Cardiovascular Disease, the Circulatory System and Breastfeeding

Antiplatelet medications, including aspirin, clopidogrel and ticagrelor,  reduce your risk of blood clots in a different way to anticoagulants. The choice of antiplatelet medication is made based on suitability, the condition being treated or prevented and your medical history. Sometimes more than one antiplatelet medicine is prescribed. Aspirin may be preferred over alternatives, especially if you are feeding a newborn, or baby under 6 months of age.

The SPS talks about using antiplatelet medicines during breastfeeding in more detail.

Aspirin (as own brand), low dose 75-150mg daily.

You can take low dose aspirin with caution while breastfeeding (SPS). There is concern over a theoretical risk of Reye’s Syndrome, which a small number of children have developed when given aspirin directly whilst they had a temperature. The risk by breastmilk is theoretical, and Reye’s syndrome has not been observed in children with a temperature and exposure to aspirin via breastmilk in practice. SPS advise that if your breastfed child develops a fever, you can temporarily stop taking aspirin if safe to do or temporarily withhold breastmilk that contains aspirin.

Low dose aspirin is used directly in babies from birth when needed for cardiovascular conditions. Aspirin is not used in babies or children under the age of 16 years for pain or fever.

Aspirin at higher doses for pain relief is not compatible with breastfeeding. See our factsheet on pain relief for more information.

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking low dose aspirin

Clopidogrel (as own brand), ticagrelor (as Brilique^®), and prasugrel (as own brand or Efient^®)

There is no information available on the use of clopidogrel, ticagrelor or prasugrel while breastfeeding.

The way these medicines work in the body means that it is unlikely that much will pass to your breastfed child.

You can take clopidogrel, ticagrelor or prasugrel with caution while breastfeeding.

Monitor your child for irritability, vomiting, changes in their dirty nappies, skin reactions or unusual bruising.

For more information, see the NHS pages Pregnancy, breastfeeding and fertility while taking clopidogrel and Pregnancy, breastfeeding, and fertility while taking ticagrelor and the e-lactancia page on Prasugrel while breastfeeding.

ACE inhibitors lower blood pressure and protect your kidneys.

ACE inhibitors are a first line treatment for high blood pressure (hypertension) in people under 55 years of age, as recommended by NICE. If you are of Black African or African Caribbean family origin, you may be offered a calcium channel blocker instead as these work better for people from these family backgrounds. In addition to hypertension, ACE inhibitors are also used to treat heart failure or after a myocardial infarction (heart attack) to protect your heart.

While you can take ACE inhibitors included in this factsheet while you are breastfeeding, newborns and babies less than 2 months of age are most likely to experience side effects such as low blood pressure; see monitoring recommendations below. Your healthcare professional will usually offer you a treatment choice where there is experience of its safety in breastfeeding, particularly if your baby is newborn or premature.

When taking an ACE inhibitor, monitor your child for drowsiness, lethargy, pallor (paleness or a change in skin tone), poor feeding, adequate wet and dirty nappies, and adequate weight gain.

Enalapril maleate

You can take Enalapril while breastfeeding.

Enalapril is the first choice ACE inhibitor according to NICE guidelines for hypertension (high blood pressure) in the postnatal period. Enalapril is also SPS’s preferred ACE inhibitor while breastfeeding. It may also be used in heart failure.

For more information, see NHS page Pregnancy, breastfeeding and fertility while taking enalapril.

Lisinopril

You can take Lisinopril with caution while breastfeeding.

Enalapril may be preferred as more evidence is available.

For more information, see NHS page Pregnancy, breastfeeding and fertility while taking lisinopril.

Ramipril

You can take Ramipril with caution while breastfeeding.

Enalapril may be preferred as more evidence is available.

For more information, see NHS page Pregnancy, breastfeeding and fertility while taking ramipril.

ARBs are used for conditions including hypertension, heart failure or post-myocardial infarction (heart attack). ARBs are similar to ACE inhibitors, but don’t cause side effects, such as dry persistent cough, which you might experience with ACE inhibitors. ARBs are useful when you did not get on with an ACE inhibitor because of side effects.

There is almost no published evidence on the use of ARBs while breastfeeding, so they are not favoured in national guidelines while breastfeeding. You can use them with caution (see below) when alternative treatments are not suitable.

