Which weak opioids can be used during breastfeeding? Considering the evidence for codeine, dihydrocodeine, and tramadol

Laura Kearney, Regional Principal Medicines Information Pharmacist, Midlands and East Medicines Advice Service (Midlands site) & UK Drugs in Lactation Advisory ServiceSource Trent Medicines Information ServicePublished

This updated medicines Q & A considers the evidence and regulatory recommendations regarding the contraindication of codeine use during breastfeeding. It also considers the evidence regarding use of dihydrocodeine and tramadol.



  • The MHRA and EMA contraindicate codeine use by breastfeeding women, due to the fatal case of morphine toxicity in a breastfed infant following maternal use.
  • Dihydrocodeine or tramadol can be considered during breastfeeding. This should be at the lowest effective dose and for the shortest duration. Regular use of any opioid in a breastfeeding mother beyond 3 days should be under close medical supervision.
  • Until more evidence becomes available, consideration should be given to the potential for ultrarapid metabolism with dihydrocodeine or tramadol use. If significant opioid adverse effects develop in the mother, this could suggest the possibility that she is an ultrarapid metaboliser and that the risk of adverse effects in the infant may be increased. All breastfeeding mothersshould be informed of the potential problems and advised to withhold breastfeeding if symptoms develop and seek medical advice.
  • Infants exposed to either dihdrocodeine or tramadol should be monitored for sedation, breathing difficulties, constipation, difficulty feeding and adequate weight gain
  • If adverse effects develop in breastfeeding infants, the opioid should preferably be replaced by an alternative non-opioid analgesic and withhold breastfeeding until the cause of the symptoms is clear.
  • Neonates and young infants are at the most risk from the adverse effects of opioids due to their immature hepatic enzyme function and therefore extra caution should be taken in infants less than 2 months of age.