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Using NSAIDS during breastfeeding

Published
Topics: Anaesthesia and painCelecoxibDiclofenac sodium · EtoricoxibIbuprofenMefenamic acidMeloxicamNaproxenSafety in Breastfeeding ·

Ibuprofen or diclofenac are the non-steroidal anti-inflammatory drugs (NSAID) of choice. Recommendations apply to full term and healthy infants.

Contents

  1. General considerations
  2. Recommendations
  3. Clinical considerations
  4. Specific recommendations
    1. Ibuprofen
    2. Diclofenac
    3. Celecoxib
    4. Etoricoxib
    5. Mefenamic acid
    6. Meloxicam
    7. Naproxen
  6. Patient Information
  7. Contact us
  8. About our recommendations
  9. Bibliography
  10. Update history

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 NSAIDs; some of them are available to self-select over the counter.

Many other analgesics can also be considered in breastfeeding. See guidance on paracetamol, weak opioids, and strong opioid analgesics.

Recommendations

There is very limited published information on the use of NSAIDs during breastfeeding; however ibuprofen and diclofenac are the preferred choices due to their shorter half-lives and extensive use during breastfeeding in clinical practice.

All other NSAIDs have longer half-lives and should be used with caution due to the potential risk of accumulation in the infant.

Mefenamic acid should be avoided during breastfeeding because it has been associated with side effects in adults such as haemolytic anaemia.

If a cyclo-oxygenase-2 (COX-2) inhibitor is required, the preferred choice is celecoxib because negligible amounts transfer into breast milk.

Clinical considerations

When using NSAIDs in breastfeeding, try to minimise infant exposure by using the lowest effective dose for the shortest effective duration.

If clinically appropriate, topical routes of administration are usually preferred due to lower systemic absorption, leading to negligible concentrations in breast milk.

If a topical NSAID needs to be applied near or on the breast itself, precautions should be taken to avoid direct contact of the infant with treated areas.  Wash the area with warm water before breastfeeding, and reapply after feeding.  Wash hands thoroughly after application and before touching the infant.

Specific recommendations

Preferred choice

Ibuprofen is the NSAID of choice for treating mild to moderate pain during breastfeeding.

Infant monitoring

As a precaution, monitor infants for vomiting and diarrhoea.

Further information

Although there is limited published evidence, there is extensive experience of use in breastfeeding. Negligible amounts pass into breast milk and these amounts are far below the doses that would normally be given to infants directly.

No side effects have been reported in breastfed infants and the properties of ibuprofen are such that there is minimal risk of it accumulating in the infant’s system.

Topical ibuprofen can also be used during breastfeeding. Negligible milk levels would be anticipated as systemic absorption from topical formulations is low.

Preferred choice

Diclofenac can be used during breastfeeding if clinically appropriate.

Infant monitoring

As a precaution, monitor infants for vomiting and diarrhoea.

Further information

Oral, rectal, and parenteral diclofenac preparations can be used during breastfeeding. Although there is limited published evidence, there is extensive experience of use in breastfeeding. Evidence shows negligible amounts pass into breast milk.

No side effects have been reported in breastfed infants and the properties of diclofenac are such that there is minimal risk of it accumulating in the infant’s system.

Topical and ophthalmic diclofenac preparations can also be used during breastfeeding.  Negligible milk levels would be anticipated as systemic absorption from topical and ophthalmic formulations is low.

Celecoxib can be used during breastfeeding if clinically appropriate, although infant monitoring is required.

Infant monitoring

As a precaution, monitor infants for vomiting and diarrhoea.

Further information

Moderate levels of published evidence of use in breastfeeding show negligible amounts are found in breast milk.

No side effects have been reported in breastfed infants

Use with caution

Etoricoxib can be used with caution during breastfeeding if clinically appropriate, although infant monitoring is required.

Infant monitoring

As a precaution, monitor infants for vomiting and diarrhoea.

Further information

There is no published evidence of use during breastfeeding.  Low levels in breastmilk would be expected given its pharmacokinetic properties; however its longer half-life increases the risk of accumulation in breastfed infants.

Not recommended for use

Mefenamic acid should be avoided during breastfeeding because side effects such as haemolytic anaemia have been reported in adults. Ibuprofen or diclofenac are preferred.

Further information

There is very limited published evidence of use and no information to confirm how much passes into breast milk.  However, low levels would be expected in breast milk given its pharmacokinetic properties.

In adults, it has been associated with a higher incidence of diarrhoea than other NSAIDs, and haemolytic anaemia.

Use with caution

Meloxicam can be used with caution during breastfeeding, although infant monitoring is required.

Infant monitoring

As a precaution, monitor infants for vomiting and diarrhoea.

Further information

There is no published evidence of use during breastfeeding.

Low levels in breastmilk would be expected given its pharmacokinetic properties. However its longer half-life increases the risk of accumulation in breastfed infants.

Use with caution

Naproxen can be used during breastfeeding for short-term use only, due to the risk of accumulation in breastfed infants. Infant monitoring is required.

Infant monitoring

Monitor infants for vomiting and diarrhoea, drowsiness, or signs of bruising or bleeding.

Further information

There is very limited published evidence of use during breastfeeding.

Very small levels in breastmilk have been reported, however its longer half-life increases the risk of accumulation in breastfed infants.

Case reports of possible side effects in breastfed infants include prolonged bleeding, thrombocytopenia, acute anaemia, hypovolaemic shock, drowsiness and vomiting, although a causal link was not confirmed in any case.

Patient Information

The NHS website provides advice for patients on the use of specific medicines in breastfeeding.

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 medicine 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.

Update history

  1. Link updated for paracetamol article.
  1. Published