using strong opioid (opiate) analgesics during breastfeeding

Last edited 05/2023 and last reviewed 08/2023

• 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

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.