Breast milk is extremely beneficial for a newborn as it provides nutrition, protective antibodies, and lowers the risk of respiratory infections, obesity, asthma, type 1 diabetes, and other diseases. Moreover, breastfeeding also enhances the emotional bond of the mother with the child while lowering the risk of breast and ovarian cancers in mothers. Mothers are recommended to exclusively breastfeed for at least 6 months, which can be extended to 12 months while introducing the baby to other foods.

During the breastfeeding period, many mothers may have the need to take specific medications for either short-term problems such as an allergy or common cold, or a chronic condition such as diabetes or high blood pressure. However, when prescribing medications to a breastfeeding mother, the doctor needs to weigh the benefits of the specific medicine against the potential risk it may cause to the baby.

Do medications transfer into mother’s milk?

The breast has milk-producing (mammary) cells and glands, which are arranged in clusters to help produce milk after the baby is delivered. During the early days of the postpartum period (after the baby is born), the gap between these cells increases, allowing some medications to pass through them and mix with milk. Though these gaps close by the second week of lactation, the exposure of the infant to the medications depends on the amount of medicines released in the milk and the amount of breast milk consumed by the infant.

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Are antibiotics and other medicines safe during lactation?

Various studies have shown that the use of most antibiotics is safe during breastfeeding but must be used only after consulting the doctor. Some of these antibiotics include: 

• Penicillins and cephalosporins: Penicillins (such as Amoxicillin) and cephalosporins (such as cefixime and cefuroxime) are the most common antibiotics prescribed to patients. Though some traces of these antibiotics are released into the breastmilk, they are safe for the infant. However, some infants may experience an allergic reaction to the antibiotic or develop diarrhoea due to some changes in the intestinal flora. 
• Co-trimoxazole: This is the combination of trimethoprim and sulfamethoxazole and is most commonly used to treat a variety of infections including middle ear, urine, lung, and intestinal infections. Though it is considered safe, co-trimoxazole should be avoided if the infant is younger than two months as it can cause bilirubin build-up in their body.
• Tetracycline: Tetracycline is used for treating a variety of bacterial infections. It is considered safe for infants as the calcium in breast milk prevents its absorption. However, derivatives of tetracycline such as doxycycline or minocycline should be avoided as they can cause toxicity in children resulting in staining of teeth and decreased bone growth.
• Metronidazole: Metronidazole (both oral and topical) helps in treating bacterial as well as parasitic infections. The amount of metronidazole released into breast milk is much lower than the dose given to infants for therapeutic reasons and therefore, it results in no adverse effects. 
• Antifungals: Fluconazole is very commonly prescribed to lactating mothers for yeast infections of the nipple. Though the infant might ingest the medication, it is 5% of the usual pediatric dosage. The use of topical (applied directly to the skin) antifungal agents such as clotrimazole or miconazole can be dangerous to the infant and hence, should be avoided. 
• Antacids: Antacid medications are given to treat indigestion and are considered safe during breastfeeding.
• Anti-hypertensives: Anti-hypertensive medicines such as metoprolol and propranolol are prescribed for lowering blood pressure. Mothers who are on these medications must continue taking them after consulting the doctor.
• Insulin: The dose of insulin for mothers affected with diabetes is usually reduced during lactation. However, the blood sugar levels of such mothers must be carefully monitored. 

To use or not to use medications during lactation

Research reveals that less than 3% of the medicines consumed by the mother is released into breast milk. Most medicines are safe for the infant if the dose is moderate. However, certain medications may cause harm to the baby and must be avoided during the phase of breastfeeding.

• Painkillers such as acetaminophen (paracetamol) and ibuprofen have been proven safe during breastfeeding. 
• Topical anti-acne creams such as benzoyl peroxide or anti-inflammatory steroid creams for eczema or a rash are considered safe during lactation. These drugs do not get absorbed into the bloodstream and breast milk.
• Sedatives such as opioids, anti-anxiety drugs (alprazolam or diazepam), antiemetic drugs (promethazine) and prescription sleeping pills should be used with caution as they can result in excessive drowsiness and breathing problems in infants. If the infant is diagnosed with sleep apnea (a condition in which the breathing briefly stops), the mother should completely avoid all sedating medications.
• Over-the-counter medications for allergy, cold or sleep should not be consumed without consulting the doctor as they contain antihistamines such as chlorpheniramine, diphenhydramine, and doxylamine that can cause drowsiness. Non-sedating anti-allergic drugs include cetirizine, loratadine and fexofenadine.
• Though hormonal contraceptives are considered safe for the baby 6 weeks after the delivery, those containing estrogens, such as combination birth control pills or vaginal rings, can reduce the quantity of the milk. Birth control pills with only progesterone are considered safe for breastfeeding women as they do not interfere with the quantity or quality of breast milk.

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How to minimize the potential risk to babies from the medications taken by the mother

Measures that can help lactating mothers reduce the risk of infants’ exposure to medications include:

• Using topical medications instead of oral or injectable forms.
• Avoiding the use of medications that were prescribed during pregnancy as they may not always be safe during breastfeeding.
• Doctors should prescribe medications with the shortest half-life, which is the time the drug takes to reduce into half. The shorter the half-life, the faster the absorption of the medicine in the body. The medicines should also have a high-protein binding property and low-fat solubility to prevent them from entering breast milk.
• Breastfeeding the infant before consuming the medicine. 
• Consuming medicines just before the longest sleep interval of the infant. For instance, taking medicines after bedtime feeding would allow it to get completely absorbed in the body before the baby wakes up.

When to contact a doctor

Lactating mothers should carefully look for any changes in the eating or sleeping habits of the baby after they take any medications. Any change in the behaviour (increased crying or colic) or physical signs (such as a rash or diarrhoea) must be reported to the doctor.

Conclusion

Breastfeeding women must not take any over-the-counter medicines without informing their doctor. This is recommended as the mother may need to take medications at a specific time or in a specific dosage to ensure the infant’s safety. The exposure of the infant to the medications can be limited by avoiding oral medications and using topical therapy if possible. Breastfeeding immediately after taking the medication is not advisable. Due to limited research on medication use during pregnancy and breastfeeding, women must consult their doctor before taking any medicines. 

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