Take particular caution if your baby is less than 2 months old or premature, as they are at the most risk from blood pressure lowering medicines. This is because their bodies can’t process the medicines as effectively as their systems aren’t well developed yet. (SPS)

Candesartan, losartan, and valsartan

You can take candesartan, losartan, and valsartan with caution when breastfeeding.

Monitor your child for drowsiness, lethargy, pallor (paleness or a change in skin tone), poor feeding, adequate wet and dirty nappies, and adequate weight gain. For more information, see the following NHS pages:

• Pregnancy, breastfeeding and fertility while taking candesartan
• Pregnancy, breastfeeding and fertility while taking losartan
• Pregnancy, breastfeeding and fertility while taking valsartan

Sacubitril with valsartan (as Entresto^®)

You can take Sacubitril with valsartan with caution while breastfeeding.

Sacubitril with valsartan is used to treat heart failure, including in children over one year of age.

Monitor your child for drowsiness, lethargy, difficulty waking, pallor (paleness or a change in skin tone), poor feeding, adequate wet and dirty nappies, and adequate weight gain.

Alternatives may be preferred if you are breastfeeding a premature infant.

Beta-blockers are classed as either selective or non-selective.

Non-selective beta blockers, such as propranolol and labetalol, work in other areas of the body as well as the heart. This is why propranolol is also used to treat non-heart conditions such as thyroid conditions and migraine prevention.

When taking a non-selective beta-blocker, monitor your child for drowsiness, lethargy, pallor (paleness or a change in skin tone), poor feeding and adequate weight gain, jitteriness, sweating, irritation, fast or slow breathing, and a different cry to usual.

Selective beta blockers, such as atenolol, bisoprolol and metoprolol, are more commonly used for heart conditions because they mostly act in the heart, with less effect on other parts of the body. Common conditions treated by selective beta-blockers include hypertension, angina, irregular heart rhythm (arrythmia) and heart failure. In some cases, they are also used to protect the heart when started early after a heart attack.

When taking a selective beta blocker, monitor your child for drowsiness, lethargy, pallor (paleness or a change in skin tone), poor feeding and adequate weight gain, jitteriness, sweating, irritation, fast or slow breathing, blue or grey lips, a different cry to usual, and low body temperature.

Labetalol, metoprolol or propranolol are the beta-blockers of choice during breastfeeding (SPS).

Propranolol hydrochloride is a non-selective beta-blocker.

Propranolol is a preferred beta-blocker while breastfeeding.

For more information, see the NHS page Propranolol: medicine for heart problems, anxiety and migraine

Labetalol hydrochloride is a non-selective beta blocker with selective alpha blocking activity, which means it also reduces blood pressure by relaxing the blood vessels (vasodilation).

Labetalol is a preferred beta-blocker while breastfeeding.

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking labetalol

Atenolol is a selective beta-blocker.

Atenolol is less likely to cause sleep disturbances than other selective beta blockers.

You can use atenolol with caution while breastfeeding. Metoprolol may be preferred.

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking atenolol

Bisoprolol fumarate is a selective beta-blocker.

You can use bisoprolol with caution while breastfeeding, metoprolol may be preferred.

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking bisoprolol

Metoprolol tartrate is a selective beta-blocker.

Metoprolol is a preferred beta-blocker while breastfeeding.

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking metoprolol

CCBs come in two different types, dihydropyridine CCBs and non-dihydropyridine CCBs. These have different effects in the body, so are not simply interchangeable.

CCBs are the first-choice treatment for hypertension if you are of Black African, or African Caribbean family origin. Nifedipine is the CCB of choice for hypertension while breastfeeding. Amlodipine is also an option if you have previously used this successfully to control your blood pressure (NICE).

Nifedipine is the dihydropyridine CCB of choice, and verapamil is the non-dihydropyridine CCB of choice during breastfeeding (SPS).

Dihydropyridine CCBs act on the muscle in the blood vessels and to a lesser extent, the muscle of the heart. They are most commonly used to control angina or to lower blood pressure (treat hypertension).

Non-dihydropyridine CCBs act on the muscle of both the heart and blood vessels. Diltiazem and verapamil are used to treat blood pressure, angina and abnormal heart rhythm.

While taking any CCBs, monitor your child for drowsiness, lethargy, pallor (paleness or a change in skin tone), poor feeding and adequate weight gain.

