Medications and Breastfeeding: What is Safe?

As a breastfeeding mother, there are so many things that you will worry about. Medications and breastfeeding is one of those things.

Several years ago, a woman named Allison called me to ask for a lactation consult. She was struggling to breastfeed her one week old baby and wanted me to help her to get on the right path. As part of the consultation, I weighed her baby and observed a breastfeeding session. Allison was a rock star. Even though, this was her first baby, she was doing a really great job with breastfeeding. She latched her baby with confidence and with a slight adjustment in his latch, he was able to transfer an ounce of breast milk from his mother’s breast. I encouraged Allison that she was doing a great job and that I expected her to meet her breastfeeding goals.

Fast forward, several years later and I encountered Allison again when she wanted me to be her children’s pediatrician. As part of my intake, I asked her how breastfeeding went after I saw her. She confessed that she had to give up breastfeeding shortly after our visit. Her psychiatrist put her on a mood stabilizing medication to help to control her postpartum depression. As a result of the medication, her milk supply dropped significantly and she gave up her goal of breastfeeding her baby for the first year of his life.

The More You Know

Unfortunately, this is a common scenario. A poor choice of medication or poor advice about medications and breastfeeding will often lead mothers astray and destroy her breastfeeding relationship with her baby.

This story made me sad as I considered how things might have been different for the mother if she had been able to advocate for herself. Having more knowledge about medications and breastfeeding, she could have potentially requested a different medication that wouldn’t have had such a significant impact on her breastfeeding journey.

While most medications are considered safe for use during breastfeeding, it is important to be aware that certain drugs can have negative effects on both breastfeeding infants and a mother’s milk supply.

This article discusses the relationship between medications and breast milk.

What determines if a medication passes through breast milk?

If a medication is applied to the skin, injected, or inhaled, it is not transferred to the breastfed baby through human milk. While topical preparations can be absorbed into the skin and enter maternal plasma, it is uncommon for them to reach high enough levels to impact the baby. Additionally, breastfed babies are rarely affected by eye drops and nasal sprays.

The transfer of most medications from a mother’s blood to her breast milk occurs through passive diffusion. If a medication is too large, it cannot transfer into breast milk. In addition, medications that are highly bound to protein do not transfer into the milk.

Also, breast milk has a slightly acidic pH of 7.2, which facilitates the transfer of drugs into breast milk if they are weak bases. Some examples of basic drugs include codeine, benzodiazepines, and amphetamines. Lastly, if a drug is able to dissolve into fat (lipids), it is more likely to passively transfer into milk as human milk is high in fat.

How do you know if a medication will affect the baby?

Several factors determine whether or not your baby will be affected by a drug that is passed through human breast milk.

Medicines Approved for Babies

In most cases, if a pediatrician would prescribe a medication directly to a baby, it is safe for a mother to take while breastfeeding. Breastfed infants will receive a smaller dose of the medication through breast milk than if they were given the medication directly.

Examples of medicines that have infant doses are Tamiflu (oseltamivir) and Amoxicillin. You can rest easy that these medications will not have an harmful effects on the baby through the breast milk.

Significance of the infant’s age and medical condition

A baby’s age and medical status also play a role in deciding what medications to take while breastfeeding. Generally, younger babies are more likely to experience adverse effects from a medication than older babies. Younger babies rely exclusively on breast milk as their sole source of nutrition. Therefore, the infant exposure is higher and they get a larger dose of the medication through human milk.

Subsequently, once a baby reaches 6 months of age, you will start to incorporate complementary foods into their diet. Additionally, as they approach 9 months old, the volume of breast milk that a baby consumes decreases.

Additional considerations when thinking about medications and breastfeeding is the breastfed infant’s health status. Premature babies are more vulnerable to the effects of medication through mother’s milk. Additionally, nursing infants with chronic conditions are more at risk for adverse reactions from exposure to medications through mother’s milk.

Which medications are safe for breastfeeding mothers?

In general, the vast majority of medications are safe to use while breastfeeding. Whether it is an over the counter medication or a prescription medication, your health care provider can help you to determine if a medication is safe for breastfeeding.

Additionally, there are also online resources available such as LactMed. You can also purchase the book called Medications and Mother’s Milk, by Thomas Hale, PhD. In addition, Dr. Hale and his team also staff the InfantRisk Center through Texas Tech University Health Science Center. Anyone can call to ask specific questions about medications and breastfeeding safety.

What pain relievers are safe for breastfeeding?

Breastfeeding mothers experience pain. Not only as a result of birth, but also at different points in your breastfeeding journey. As a result, it is important to know what you can take for pain relief.

Opiate pain medications and breastfeeding

As a hospital pediatrician, I provided care for newborns in their first few days of life and observed the impact of pain medications on both the mother and the baby’s breastfeeding success in the early postpartum period.

In modern medicine, opiates are commonly used to manage post-operative and post-child birth pain. However, in light of the growing awareness of the opiate crisis, doctors are now prescribing them less frequently.

