Analgesics (Pain killers) and Breastfeeding

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The information provided is taken from various reference sources.  It is provided as a guideline.  No responsibility can be taken by the author or the Breastfeeding Network for the way in which the information is used.  Clinical decisions remain the responsibility of medical and breastfeeding practitioners.  The data presented here is intended to provide some immediate information but cannot replace input from professionals.

Paracetamol and Ibuprofen form the basis for safe analgesics for breastfeeding mothers. 

Stronger drugs are available but should be taken with caution and babies observed for drowsiness. 

  • There are a wide variety of commercially available painkillers available over-the counter and on prescription. The breastfeeding mother should check with the pharmacist before purchasing a brand to ensure that it does not contain aspirin. Codeine should be used with caution and the baby observed for any signs of drowsiness/poor feeding.

    NB: Many of these products are available in supermarkets, garages etc. as well as through pharmacies.

    OTC (Over the counter) Preparations

    Individual ingredients need to be checked as there are many products available.

    Preparations containing paracetamol are suitable for use by breastfeeding mothers up to the maximum dose of two tablets four times a day.

    If the baby needs to take paracetamol suspension, transfer from the mother’s medication is too small to be harmful in addition. Both can take their own full and normal doses.

    Branded forms include Panadol®, Hedex®, Anadin®. Paracetamol may also be included in cold remedies and it is important not to take double the ingredient by accident – please check with the local pharmacist.

    Products containing ibuprofen are also safe for a breastfeeding mother to take. Transfer of non-steroidal anti-inflammatory drugs is generally small. Branded ibuprofen products include Brufen® and Advil® and most pharmacies stock own-brand generic products.

    If the baby needs to take ibuprofen suspension, transfer from the mother’s medication is too small to be harmful in addition. Both can take their own full and normal doses.

    Paracetamol and ibuprofen can be taken together (to their maximum daily dose of eight paracetamol in 24 hours + three doses of ibuprofen 400milligrammes in 24 hours) for the relief of severe pain. Ibuprofen is contra-indicated in people with a history of peptic ulcer (as it can cause gastric bleeding) or who have asthma (it can cause bronchospasm in people who are sensitive).

    Aspirin (Dispirin®) as a painkiller should be avoided because of the increased risk of Reye’s syndrome in paediatric viral infections. The amount transferring is a very small but as there are suitable alternatives, it is best avoided. If it has been taken accidentally at a dose of 600mg, please contact the Drugs in Breastmilk service to discuss. http://breastfeeding-and-medication.co.uk/thoughts/accidentally-taking-one-dose-of-aspirin-when-breastfeeding.

    75-150milligrammes aspirin dispersible tablets are frequently given as a blood thinning agent. The amount transferred into breastmilk is likely to be very small compared to an analgesic/antipyretic dose of 600milligrammes taken four times a day which is reported to be 0.25milligrammes/kg/day (Hale 2019). http://breastfeeding-and-medication.co.uk/fact-sheet/low-dose-aspirin-and-breastfeeding.

    Codeine is no longer recommended as routine medication for breastfeeding mothers (MHRA June 2013, BNF ) with particular caution where the mother has never taken the drug before or has found that the drug causes her to be drowsy, dizzy or experience severe constipation. See information sheet on Codeine on the website www.breastfeedingnetwork.org.uk   

    Use of codeine is not recommended to be prescribed to breastfeeding mothers. If essential, and only where there is no alternative, it should be at the lowest effective dose, for the shortest possible duration and the mother made aware that she should cease the drug and seek medical advice, if she notices side effects in her baby such as:

    • Breathing Problems
    • Lethargy
    • Poor Feeding
    • Drowsiness
    • Bradycardia (slow heart beat)

    If adverse effects develop in breastfeeding infants the possibility of toxicity should be considered, regardless of maternal dose (Madadi 2009, UKMI 2012). Codeine should be replaced by a suitable non-opioid analgesic. Breastfeeding should not be interrupted unless the symptoms are extreme e.g. necessitating admission, and then only for the shortest duration possible in line with NICE recommendations (NICE Maternal and Child Nutrition Recommendation 15; www.nice.org.uk PH11 March 2008).

    IF the mother has no alternative analgesic agent available or is unable to contact a Doctor to request a different prescription, codeine containing products may be used – after full discussion of the risks and observation of the baby for drowsiness – for the minimal period possible. “present in milk and mothers vary considerably in their capacity to metabolise codeine; risk of opioid toxicity in infant (recommendation also supported by tertiary sources)” BNF May 2020.

    The recommendation to avoid codeine during lactation follows an adverse event report from Canada, where a breastfed baby died at 12 days of age (Koren 2006). At post mortem he was found to have very high levels of morphine in his blood because his mother had multiple copies of the gene which metabolises codeine into morphine and was taking compound codeine analgesics for episiotomy pain. The mother had reported side effects of constipation and somnolence in herself. She had sought medical help on several occasions prior to the baby’s death as he was lethargic and had intermittent periods of difficulty in breastfeeding. A further 44 adverse events have been reported to the MHRA (personal communication July 2013).

