Medicines and Breastfeeding: complicated questions
Published in Healthcare & Nursing, Pharmacy & Pharmacology, and Paediatrics, Reproductive Medicine & Geriatrics
Introduction
There is too little information on the impact of prescribed medicines on breastfeeding and breastfed infants. Families’ questions usually focus on the compatibility of the medicines with breastfeeding, and whether breastfeeding will leave infants vulnerable to adverse drug reactions from maternal medicines. However, the more insidious and pervasive harm from reduced breastfeeding rates following administration of medicines in late pregnancy, labour and postpartum is a more common and potentially soluble problem.
Do prescribed medicines reduce the chances of successful breastfeeding?
Some medicines affect the biological processes of lactation, for example: amphetamines, antidepressants, oestrogens, aripiprazole, possibly diuretics, alcohol, oxytocin and opioids (Anderson 2017a,b). Systematic review suggests that prescription medicines, marijuana, and pesticides reduce breastfeeding rates and duration, due to weak suckling, adverse effects on infants and families’ concerns (Jordan et al 2023). Early discontinuation of breastfeeding is associated with mental health medicines, antidepressants and antiepileptics: we found that 22% of women using antidepressants were breastfeeding at 6 weeks, compared with 33% of women not prescribed antidepressants and 26% of unmedicated women with depression (Jordan et al 2019).
Opioids administered in labour by any route are sedative and may affect infants’ ability to root and latch, and oxytocin may weaken the milk-ejection reflex. Data from systematic reviews (Heeson et al 2021) and large cohorts indicate that medicines used in labour are associated with lower breastfeeding rates (Jordan et al 2009, Andrew 2022). Risks appear to increase with the dose of opioid received (Jordan et al 2005).
Do infants suffer adverse drug reactions (ADRs) following exposure via breastmilk?
Most maternal medicines are safe for most infants. The benefits of breastfeeding outweigh the risks of harm from exposure to most medicines; however, the British National Formulary (BNF, 2023) reports exceptions, including some medicines prescribed for severe mental illness, cancer or conditions affecting the immune system. Seriously ill women may need powerful medicines where there is little or no information on breastfeeding in humans.
Although healthy term neonates are able to remove most medicines from their bodies, the kidneys and livers of some preterm and sick infants may not be fully functional, risking accumulation of medicines and adverse effects. For some medicines, such as codeine, a few infants are genetically vulnerable to severe adverse reactions, and reviews suggest considerable variation in infants’ ability to metabolise maternal medicines (Jordan et al 2022). There is a remote possibility that even small amounts of a substance in breastmilk may trigger hypersensitivity or allergic responses (BNF 2023). Accordingly, infants should be monitored for the adverse effects of maternal medicines.
Responding to the challenges: collective responsibility
The professional group best suited to supporting women and monitoring infants should be identified at policy and practice level. These should not be ‘orphan tasks’.
Prescribers and pharmacists
- Women of childbearing age using long-term medicines need to discuss optimising prescribing for pregnancy and breastfeeding pre-conception, before and after birth, and in response to the results of infant monitoring.
Midwifery and obstetric teams
- Women whose labours have been medicated should receive targeted breastfeeding support postpartum and over the first few days.
- Where women are using medicines long-term, practical support, and reassurance based on infant monitoring are needed. Many women using long-term medicines successfully breastfeed, and short-term support can overcome initial difficulties.
Primary care teams: community nurses, health visitors (in some countries), pharmacists, and doctors
- Information on prescription use is available to healthcare professionals: these electronic systems should be used to identify women needing support during pregnancy and breastfeeding.
- Women using prescription medicines are at risk of early discontinuation of breastfeeding.
- Infants should be checked regularly for adverse effects of prescription medicines in breastmilk. If sedative medicines, including mental health medicines, opioids or antiepileptics are used, infants must be monitored regularly for sleep duration, feeding difficulties, weight gain, and development. Standard, routine checks are insufficient, and additional contacts should be scheduled to pre-empt problems and offer reassurance.
- Women also need support to adhere to their prescription regimens, and reassurance that their infants are not being harmed by medicines in breastmilk. Women with long-terms conditions may discontinue their medicines whilst breastfeeding, jeopardising their own health (Scime et al 2023). We found that women discontinuing their asthma medicines had lower breastfeeding rates than more seriously affected women adhering to prescribed regimens (Davies et al 2020).
