The information on whether to take medication when breastfeeding is often confusing. As a result, women may want to stop medication or feel forced into stopping breastfeeding. In this article Wendy Jones PhD MRPharmS MBE, pharmacist dispels some of the myths and points to resources to help midwives give the best information.
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Breastfeeding and Medication: do they mix?
How do you feel when you are asked by a mother antenatally or postnatally, whether she can breastfeed on a medication she has bought or been prescribed? How do you think she is feeling? The number of women with a chronic medical condition who are now going on to get pregnant and breastfeed is increasing. According to one piece of research (Jølving 2016), during the past 25 years to 2013 the prevalence of maternal chronic disease during pregnancy has increased four-fold, reaching 15.76%. Scime in 2021 recorded an incidence of 10-12% maternal chronic diseases in a Canadian population. So, midwives will inevitably be amongst the forefront of professionals supporting breastfeeding women needing regular medication for a chronic condition.
You are possibly the first person that a pregnant mother may ask about her medication whilst you are discussing their infant feeding choices. Being pregnant whilst taking a medication is scary, however much we reassure them. Mothers are much more likely to consider stopping medication before conception remembering the damage caused by thalidomide. This can cause problems early in pregnancy in conditions such as anxiety and depression.
However, with breastfeeding there is an option to avoid any risk, by using commercial infant formula. As a mother who gave birth for the first time in 1980, where no one else in my maternity ward was breastfeeding, I have become more and more passionate that breastmilk and infant formula are very, very different and that we cannot ignore the research. We also cannot ignore the emerging studies and understanding of pharmacokinetics that taking medication during breastfeeding does not dilute the magic properties of breastmilk.
Whilst working as a community pharmacist ( and with 3 children) I began a PhD project comparing the experiences of mothers, pharmacists and GPs around breastfeeding and medication. My passion grew to educate professionals when reading comments from the doctors and pharmacists. My heart bled for mothers still broken and guilty that they had been forced to stop breastfeeding against their wishes. I found some websites and books that showed that there was research about the amount of drugs that passes into milk. The information now available has grown considerably and there are readily available expert sources which pull together the data along with the pharmacokinetics of the drugs.
Over the last 22 years I have written a lot of information about common conditions which many breastfeeding women experience, from treating threadworms to pain relief, to having an MRI scan. I have tried to empower women to question their professionals when told that they should not breastfeed. Slowly it feels that this is adding to the continued education of prescribers.
I was, at one stage, before handing over my role within the Breastfeeding Network, messaged by 10,000 people a year via various social media outlets and emails. The stories on occasions were heart breaking. It felt as if so many professionals saw no difference between breastmilk and commercial infant formula. Added to that was the perceived risk of the amount of drug passing to the baby and a lack of understanding of the pharmacokinetics of how drugs pass into breastmilk. Until fairly recently this was a topic not covered by undergraduate education of any professionals but was learned “on the job”, if a mentor happened to be informed, or when the professionals had their own baby and encountered an issue. I wish I had £5 for everyone who told me “ I didn’t get it until I had my own baby”. I could add a lot of funding towards breastfeeding support!
In most published papers there are less than 20 babies exposed to a medication via milk, where levels of a drug are measured in the milk and outcomes for the baby recorded (usually only for a few days). Why? This is very different to the studies required for pharmaceutical licenses which is why the standard patient information leaflet (PIL) in every box of tablets/ creams etc says “ do not use if you are breastfeeding” or “ ask a health professional before using this product if you are breastfeeding”. It just means they are not required to take responsibility because they have not been able to do the studies. Does this mean that the published breastfeeding studies are not valid? No, it doesn’t because the reports are usually accompanied by pharmacokinetic data on the drug which provides a theoretical picture of transfer to back up the reports. Pharmaceutical companies do not finance studies into the amount of their drug passing through milk, with a very few exceptions and any funding elsewhere is very hard to source.
There is also a publication bias on research into drugs in breastmilk. If a practitioner studies a group of mothers on drug x and the babies feed normally, gain weight normally and show no adverse events, would it be worth the time and effort to write and publish a paper? In most cases it does not happen because scientific journals ( just as our daily newspapers) prefer something “interesting” to have happened. So, the outcome of the group of mother and baby dyads is lost to our knowledge unless the researcher is particularly keen to share the information.
Many times over the years of supporting mothers via phone calls or social media I have received queries about a mother about to give birth or on the post-natal ward and who is taking medication. There is no documentation as to whether she can breastfeed or not. This adds to the anxiety which is so common in new mothers.
My dream for the future is that everyone involved in supporting mothers and their children should understand the need to support lactation at whatever age the nursling is, respecting the mother’s choice without question. Further, that they understand that medication and breastfeeding can go together and that there are expert sources readily available to provide information as well as people available to answer questions when practitioners feel that the decision is difficult. In the UK we have UKDILAS, part of the Specialist Pharmacy Service, who write factsheets and are available to answer questions from professionals within working hours. There are also pharmacists who operate the Breastfeeding Network (BfN) Drugs in Breastmilk Service on social media and via email on a voluntary basis. I continue to write books, training material and factsheets on my own website Breastfeeding and Medication as well as those available on the BfN site. There are other expert sources such as LactMed available as a free to access database and a pay to access database or book called Medications and Mother’s Milk. The BNF is changing information to include expert advice following involvement with a consortium set up by the MHRA ( Safer Medicines in Pregnancy and Breastfeeding Consortium).
The information on drugs in breastmilk is available and there is a medication compatible with breastfeeding for almost every illness which might affect a breastfeeding mother, apart from cancer. We know how invaluable breastfeeding is for mothers and babies. The two topics can go together if we respect the choices and the right of women to be involved in decisions about their health. When this is in place I will be able to retire and enjoy my grandchildren!
References
Brown A and Jones W A Guide to Supporting Breastfeeding for the Medical Profession 2019 Routledge
Drugs and Lactation Database (LactMed®) https://www.ncbi.nlm.nih.gov/books/NBK501922/
Hale TW and Krutsch K Hale’s Medications & Mothers’ Milk™ 2023: A Manual of Lactational Pharmacology (also available as https://www.halesmeds.com/ by subscription). Springer Pub
Jølving LR, Nielsen J, Kesmodel US, Nielsen RG, Beck-Nielsen SS, Nørgård BM. Prevalence of maternal chronic diseases during pregnancy – a nationwide population-based study from 1989 to 2013. Acta Obstet Gynecol Scand. 2016 Nov;95(11):1295-1304.
Jones W Breastfeeding and Medication 2013 Routledge
Scime, N.V., Metcalfe, A., Nettel-Aguirre, A. et al. Association of prenatal medical risk with breastfeeding outcomes up to 12 months in the All Our Families community-based birth cohort. Int Breastfeed J 16, 69 (2021). https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-021-00413-0
Wendy Jones PhD MRPharmS MBE
February 2023
To contact Wendy please email [email protected]