    Codeine combinations have in the past formed the mainstay of analgesic use, particularly in the early postpartum period. The genotype producing ultra-rapid metabolism is rare but is impossible to identify without genetic testing. It affects approximately 3% of Europeans (vanderVaart 2011). They should be used with caution.

    Co-codamol tablets contain 8milligrammes of codeine per tablet are available to purchase from community pharmacies. Prescription only co-codamol contains 30milligrammes codeine per tablet. Branded products include Solpadeine®, Ultramol®, Paracodol®, Solpadol®, Tylex®, Codeine Phosphate.

    Codeine is also a constituent of a wide variety of preparations available OTC which contain multiple analgesic ingredients e.g. Veganin®, Feminax®, Syndol®, Propain®, Migraleve®.

    Any baby with respiratory difficulties should definitely not be exposed to opioids of any kind. The sensitivity of a nursling to codeine does not decline with age if the mother has the gene which concentrates morphine in milk.

    Using the half life of codeine as 3 hours – it takes 15 hours for a dose to be regarded as no longer in breastmilk.

    Dihydrocodeine is the preferred opiate analgesic if mothers need stronger painkillers. This is because it has a cleaner metabolism than codeine and is less associated with adverse effects in the baby. It is frequently used as the drug after caesarean section. It can be purchased over the counter as Paramol™ .  https://breastfeeding-and-medication.co.uk/thoughts/dihydrocodeine-and-breastfeeding  

    Prescription analgesics

    The most widely prescribed analgesics are listed below. However, there are many combinations used. Non-steroidal anti-inflammatory drugs are generally safe to be taken during breastfeeding as they transfer in small amounts into breastmilk (see ibuprofen)

    • Diclofenac, (Voltarol® , Diclomax®, Motifene®),
    • Naproxen (Naprosyn®, Synflex®)- longer half-life than diclofenac but amount secreted into breastmilk is small. https://breastfeeding-and-medication.co.uk/fact-sheet/naproxen-and-breastfeeding
    • Indometacin (Indocid®) should be avoided if possible as there is one report of convulsions in a neonate exposed to this drug through breastmilk (Hale 2019).
    • Mefenamic acid (Ponstan®) is frequently given to reduce period pain and transfers into breastmilk in small amounts (BNF 2017)

    There is less information on the transfer of the newer Cox 2 anti-inflammatories which are used for patients who are at risk from gastric bleeding. They can be avoided by taking a combination of traditional NSAID with a proton pump inhibitor e.g. omeprazole, a combination of which is safe in breastfeeding. However, it appears that the amount of celecoxib (Celebrex®) passing through breastmilk is too small to be harmful.

    Codeine preparations – should not be prescribed or purchased for use by a breastfeeding mother (codeine phosphate or paracetamol 500milligrammes plus codeine 8milligrammes or 30milligrammes per tablet.

    Dihydrocodeine

    Co-dydramol (paracetamol and dihydrocodeine) is the preferred weak opioid for pain in the breastfeeding woman The metabolism of dihydrocodeine is not affected by individual metabolic capacity as the analgesic effect is produced by the parent drug compared to codeine which is a pro drug. Dihydrocodeine 30milligrammes is preferred over codeine as it has a cleaner metabolism. https://breastfeeding-and-medication.co.uk/thoughts/dihydrocodeine-and-breastfeeding .

    Tramadol

    Tramadol is a new type of drug which resembles morphine but is said to be less addictive. It is a stronger pain killer. Small amounts of Tramadol are secreted into breastmilk. One study of 75 women showed no adverse effects in breastfed infants whose mothers had taken it. As with other opioid analgesics it is necessary to observe the baby for drowsiness and  feeding difficulties and should not be given to any baby with breathing problems. Mothers may be ultra-rapid metabolisers of tramadol as well as codeine. If any side effects are noted in the baby the drug should be discontinued and medical advice sought immediately. It should be used in the lowest dose for the minimum time necessary.

    Other Opioid analgesics

    Oral morphine (Oramorph®) is frequently used by mothers after a caesarean section and is compatible with breastfeeding.

    Opioid analgesics e.g. morphine and diamorphine are generally used post-operatively and only for short periods. If they are used for any significant length of time, the baby should be observed for sedation. Opioids  all have a potential for misuse and addiction. If a mother requires this level of pain relief she may not feel well enough to breastfeed and means of maintaining her milk supply should be considered. However, individual wishes should always be borne in mind and she should not be discouraged in breastfeeding as normal. The lowest effective dose, for the shortest period is recommended.

    References

© Dr Wendy Jones MBE, MRPharmS and the Breastfeeding Network November 2020