Breastfeeding and medications

Can you breastfeed while taking ibuprofen? What about pseudoephedrine? Or even chemotherapy? The published advice on medications and breastfeeding isn’t always clear, so who do you turn to for advice?

Laura Kearney is a clinical lead pharmacist for UKDILAS, an NHS service which provides evidence-based information and advice to healthcare professionals, and professionals and supporters who are working with parents. She’s here to explain how her service works, and to guide us through the evidence for some of the most common medications.

My new book, ‘Supporting the Transition from Breastfeeding: a Guide to Weaning for Professionals, Supporters and Parents’, is out now.

You can get 10% off the book at the Jessica Kingsley press website, that's uk.jkp.com using the code MMPE10 at checkout.

Follow me on Twitter @MakesMilk and on Instagram  @emmapickettibclc or find out more on my website www.emmapickettbreastfeedingsupport.com

Those working with breastfeeding parents can contact Laura’s service on

https://www.sps.nhs.uk/home/about-sps/get-in-touch/medicines-information-services-contact-details/breastfeeding-medicines-advice-service/

Breastfeeding and medications information sheets are available to all here

https://www.sps.nhs.uk/home/guidance/safety-in-breastfeeding/

This podcast is presented by Emma Pickett IBCLC, and produced by Emily Crosby Media.

Transcript

Hi. I'm Emma Pickett, and I'm a lactation consultant from London. When I first started calling myself Makes Milk, that was my superpower at the time, because I was breastfeeding my own two children. And now I'm helping families on their journey. I want your feeding journey to work for you from the very beginning to the very end. And I'm big on making sure parents get support at the end to join me for conversations on how breastfeeding is amazing. And also, sometimes really, really hard. We'll look honestly and openly about that process of making milk. And of course, breastfeeding and chest feeding are a lot more than just making milk. 

Emma Pickett  00:47

I'm very happy to be joined today by pharmacist Laura Kearney. Now since I first qualified as a breastfeeding counsellor, back in 2007. I'm sad to say I've met many mums and parents who've either had their breastfeeding journey cut short, or very nearly cut short by myths to do with breastfeeding and medication. So many mums are told incorrectly in the UK that their medication is not compatible with breastfeeding, or they're really struggling to get information to find out either way. So in the UK, we're very lucky we've got two services that provide evidence based information around breastfeeding and medication. One is the drugs in breast milk service, which is provided by the breastfeeding network. This service originally founded by the brilliant Dr. Wendy Jones, MBE staffed by a team of volunteer pharmacists, they answer queries from parents or people supporting those parents directly via Facebook messaging or email. And they've also got lots of fact sheets on the breastfeeding Network website. In the UK, we're also lucky to have another service called the UK DILAS service or DILAS service. That's UK DILAS service, which is an NHS service, providing evidence based information and advice to healthcare professionals, and professionals and supporters who are working with parents. And they also talk about the use of medicines during breastfeeding. And Laura is a clinical lead pharmacist for that service. And she's very kindly going to join me today to answer some questions about medications and breastfeeding and the work that she does. Thanks very much for joining me, Laura, can you explain a little bit more about how UK dialysis works?

Laura Kearney  02:23

Yeah, so thanks very much for having me. So any health care professional or anyone who's working with breastfeeding services or with breastfeeding families can contact us by phone or email. And this can be for regular medicines and situations. But where we super specialise in is advice on more complex cases. So that might be things like premature infants, multiple medicines involved involving very complex clinical care, substances of abuse, perhaps accidental ingestion. And we're also advising on milk donation situations as well. But as well as the sort of helpline and answering inquiries, we're working on lots of other things as well. So we publish our information on the specialist pharmacy services websites or the SPS website. And on there, we have around 40 articles on lots of different topics around medicines and breastfeeding. So that includes antidepressants, vitamin D, painkillers, antihypertensives, so people can access that information whenever they want to. We also write the breastfeeding advice for the patient information leaflets on the NHS website as well. And we do get involved in advising on policy. So a good example of that recently is many people might have heard about the launch of the pharmacy first scheme, which is where you can access prescription only medicines straight through your pharmacy by going into a community pharmacy. And we help to advise on whether breastfeeding patients could be included within that scheme. So that was really good to get involved in that. And we also do a bit of training as well. So this might be local, just within the UK dialysis team sort of wider within the trust that we're based in or or it might go even wider than that as well. 

Emma Pickett  04:15

Okay, gosh, you do a heck of a lot. So we will put in the show notes. A link to the SPS website. helped me out here we've got the specialist pharmacy service. That's the is that the umbrella organisation that UKDILAS sits underneath.