Policy makers
- Breastfeeding, infant development and medicines adherence are surrounded by social stigma, making for difficult conversations for busy professionals. Using protocols, checklists and decision support helps professionals by legitimising awkward questions on difficult topics. However, no structured monitoring protocols are available, and these should be developed and implemented as soon as possible.
- The pharmaco-epidemiology of breastfeeding is characterised by the absence of whole-population databases with information on breastfeeding, infant outcomes and prescribing (Jordan et al 2002, 2023). There is almost no information on hospital prescribing. Policy makers should ensure that data are available on all maternal and infant outcomes.
Sources of information
LACTMED: Drugs and lactation database (lactmed). In.: Bethesda (MD): National Library of Medicine (US); 2006.
References
Anderson P: Drugs that suppress lactation, part 1. Breastfeed Med 2017, 12:128-130, PMID: 28394656 DOI: 10.1089/bfm.2017.0012,
Anderson P: Drugs that suppress lactation, part 2. Breastfeed Med 2017, 12:199-201 PMID: 28338339 DOI: 10.1089/bfm.2017.0029
Andrew MS, Selvaratnam RJ, Davies-Tuck M, Howland K, Davey MA. The association between intrapartum interventions and immediate and ongoing breastfeeding outcomes: an Australian retrospective population-based cohort study. International breastfeeding journal. 2022;17(1):48.
Davies G, Jordan S, Thayer D, Tucker D, Humphreys I (2020) Medicines prescribed for asthma, discontinuation and perinatal outcomes, including breastfeeding: A population cohort analysis. PLOS ONE 15(12): e0242489. https://doi.org/10.1371/journal.pone.0242489
Heesen P, Halpern SH, Beilin Y, Mauri PA, Eidelman LA, Heesen M, Orbach-Zinger S. Labor neuraxial analgesia and breastfeeding: An updated systematic review. J Clin Anesth. 2021 Feb;68:110105. doi: 10.1016/j.jclinane.2020.110105. Epub 2020 Oct 15. PMID: 33069970.
Joint Formulary Committee. British National Formulary. 85th ed. London: BMJ and Pharmaceutical Press; 2023
Jordan S, Bromley R, Damase-Michel C, Given J, Komninou S, Loane M, Marfell N, Dolk H. Breastfeeding, pregnancy, medicines, neurodevelopment, and population databases: the information desert. Int Breastfeed J. 2022 Aug 2;17(1):55. doi: 10.1186/s13006-022-00494-5. PMID: 35915474. https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-022-00494-5
Jordan S, Davies GI, Thayer DS, Tucker D, Humphreys I (2019) Antidepressant prescriptions, discontinuation, depression and perinatal outcomes, including breastfeeding: A population cohort analysis. PLOS ONE 14(11): e0225133. https://doi.org/10.1371/journal.pone.0225133
Jordan S, Emery S, Watkins A, Evans J, Storey M, Morgan G. Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the Cardiff Births Survey. BJOG 2009; 116(12) 1622-30 DOI: 10.1111/j.1471-0528.2009.02256.x.
Jordan S., Emery S., Bradshaw C., Watkins A., Friswell W. 2005 The Impact of Intrapartum Analgesia on Infant Feeding. BJOG: An International Journal of Obstetrics and Gynecology. 112, 927-34. http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2005.00548.x/full
Jordan S, Komninou S, Lopez Leon S (2023) Where are the data linking infant outcomes, breastfeeding and medicine exposure? A systematic scoping review. PLOS ONE 18(4): e0284128. https://doi.org/10.1371/journal.pone.0284128
Scime NV, Metcalfe A, Nettel-Aguirre A, Tough SC, Chaput KH. Association of postpartum medication practices with early breastfeeding cessation among mothers with chronic conditions: A prospective cohort study. Acta Obstet Gynecol Scand. 2023 Apr;102(4):420-429. doi: 10.1111/aogs.14516. Epub 2023 Jan 27. PMID: 36707933; PMCID: PMC10008275.
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International Breastfeeding Journal
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Implementing the International Code of Marketing of Breast-milk Substitutes: Legislation, monitoring, enforcement, advocacy
Breastfeeding is the most cost-effective intervention available to protect and promote health and well-being of children, women and populations worldwide. The evidence shows that breastfeeding save lives, reduces the burden of infectious and chronic diseases, supports optimal cognitive development, and contributes to maternal health by reducing the risk of breast and ovarian cancer, type 2 diabetes, and postpartum depression. The 2023 Lancet Breastfeeding Series has documented that scaling up breastfeeding to near universal levels could prevent over 800,000 child deaths annually and avert an estimated 20,000 maternal deaths from breast cancer each year. Beyond its individual health benefits, breastfeeding carries implications for planetary health. It is a sustainable, zero-waste, low-carb food system that requires no packing, no supply chains, and no manufacturing.
