Using strong opioid (opiate) analgesics during breastfeeding

Using strong opioid analgesics during breastfeeding

• morphine is considered to be the strong opioid of choice for the treatment of severe pain in breastfeeding (1)
  • 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
  • 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
    
• a review states (2):
  • morphine administered orally or via patient controlled analgesia (PCA) must be used cautiously because of the variability of morphine and morphine-6-glucoride in foremilk (colostrum) and hind milk
  • been reported that infants may receive between 0.8-12% of the maternal morphine oral dose and concentrations of up to 1,084 ng/ml of morphine-6-glucoride have been found in breast milk of mothers using PCA
    • these levels may be dangerous to newborns, infants, and toddlers; and thus close attention must be paid to the infant when mother is receiving this medication
  • however
    • low-dose morphine is frequently the opioid of choice as passage to breast milk is the less than with other narcotic agents
    • the bioavailability of morphine is low when taken orally and less is transmitted to the infant after hepatic metabolism in the mother
    • for additional safety, mothers should closely monitor their infant for signs and symptoms of behavioral changes while consuming medications
      • infant monitoring
      • as a precaution, monitor the infant for the following symptoms (1):
        • 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

With respect to other strong opioids analgesics during breastfeeding (1):

• diamorphine can be used with caution in breastfeeding for pain, but infant monitoring is required - morphine is preferred
• 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
• 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
  • a study investigated controlled-release oxycodone tablet treatment for postoperative pain management and determined the excretion of oxycodone into breast milk (3)
    • study authors noted that
      • although oxycodone concentrations are higher in breast milk than maternal plasma, oxycodone clearance is relatively high, therefore the relative infant dose remains in a relatively low range
      • concluded that the oxycodone dose received from colostrum and breast milk during the first three postoperative days after Caesarean delivery, with the stated administration schedule, is assumed safe for healthy, term neonates
      • noted however that in extreme cases (e.g. high breast milk intake and high maternal oxycodone consumption, lower than usual clearance in the neonate) it is possible for the neonate to receive a dose through breast milk that may elicit opioid effects
• pethidine can be used with caution in breastfeeding for short-term pain, but morphine or fentanyl are preferred
• hydromorphone is not recommended in breastfeeding. Morphine or another appropriate analgesic is preferred

Notes:

• 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.

Reference:

• NHS Specialist Pharmacy Service (May 2023). Using strong opioid analgesics during breastfeeding
• Cobb B, Liu R, Valentine E, Onuoha O. Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk. Transl Perioper Pain Med. 2015;1(2):1-7. PMID: 26413558; PMCID: PMC4582419.
• Pesonen A, Hakomäki H, Kokki H, Ranta V-P, Rinne V, Kokki M. Breast milk oxycodone concentrations in mothers given oxycodone for post-Caesarean delivery pain management. Br J Clin Pharmacol. 2024; 1-10.