods from returning (the lactational amenorrheic method) and barrier methods.

In theory, encapsulated placenta may decrease milk supply.

3) Making the right decision for you and your baby

Mothers who temporarily stop breastfeeding because of receiving inaccurate information or having concerns about medication may wean unnecessarily. On the other hand, if they decide against medication because of breastfeeding concerns, their health may suffer (McClatchey 2017).

It is important that breastfeeding mothers work with their health-care providers. Pharmacists and breastfeeding specialists can be very helpful. Mothers should use current and accurate information to guide decisions.

E) Minimizing the baby’s risk of reacting to the mother’s medication

1) Minimize the baby’s exposure

In general, it is best for breastfeeding mothers to take the minimum effective dosage of medication for the shortest time. Similarly, mothers who smoke or use cannabis and are unable to stop, are advised to minimize their baby’s exposure to these products.

Taking medication right before the baby’s longest sleep can minimize the amount of medication in the milk.

2) Be extra observant if your baby has a higher risk of reacting to your medication

The risk of your baby reacting to your medication may increase if:

  • The baby:
    • Is premature
    • Is younger. Babies who react to a mother’s medication are generally under two months of age and rarely over six months (Sachs 2013).
    • Has a medical condition.
  • You are:
    • Taking doses above the recommended maximum.
    • Combining medications with similar side-effects (Anderson 2016).
    • Taking medication that can stay in your body or the baby's body for a long time.
    • Taking medication for a long time.

F) When medication makes breastfeeding unsafe for the baby

There are a small number of times when a mother should not breastfeed while taking medication. They may require temporary or permanent weaning. These include:

Additional medications of concern include:

  • Amiodarone
  • Chloramphenicol
  • Ergotamine
  • Gold salts
  • Phenindione
  • Retinoids
  • Tetracyclines (use for more than 3 weeks)
  • Certain psychotropic medications
  • Codeine and related pain medications

There are rare reports of babies developing allergic reactions to a mother’s medication (Anderson 2016).

Herbs and encapsulated placenta can pose a risk to the baby.

1) Evaluate the risks

Before you decide on the use of medication, make sure you know whether the medication is compatible with breastfeeding and what the risks are. Speak with your health-care providers, including your pharmacist, and consult reliable resources described above.

If a medication is not compatible, ask your health-care providers about alternative medication.

2) Consider partial breastfeeding

Younger babies who are exclusively breastfed may be able to safely partially breastfeed until the medication is stopped. This would reduce the amount of medication the baby takes in but not eliminate it. This is done by alternating breastfeeding with giving replacement feeds of appropriate milk while expressing milk and then discarding it (pump and dump).

Babies who are partially breastfed or are supplemented because their mother has a low milk supply are exposed to less medication than those who are exclusively breastfed. Similarly older babies and children who breastfeed infrequently generally take in less medication than an exclusively breastfed baby.

This choice of whether to breastfeed depends on the nature of the concerns with the medication and how long it will be needed.

3) Temporarily stopping breastfeeding

If you cannot breastfeed while on a particular medication but wish to resume after stopping it, you need to pump and dump until most of the medication is out of your system. The amount of time this takes depends on the drug. Babies are given replacement feeds with appropriate milk during this time.

Pumping and dumping without breastfeeding for more than a few days can do major harm to breastfeeding:

4) Weaning

You may need to wean your baby if the medication poses a major danger and is present for long periods in your system. If you need to wean, make sure you do it safely.

References

Academy of Breastfeeding Medicine (ABM) [Internet]. New Rochelle N.Y: Academy of Breastfeeding Medicine; [date unknown] [cited 2018 Nov 18]
 
Arguello B, Salgado TM, Fernandez-Llimos F. Assessing the information in the Summaries of Product Characteristics for the use of medicines in pregnancy and lactation. Br J Clin Pharmacol. 2015 Mar;79(3):537-44
 
Anderson PO. Adverse Drug Reactions. Breastfeeding Medicine 2016;11(10)

Byrne JJ, Saucedo AM, Spong CY. Evaluation of Drug Labels Following the 2015 Pregnancy and Lactation Labeling Rule. JAMA Netw Open. 2020 Aug 3;3(8):e2015094

e-lactancia. [Internet]. [Place unknown]: Asociación para la Promoción e Investigación científica y cultural de la Lactancia Materna (APILAM) [date unknown][cited 2018 Apr 1]
 
Infant Risk Center [Internet]. Amarillo: Texas Tech University Health Sciences Center; [date unknown] [cited 2018 Jan 5]
 
McClatchey AK, Shield A, Cheong LH, et al. Why does the need for medication become a barrier to breastfeeding? A narrative review. Women Birth. 2017 Dec 16. pii: S1871-5192(17)30241-X
 
Rowe H, Baker T, Hale TW. Maternal medication, drug use, and breastfeeding. Child Adolesc Psychiatr Clin N Am. 2015 Jan;24(1):1-20
 
Sachs HC and the Committee on Drugs, American Academy of Pediatrics. The transfer of drugs and therapeutics into human breast milk: an update on selected topics.. Pediatrics 2013;132(3)
 
United States National Institute of Health (NIH). National Library of Medicine, Toxnet, Drugs and Lactation Database (LactMed) [Internet]. Bethesda: U.S. National Library of Medicine; [date unknown] [cited 2018 Oct 10]