Yet despite the strong evidence, breastfeeding rates remain far below recommended levels in almost every region of the world. Among the main and well-documented barriers to optimal breastfeeding are the inappropriate marketing practices of the breastmilk substitutes (BMS). Aggressive, misleading, and pervasive commercial promotion of the commercial milk formula and related products, targeting mothers, families, and health workers through advertising, free samples, sponsorships, and increasingly through digital and social media, systematically undermines breastfeeding initiation, exclusivity, and duration.
The World Health Organization responded to this challenge more than four decades ago with the adoption of the International Code of Marketing of Breastmilk Substitutes (the Code) by the World Health Assembly (WHA) in 1981, subsequently strengthened through multiple WHA resolutions. The Code and resolutions establish a framework to restrict inappropriate BMS marketing, protect health systems from commercial influence, and ensure that parents and caregivers receive accurate, unbiased information about infant feeding. Most recently, WHA resolution reaffirmed the urgency of regulating digital marketing of BMS and commercial foods for infants and young children.
Despite this international regulatory framework, frequent and continuous violations of the Code and of local legislation have been extensively documented globally. The 2026 WHO/UNICEF/IBFAN status report confirms that while 148 countries have enacted at least some Code-related legal measures, only 37 countries are substantially aligned with the Code, and 46 still have no legal measures. More critically, even among countries with legislation in place, implementation remains insufficient. One of the most significant and persistent gaps is the absence of clear, functional mechanism for monitoring compliance with the Code and local legislation. Equally concerning is the widespread lack of meaningful sanctions for violations. While 95 countries define sanctions, enforcement remains weak, inconsistent, and in many cases absent, allowing the BMS industry to operate with impunity. These structural failures allow unethical marketing practices to persist, undermine breastfeeding practices, and contravene obligations under international human rights instruments, including the Convention of the Rights of the Child.
The International Breastfeeding Journal invites submissions for this special collection dedicated to advancing the science, and practice of Code implementation and enforcement globally. The central purpose of this special collection is to build a comprehensive knowledge base that documents real-world experiences of Code implementation: what has been attempted, what has worked, what has failed, and what lessons can be drawn for strengthening regulatory and enforcement framework worldwide.
This special collection seeks contributions from all global regions, with particular interest in experiences from low-and-middle income countries and from context that are frequently underrepresented in international literature. We are interested not only in success experiences but also in the challenges, barriers, and setbacks that countries, institutions, and advocates have faced in their efforts to implement and enforce the Code.
We welcome original research articles, systematic and narrative reviews, and countries case studies addressing, but not limited, to the following themes:
- National legislative processes: Experiences of the Code enactment, strengthening, and reform including political, legal, and industry-related barriers and facilitators.
- Monitoring and enforcement mechanisms: Design, implementation, effectiveness, and outcome of compliance monitoring systems.
- Sanctions and accountability: Experiences with the application of sanctions for Code violations, and their impact on industry behavior and breastfeeding outcomes.
- Conflicts of interest in health systems: Evidence of industry influence on health workers, professionals’ associations, and health facilities, and strategies for protecting against commercial interference.
- Civil society, community, and media roles in Code monitoring, reporting, and advocacy.
- Health system protections: Implementation and enforcement of bans on free supplies, gifts, and incentives to health workers, and industry sponsorship of professional and scientific meetings.
- Digital and social media marketing surveillance and regulation: Scope, strategies, and methodologies for detecting and documenting online and social media Code violations, and regulatory responses.
This Collection supports and amplifies research related to SDG 3, Good Health and Well-Being and SDG 2, End hunger, achieve food security and improved nutrition and promote sustainable agriculture.
All submissions in this Collection undergo the journal’s standard peer review process. Similarly, all manuscripts authored by a Guest Editor(s) will be handled by the Editor-in-Chief. As an open access publication, this journal levies an article processing fee. We recognize that many key stakeholders may not have access to such resources and are committed to supporting participation in this issue wherever resources are a barrier. For more information about what support may be available, please visit OA funding and support, or email OAfundingpolicy@springernature.com or the Editor-in-Chief.
Publishing Model: Open Access
Deadline: Apr 30, 2027
