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Using strong opioid analgesics during breastfeeding

Published
Topics: Anaesthesia and painBuprenorphineDiamorphine · FentanylHydromorphoneMorphineOxycodonePethidineSafety in Breastfeeding ·

Morphine is the strong opioid analgesic of choice for treating pain in breastfeeding. Recommendations apply to full term and healthy infants only.

Contents

  1. General considerations
  2. Recommendation
    1. Evidence
  4. Choice of opioid analgesic
  5. Withdrawal
  6. Specific recommendations
    1. Morphine
    2. Buprenorphine
    3. Diamorphine
    4. Fentanyl
    5. Fentanyl injection
    6. Hydromorphone
    7. Oxycodone
    8. Pethidine
  8. Patient Information
  9. Further advice
  10. About our recommendations
  11. Bibliography

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 (SPS page) 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

Use with caution

Morphine can be used with caution in breastfeeding for pain, but infant monitoring is still required.

Infant monitoring

As a precaution, monitor the infant for the following symptoms:

  • drowsiness
  • adequate weight gain
  • constipation
  • looking pale
  • slowed breathing rate
  • developmental milestones

Especially in infants up to one month old, exclusively breastfed infants, and with higher morphine doses or modified release preparations.

Further information

There is significant published evidence of use in breastfeeding, which shows that morphine passes into breast milk in moderate amounts, although this is variable.

Lower doses and immediate release preparations are preferred and are less likely to cause any problems. Morphine is used in full-term neonates from birth.

Use with caution

Buprenorphine can be used with caution in breastfeeding for pain, but infant monitoring is still required. Morphine is preferred.

Infant monitoring

As a precaution, monitor the infant for the following symptoms:

  • drowsiness
  • adequate weight gain
  • constipation
  • looking pale
  • slowed breathing rate
  • developmental milestones

Especially in infants up to one month old and exclusively breastfed infants.

Further information

Only very small amounts are found in breast milk.

Use with caution

Diamorphine can be used with caution in breastfeeding for pain, but infant monitoring is required. Morphine is preferred.

Infant monitoring

As a precaution, monitor the infant for the following symptoms:

  • drowsiness
  • adequate weight gain
  • constipation
  • looking pale
  • slowed breathing rate
  • developmental milestones

Especially in infants up to one month old and exclusively breastfed infants.

Further information

Diamorphine use during breastfeeding has not been fully studied, but it is known that there is a risk of serious adverse effects in breastfed infants.

Use with caution

Fentanyl can be used with caution in breastfeeding for pain when administered in the form of tablets, lozenges, nasal sprays and transdermal patches. Infant monitoring is still required.

Infant monitoring

As a precaution, monitor the infant for the following symptoms:

  • drowsiness
  • adequate weight gain
  • constipation
  • looking pale
  • slowed breathing rate
  • developmental milestones

Especially in infants up to one month old and exclusively breastfed infants.

Further information

Low amounts are expected in breast milk due to the short half-life and therefore, adverse effects are not considered likely.

Preferred administration route

Fentanyl is considered compatible with breastfeeding for short-term pain when administered intravenously as part of analgesic care during surgery, or as an epidural. However, infant monitoring is still required.

Infant monitoring

As a precaution, monitor the infant for the following symptoms:

  • drowsiness
  • constipation
  • looking pale
  • slowed breathing rate

Further information

Due to the short use of fentanyl for surgery, and that very small amounts pass into breast milk, side-effects are considered very unlikely. Breastfeeding can resume as soon as the mother is able to do so post-surgery.

Not recommended for use

Hydromorphone is not recommended in breastfeeding. Morphine or another appropriate analgesic is preferred.

Further information

There is limited published evidence of use during breastfeeding and small amounts are expected in breast milk.

However, there is a case report of sedation, severe apnoea and bradycardia in a breastfed infant.

Use with caution

Oxycodone is not a preferred option but can be used with caution in breastfeeding for pain, including in combination with naloxone. However, morphine or another appropriate analgesic is preferred. Infant monitoring is required.

Infant monitoring

As a precaution, monitor the infant for the following symptoms:

  • drowsiness
  • adequate weight gain
  • constipation
  • looking pale
  • slowed breathing rate
  • developmental milestones

Especially in infants up to one month old and exclusively breastfed infants.

Further information

Although oxycodone only passes into breast milk in small amounts, dose-dependent sedation has occurred in breastfed infants. Doses greater than 40mg each day should be avoided in breast feeding mothers where possible.

Oxycodone elimination in young infants is both variable and decreased, therefore avoid use in breastfeeding neonates, where possible. Exposed infants should be monitored very carefully.

Use with caution

Pethidine can be used with caution in breastfeeding for short-term pain, but morphine or fentanyl are preferred.

Infant monitoring

As a precaution, monitor the infant for the following symptoms:

  • drowsiness
  • changes in feeding
  • constipation
  • looking pale
  • slowed breathing rate

Further information

Although small, but variable, amounts pass into breast milk, the long half-life increases the risk of accumulation and side-effects, especially in neonates.

Infant sedation has been reported after repeated maternal doses, therefore only use for short-term pain control.

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.