Pain medication

Can I take pain medication if I am breastfeeding?

Breastfeeding mothers may take pain medication, but they should take it at the lowest effective dosage and for the shortest time possible. Acetaminophen is a good choice. It also reduces pain and fever and is considered safe if used in the recommended amounts. Non-steroidal anti-inflammatory drugs, such as ibuprofen and diclofenac, are also considered compatible with breastfeeding. If mothers are using opioids for pain, their baby should be closely monitored. The drugs can pass into breast milk and affect babies the same way they affect adults, causing sleepiness and in extreme cases stopping breathing. The opioid codeine is no longer recommended for breastfeeding mothers because of its risk to babies.

A) When considering pain medication

Recommendations about using medication while breastfeeding can change. Please discuss concerns with your health-care providers and consider using additional resources for more information.

Pain medication should be taken at the lowest effective dosage and for the shortest time possible.

B) Over-the-counter pain medication

Acetaminophen (paracetamol) is a good choice for pain and reducing fever in breastfeeding mothers. It is considered very safe when taken in the recommended amounts.

Short-term use of non-steroidal anti-inflammatory drugs (NSAIDs) is considered to be generally compatible (pose very little or no risk to the baby) with breastfeeding (Sachs 2013). These medications can reduce both pain and inflammation and include:

  • Ibuprofen
  • Indomethacin
  • Diclofenac
  • Naproxen

Aspirin (acetylsalicylic acid or ASA) is converted to salicylate in the blood and enters breast milk in higher doses than other medication. Low daily doses of the drug are acceptable to keep a mother’s blood from clotting, but high daily doses are not recommended. 

C) Opioid medication

1) General information about opioids

Opioid drugs are a family of drugs that include morphine, heroin, fentanyl and codeine. They are used for pain control and are only available by prescription. They can cause sleepiness and in extreme cases, people stop breathing. When given to breastfeeding mothers, they can pass into milk and affect babies in the same way.

The risk of sleepiness is compounded when opioids are combined with other medications that also have a sedating quality. Side-effects in the baby are also more likely if the baby is premature or at risk of any of the following:

  • Not breathing
  • Low blood pressure
  • Muscle weakness

The babies of mothers using opioids should be closely monitored. It is best to use the lowest possible doses for the shortest time (Ito 2016). Some members of the opioid family are preferred over others. 

2) Codeine

Codeine is an opioid taken as a pill. Since 2006, it is no longer recommended for use by breastfeeding mothers because it is thought to be dangerous for some babies (Martin 2018). 

Some people have a gene (a CYP2D6 super-metabolizer) that results in codeine rapidly being changed into morphine. The gene can occur in anyone but is present in as many as 28% of people with North African, Ethiopian, and Arab origins (Dean 2012). Genetic testing can be done but it is not yet a routine test.  

Breastfeeding mothers who have this gene and use codeine may produce breast milk with high levels of morphine. As a result, it is feared their babies may become very sleepy, be unable to breathe, and even die (Madadi 2007).

However, this recommendation may change as it was based on a single highly-publicized case (Zipursky 2020).

3) Tramadol 

Similar concerns have been raised about the use of tramadol, another opioid medication, when more than one dose is taken (FDA 2018). However, there is some evidence that this recommendation should be relaxed (Palmer 2018). If tramadol is used, the baby should be watched for increased sleepiness, difficulty breastfeeding, and breathing difficulties or limpness.

D) Epidural pain relief 

Some studies of epidural pain control during labour show it decreases breastfeeding rates but other studies show no effect (Heesen 2020; Lim 2018).

References

Dean L. Codeine Therapy and CYP2D6 Genotype. 2012 Sep 20 [Updated 2017 Mar 16]. In: Pratt V, McLeod H, Dean L, et al., editors. Medical Genetics Summaries [Internet]. Bethesda (MD): National Center for Biotechnology Information (US); 2012

Heesen P, Halpern SH, Beilin Y, et al. Labor neuraxial analgesia and breastfeeding: An updated systematic review. J Clin Anesth. 2020 Oct 15;68:110105

Ito S. Opioids in Breast Milk: Pharmacokinetic Principles and Clinical Implications. J Clin Pharmacol. 2018 Oct;58 Suppl 10:S151-S163

Lim G, Facco FL, Nathan N, et al. A Review of the Impact of Obstetric Anesthesia on Maternal and Neonatal Outcomes. Anesthesiology. 2018 Jul;129(1):192-215
 
Madadi P, Koren G, Cairns J, et al. Safety of codeine during breastfeeding: fatal morphine poisoning in the breastfed neonate of a mother prescribed codeine. Can Fam Physician. 2007 Jan;53(1):33-5
 
Martin E, Vickers B, Landau R, et al. ABM Clinical Protocol #28, Peripartum Analgesia and Anesthesia for the Breastfeeding Mother. Breastfeed Med. 2018 Apr;13(3):164-171
 
Palmer GM, Anderson BJ, Linscott DK, et al. Tramadol, breast feeding and safety in the newborn. Arch Dis Child. 2018 Mar 29
 
Reece-Stremtan S, Campos M, Kokajko L; The Academy of Breastfeeding Medicine. ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2017. Breastfeeding Medicine. November 2017, 12(9): 500-506
 
Sachs HC; Committee On Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics. 2013 Sep;132(3):e796-809
 
United States Food and Drug Administration (FDA). FDA Drug Safety Communication: FDA Drug Safety Communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. [Internet]. Maryland: United States Food and Drug Administration; 2018 Jan 11 [cited 2019 May 27]
 
Zipursky J, Juurlink DN. The Implausibility of Neonatal Opioid Toxicity from Breastfeeding. Clin Pharmacol Ther. 2020 May 7