Nifedipine is a dihydropyridine CCB.

Nifedipine is also used to treat Raynaud’s syndrome, and to prevent angina symptoms.

Nifedipine is a CCB of choice while breastfeeding.

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking nifedipine

Amlodipine is a dihydropyridine CCB.

Amlodipine is similar to nifedipine. It has a longer duration of action, so can be taken just once daily.

You can use amlodipine with caution while breastfeeding.

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking amlodipine

Felodipine is a dihydropyridine CCB.

Felodipine is similar to nifedipine. It has a longer duration of action, so can be taken just once daily.

You can use felodipine with caution while breastfeeding.

Alternatives such as nifedipine may be preferred as more evidence is available.

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking felodipine

Diltiazem hydrochloride is a non-dihydropyridine CCB.

You can use diltiazem with caution while breastfeeding. Verapamil may be preferred as more evidence is available.

As an ointment, diltiazem is also used for treating anal fissures. You can read more about anal fissure treatment in our factsheet Haemorrhoids and Anal Fissure Treatment

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking diltiazem

Verapamil hydrochloride is a non-dihydropyridine CCB.

Verapamil is the non-dihydropyridine CCB of choice while breastfeeding.

For more information, see the NHS page on Verapamil.

Digoxin is a cardiac glycoside medicine used to treat heart failure and arrythmias.

Limited evidence available suggests only small amounts of digoxin enter breastmilk. No concerns have been reported in children who are exposed to digoxin through breastmilk.

Monitor your child for drowsiness, lethargy, pallor (paleness or a change in skin tone), poor feeding and adequate weight gain.

You can use digoxin with caution while breastfeeding.

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking digoxin

Glyceryl trinitrate (GTN) is used to treat angina. It is also used in surgery and certain procedures.

You can take GTN while you are breastfeeding.

GTN leaves your body very quickly. It is completely cleared within 5-15 minutes of a dose being taken so cannot enter your milk in any significant amounts.

As an ointment, GTN is also used to treat anal fissures. You can read more about anal fissure treatment in our factsheet Haemorrhoids and Anal Fissure Treatment

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking glyceryl trinitrate (GTN)

Isosorbide dinitrate and Isosorbide mononitrate are usually used to prevent angina.

There is no data available on the use of isosorbide while breastfeeding.

You can take isosorbide with caution while breastfeeding.

Monitor your child for drowsiness, lethargy, pallor (paleness or a change in skin tone), poor feeding and adequate weight gain.

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking isosorbide mononitrate and isosorbide dinitrate

Ivabradine is usually used to treat angina and heart failure. It has recently been used to treat Postural Orthostatic Tachycardia Syndrome (POTS) as well. This is an off-label use. This means the manufacturer hasn’t yet applied to add this use to the legal licencing of the medication.

There is no data available on the use of ivabradine while breastfeeding. Alternatives may be preferred.

Use of ivabradine while breastfeeding should be taken with high caution under close supervision of your specialist.

Monitor your child for drowsiness, lethargy, pallor (paleness or a change in skin tone), poor feeding and adequate weight gain. Your specialist will need to monitor your child for changes in their heart rhythm and heart rate.

Avoid if you are breastfeeding a newborn or premature infant.

For more information, see e-lactancia- Ivabradine- Is It Compatible?

Doxazosin mesilate is used to treat hypertension.

Limited data available suggests no concerns have been reported in children who are exposed to doxazosin through breastmilk.

You can take doxazosin mesilate with caution while you are breastfeeding.

  Monitor your child for drowsiness, lethargy, pallor (paleness or a change in skin tone), poor feeding and adequate weight gain.

You may prefer an alternative, particularly if you are feeding a newborn or premature infant.

For more information, see the NHS page Pregnancy, breastfeeding and fertility while taking doxazosin

There are different types of diuretic. They each work in slightly different ways. They help your body remove extra fluid. Diuretics aren’t commonly used while breastfeeding due to their impact on milk supply. Contact the Drugs in Breastmilk Service to discuss individual drugs.

Methyldopa is used for hypertension (particularly in pregnancy).

Very low amounts have been reported in breastmilk.

You can take Methyldopa while breastfeeding.

Monitor your child for drowsiness, lethargy, pallor (paleness or a change in skin tone), poor feeding and adequate weight gain.

For more information, see the E-Lactancia page on methyldopa