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Using contrast agents during breastfeeding

Published
Topics: BariumGadobutrolGadoteric acid · GadoteridolIodixanolIohexolIomeprolIopamidolIoversolMeglumine amidotrizoate + Sodium amidotrizoateSafety in BreastfeedingSodium amidotrizoateTesting and diagnosis ·

Breastfeeding need not be withheld after commonly used amidotrizoate, barium, gadolinium or iodinated contrast agents. Applies to full term and healthy infants.

Contents

  1. General considerations
  2. Recommendations
  3. Specific recommendations
    1. Amidotrizoate agents (Gastrografin, Urografin)
    2. Barium sulfate
    3. Gadolinium-based agents (gadobutrol, gadoteridol, gadoteric acid meglumine)
    4. Iodinated agents (iodixanol, iohexol, iomeprol, iopamidol, ioversol)
  5. Contact us
  6. About our recommendations
  7. Bibliography

General considerations

It is important to complete an individual risk assessment (SPS page) for your patient and to apply the principles of prescribing in breastfeeding (SPS page) when looking at the available information and making treatment decisions.

This article includes the most commonly used contrast agents. Other agents are available. Contact our specialist service for further advice.

Recommendations

Although there is limited published evidence about the use of amidotrizoate, barium, iodinated, and gadolinium-based contrast agents in breastfeeding, significant transfer into breast milk is not expected due to the properties of these agents. In addition, their poor oral bioavailability means that they are unlikely to be absorbed from breast milk in clinically significant amounts, and therefore unlikely to cause side effects in breastfed infants.

No interruption to breastfeeding is necessary following the use of the most commonly used agents included here.

This advice is also supported by the Royal College of Radiologists and Society of Radiographers.

Specific recommendations

No interruption to breastfeeding is necessary following the use of contrast agents containing sodium amidotrizoate or meglumine amidotrizoate.

Infant monitoring

No specific infant monitoring is usually required. If a side effect is suspected, contact a healthcare professional for further advice.

Further information

Limited published evidence shows that amidotrizoates transfer into breast milk in negligible or undetectable amounts following intravenous use. There are no data about milk levels following oral or rectal use, but these would be expected to be even lower due to poor bioavailability.

Infants are unlikely to absorb significant amounts from any that does transfer into breast milk due to their poor oral bioavailability, and side effects are unlikely.

They can be used directly in children including neonates at much higher doses than would be expected from breast milk.

No interruption to breastfeeding is necessary.

Infant monitoring

No specific infant monitoring is usually required. If a side effect is suspected, contact a healthcare professional for further advice.

Further information

There is no published evidence about the use of barium sulfate in breastfeeding. It is not absorbed from the gastrointestinal tract, and therefore it is not expected to transfer into breast milk, or cause side-effects in breast fed infants.

No interruption to breastfeeding is necessary.

Infant monitoring

No specific infant monitoring is usually required. If a side effect is suspected, contact a healthcare professional for further advice.

Further information

Gadolinium-based contrast agents have high molecular weights, short half-lives, and poor lipid solubility, which make significant transfer into breast milk unlikely.

There is no specific published evidence about the use of gadobutrol, gadoteridol or gadoteric acid meglumine in breastfeeding, or their transfer into breast milk.

Published evidence for another gadolinium-based agent (gadopentetate dimeglumine) shows negligible or undetectable amounts in breast milk.

Due to poor oral bioavailability, infants are unlikely to absorb significant amounts from any that does transfer into breast milk, and side effects are unlikely. Gadobutrol, gadoteridol and gadoteric acid meglumine can be used directly in infants including neonates at much higher doses than would be expected from breast milk.

No interruption to breastfeeding is necessary.

Infant monitoring

Although highly unlikely to occur, as a precaution, monitor infants for signs of hypothyroidism. This includes drowsiness, poor feeding (including not waking to feed), adequate weight gain, constipation, jaundice (including yellow skin and eyes, pale stools or dark urine) and floppiness.

Monitoring the infant will quickly pick up any potential issues, but usually further investigation is required before the cause can be identified. If a side effect is suspected, contact a healthcare professional for further advice.

Further information

Iodinated contrast agents have high molecular weights, short half-lives, and poor lipid solubility, which make significant transfer into breast milk unlikely.

Two case studies show very small to negligible levels of iodine in breast milk following standard doses of iodixanol and iohexol. Infant iodine levels have not been measured.

Iodinated contrast agents have poor oral bioavailability, so infants are unlikely to absorb significant amounts from any that does transfer into breast milk, and side effects are unlikely. They can also be used directly in infants including neonates. Over 24 hours, a breastfed infant would be exposed via breast milk to less than 1% of the paediatric dose.

Transient hypothyroidism was reported in one premature infant, following a maternal dose of iomeprol, however it is unlikely that iomeprol was the cause. The mother in this case had a history of subclinical hypothyroidism and was taking levothyroxine.

Contact us

Get in touch with the UK Drugs In Lactation Advisory Service (UKDILAS) (SPS page), our specialist breastfeeding medicines advice service if you need support in the following situations:

  • you need further advice
  • the contrast agent in question is not included here
  • the infant is unwell or premature
  • multiple medicines are being taken

About our recommendations

Recommendations are based on published evidence where available. However, evidence is generally very poor and limited, and can require professional interpretation. Assessments are often based on reviewing case reports which can be conflicting and lack detail.

If there is no published clinical evidence, assessments are based on: pharmacodynamic and pharmacokinetic principles, extrapolation from similar drugs, risk assessment of normal clinical use, expert advice, and unpublished data. Simulated data is now increasingly being used due to the ethical difficulties around gathering good quality evidence in this area.

Bibliography

Full referencing is available on request.