General considerations
It is important to complete an individual risk assessment for your patient and to apply the principles of prescribing in breastfeeding when looking at the available information and making treatment decisions.
Recommendation
Morphine is considered to be the strong opioid of choice for the treatment of severe pain in breastfeeding.
However, the use of any opioid should be at the lowest effective dose and only short-term. A non-opioid analgesic should be used whenever possible.
The National Institute for Healthcare Excellence (NICE) advises avoiding sharing a bed with the infant when sedating medication has been used, due to the increased risk of sudden unexpected death in infancy.
Evidence
The evidence relating to the safe use of opioid analgesics in breastfeeding mothers is very variable between individual medicines.
Choice of opioid analgesic
This group of medicines presents a complex picture of different indications (including mild to moderate pain, moderate to severe pain, obstetric pain, and palliative care ) and administration routes (oral, sublingual, transdermal, intravenous, intramuscular, subcutaneous, epidural, intrathecal). Therefore, the choice of medicine may have to be made on the individual clinical situation, and a recommendation for an equivalent alternative opioid is not always possible.
Some weak opioid analgesics can also be considered during breastfeeding and may also be a suitable choice.
Withdrawal
Infants exposed to opioids during pregnancy or for longer periods while breastfeeding, should be observed for withdrawal symptoms if the mother suddenly stops taking the medication or breastfeeding suddenly stops.
Specific recommendations
Patient Information
The NHS website provides advice for patients on the use of specific medicines in breastfeeding.
Further advice
Get in touch with the UK Drugs In Lactation Advisory Service (UKDILAS), our specialist breastfeeding medicines advice service, if:
- the infant is premature or unwell
- multiple medicines are being taken
- the opioid in question is not included in our advice
- the medicine is not recommended here, and you would like further support regarding your specific case
- high doses are being considered
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 are now increasingly being used due to the ethical difficulties around gathering good quality evidence in this area.
Bibliography
Full referencing is available on request.