Your obstetrician may prescribe opiate medications for postpartum mothers for short-term use. These medications are generally safe for breastfeeding mothers in the short term. However, infants do have exposure through breast milk to these medications. As a result, you should observe your infant for signs of drowsiness.

Potentially Dangerous Pain Medicines

Breastfeeding mothers should not take Tramadol or Tylenol with codeine. Both of these medications are pro-drugs that require conversion into active metabolites. The liver has enzymes that perform this conversion.

In our bodies, codeine is metabolized into morphine which is the active drug. Morphine is a potent medication that effectively treats pain by altering the brain’s perception and response to pain.

Some individuals metabolize pro-drugs quickly, which can result in the rapid conversion of codeine into potentially dangerous levels of morphine. This quick metabolism may lead to a significant amount of morphine passing to the baby through breast milk. Codeine is not only used for pain, but it can be prescribed as a cough suppressant as well.

Either way, as a breastfeeding expert, I would advise you to avoid both codeine and tramadol.

Safer Options for Pain

Acetaminophen and ibuprofen are commonly used over the counter pain medications that can be safely used by breastfeeding mothers to relieve pain. Additionally, Ibuprofen is a nonsteroidal anti-inflammatory drug, and can also be used to relieve inflammation. I often recommend that breastfeeding mothers take ibuprofen for inflammatory conditions such as plugged ducts and mastitis.

Aside from medications, there are numerous non-drug methods available to alleviate pain. These include massage, heat therapy, stretching, bathing or showering with warm water, and resting.

Which medications potentially decrease milk supply?

While many medications are safe for use during breastfeeding, others should be avoided because they have the potential to decrease breast milk production.

• Mood stabilizers and anti-seizure medications may have a negative impact on milk supply. This can affect women with epilepsy or bipolar disorder. Medications like aripiprazole have been found to decrease milk production in breastfeeding mothers.

• Decongestants and cold medicines containing antihistamines, steroids, and pseudoephedrine can potentially decrease breast milk supply. Pseudoephedrine (Sudafed) is a medication that I use to reduce breast milk production in cases of oversupply.
• Oral contraceptive pills that contain estrogen have been found to decrease milk supply. As a result, many women choose to use progesterone-only ( mini – pills) or intrauterine contraceptive devices to prevent pregnancy while breastfeeding.
• Some medications that are used to treat high blood pressure will have a negative impact on breast milk production. Check with your healthcare provider for alternatives that are less likely to affect breast milk production.

What About Herbal Remedies?

Herbal remedies have been used since the beginning of time. As a result of our current cultural moment, herbs are being used in even higher quanities than they were in the past. Just because something is natural does not mean that it is safe for breast-feeding mothers to use herbal products while nursing a baby.

Utilizing herbs to enhance milk production

Traditionally, there are several herbs that have been said to potentially increase milk supply in lactating women. It is worth noting that some of these herbs may get to the baby through breast milk.

• Fenugreek is a herb that originates from the Mediterranean region, southern Europe, and western Asia. It is believed to potentially increase breast milk supply, but there is limited scientific evidence to support this claim. When taken in high doses, it can cause gastrointestinal upset and gas in infants and may also result in a maple syrup scent for both the baby and mother.
• Blessed Thistle is a flowering plant with sharp prickles on the stems and leaves. It is native to the Mediterranean region. It has traditionally been used to relieve digestive issues, but in large quantities it can cause GI disturbances. Limited studies show no harm to breastfeeding babies, but there is no strong evidence to support its ability to increase breast milk supply.
• Goat’s Rue is a plant that is known for its medicinal properties. One of the chemicals in this plant, galegine, is used in the production of the drug metformin, which is used to lower blood sugar in diabetic patients. It is believed that Goat’s Rue can also increase milk supply in breastfeeding mothers by improving insulin sensitivity.

Use Herbal Remedies with Caution

Just like certain maternal medications, some herbs can reduce milk supply in breast-feeding women. For example, peppermint and sage are two herbs that have been known to decrease milk supply.

An additional caution is that the FDA does not regulate herbs and other supplements in this country. This means there is no oversight for their production and manufacturing. As a result, it’s uncertain if you are actually getting the compound that you think that you are getting. If you decide to use herbs, particularly during breastfeeding, ensure to use a reputable site.

There are two good resources for the use of herbs in breastfeeding:

Natural Medicine Database

National Center for Complementary and Integrative Health

How Can 127 Pediatrics Help You?

In conclusion, there are many things to consider when looking at medications and breastfeeding. If you are wondering about illicit drugs or taking other drugs during lactation, I have covered this topic separately.

At 127 Pediatrics, we are passionate about helping breastfeeding mothers to succeed at meeting their breastfeeding goals. Download our math of breastfeeding guide. It will help you to stay on track with breastfeeding.

© 127 Pediatrics, March 2024

This article is for information purposes only and not to be viewed as medical advice.

In addition, if you want more information on this topic, listen to my podcast interview where I talk with the Milk Diva about medications and breastfeeding.