Nausea management if breastfeeding

A review notes (1):

• choice of anti-emetic will depend on the individual clinical situation and the indication which includes general nausea and vomiting, motion sickness, or after chemotherapy or surgery.
  • treatment choice should primarily be directed at controlling symptoms, with safety in breastfeeding a secondary consideration
    • therefore, recommending the preferred choice anti-emetic is not always possible
    • non-pharmacological measures could be tried first, if appropriate.
• where possible, use the lowest effective dose of an anti-emetic and use short-term
• most of the anti-emetics can cause drowsiness
  • NICE advises avoiding sharing a bed with an infant when sedating medication has been used, due to the increased risk of sudden unexpected death in infancy

With respect to specific anti-emetics (1):

• cyclizine
  • for short-term use, can be used with caution during breastfeeding, but monitoring is required
  • monitor the infant for drowsiness, poor feeding (including not waking to feed) and urinary retention
  • repeated use may pose a risk of infant sedation
• hyoscine hydrobromide
  • for occasional short-term use, can be used with caution during breastfeeding, but precautionary monitoring is required
  • monitor the infant for drowsiness, irritability, dry mouth (which may cause difficulty feeding), dry eyes, urinary retention and constipation
  • there is a small risk that repeated use may interfere with milk production, although there is no published evidence to support this
  • is used in infants over 1 month old and is the preferred medicine for motion sickness during breastfeeding
• metoclopramide
  • for short-term use, can be used with caution during breastfeeding for nausea, but monitoring is required
  • assessment does not cover the use of metoclopramide for poor breast milk supply
  • monitor the infant for sedation, gastrointestinal disturbances, difficulty feeding, irritability, and extrapyramidal symptoms such as tremor, or sudden or jerky movements
  • there is a moderate amount of published evidence of use during breastfeeding which shows very small to moderate amounts in breast milk
  • dose should not exceed 30mg daily for a maximum of five days
  • avoid in people with a history of depression
• prochlorperazine
  • used for occasional doses and short-term, can be used with caution during breastfeeding, but monitoring is required
  • monitor infants for sedation, irritability, poor feeding, dry mouth, adequate weight gain, and extrapyramidal symptoms, such as tremor and sudden jerky movements
  • is no published evidence of use during breastfeeding
    • its properties make it highly unlikely that significant quantities will pass into breast milk
    • also has low oral bioavailability, therefore any that does pass into breast milk is unlikely to be absorbed by the infant in significant quantities.
  • repeated use may pose a risk of infant sedation and may affect lactation
• promethazine
  • used for occasional doses and short-term, can be used with caution during breastfeeding, but monitoring is required
  • monitor infant for sedation or irritability, not waking to feed/poor feeding, dry mouth, adequate weight gain, extrapyramidal symptoms, such as tremor and sudden jerky movements
  • highly unlikely that significant quantities will pass into breast milk
    • also has low oral bioavailability; therefore any that does pass into breast milk is unlikely to be absorbed by the infant in significant quantities.
  • repeated use may pose a risk of infant sedation and may interfere with lactation
• ondansetron
  • can be used with caution during breastfeeding, but monitoring is required
  • monitor infant for sedation, irritability, diarrhoea or constipation and urinary retention
  • there is no published evidence of use during breastfeeding
    • its properties make it unlikely that it will be excreted in breast milk in significant quantities
    • no problems have been reported in breastfed infants (1)

Reference:

1. NHS Specialist Pharmacy Service (March 26th 2024). Treating nausea during breastfeeding