Laura Kearney  04:30

Yeah, so that's an NHS England owned organisation and there's lots of different arms of pharmacy which come under that umbrella. Medicines information is one of those areas that comes into that and then we sit under medicines information. So yes, it's a really wide and broad website. And we've been doing a lot of information to try and improve how the breastfeeding information is actually found in and amongst all that as well. The information that's on there, but it is a super good website. And it's good for lots of other things as well. So, see, yeah, but we can provide a link which which goes direct to where our information is held.

Emma Pickett  05:11

Okay. Brilliant. And, and UKDILAS. That's UK drugs in lactation advisory services that am I getting that correctly? Right? That's right. Yeah. Okay, cool. So you do a heck of a lot, Laura. Obviously, lots of people in your profession do but you're wearing lots of different hats. What does sort of typical working day look like for you? 

Laura Kearney  05:31

Well, I always like to start with a coffee. But yeah, if I sort of talk to you some of the stuff that we've been doing more recently, so this published information on the SPS website, we've been going through quite a huge project of modernising and updating all of that and making it really relevant. So typically, I'll be kind of reviewing and checking some of that information. We also delivering a training session at Aston University in a couple of weeks for the undergraduate Pharmacy course, which is really exciting, because that's the first time that medicines information and UK divers has been asked to provide some training for the undergraduate degree programme. So obviously been doing some preparation from that.

Emma Pickett  06:16

So you're sitting at a computer doing all these different projects, and phone calls can come in at any moment from from for the advisory services that or emails can come in at any moment? Or do you have a time when you're sort of on duty that were calls and emails might come in?

Laura Kearney  06:30

Yeah, so because we work as a team, there are sheduled times when people are scheduled to take in the calls or answer the email. So obviously, there's periods where you get protected time to do stuff. But there's periods where you will be on the phones or checking the emails to make sure that the calls are being answered and obviously dealt with. So yeah, that's kind of roughly how it works. Yeah, so we've been sort of advising on which medications are okay to take whilst donating milk. And one of the recent things that we've been doing a really deep dive into is the issue around vitamin D. So lots of women are on vitamin D, lots of women have had to be treated for vitamin D deficiency, which means they're actually now on quite, you know, higher maintenance levels than you find in the average multivitamin preparation. So consequently, lots of women have been turned down to donate because of the sort of current threshold that we have. So we've done like a really deep dive into the evidence and the safety around it all and kind of very happy to say that we have actually been able to raise that threshold a bit higher, which hopefully means that a lot more women can safely donate whilst taking these slightly higher doses of vitamin D. In terms of inquiries, as we sort of just touched on there. I think my role in all of that is more around providing guidance in the kind of super tricky situations. So we're really lucky that we do work as a team. So if we are unsure of something, we can kind of bounce off each other, ask each other and discuss the individual cases. But I will sort of help out where perhaps there really isn't any information or the resources are particularly conflicting. So you're a little unsure about which way to go and to try and sort of give a little bit more practical advice about how we might manage that situation. And sometimes it's, it is a bit of a safety check as well. So, you know, you've more or less got the answer, but you just want to run it past one of your colleagues, just to make sure that actually what you are about to advise is, is the best way forward. 

Emma Pickett  08:42

Yeah, I mean, we actually first came across each other because I called your service with an inquiry on behalf of a mom, I don't have permission to share the details of that. So I won't, but you went off, you spent 40 minutes researching and getting all the information. You phoned me back, you said right, this is the story. You were you were really good at explaining why it was complicated and where you got your information from and, and, you know, you came up with an answer for us that obviously then the mom had to make a decision based on the information you gave, but it was really clear to me how very, very thorough you were, you were not just you know, Googling something or looking at one fact sheet or you know, it was obviously really taking your time so I can appreciate it for complex cases, you are an absolute asset. And, and just to clarify, then somebody obviously, I'm a lactation consultant, but somebody who's a peer supporter or breastfeeding counsellor, they can call you to it's not necessarily a registered health care professional or a lactation consultant, yet,

Laura Kearney  09:35

so it's anyone who works with breastfeeding families in any capacity. So, you know, on occasion, we have also been contacted by social care for kind of safeguarding reasons as well. So it really is kind of open to anyone in the UK who's who's working with breastfeeding families.

Emma Pickett  09:55

Okay. Okay, let's go back to basics for a moment. So, so many drugs because that we see on the shelves in pharmacies or we get prescribed to us have that lovely little label that says, you know, if you're pregnant or you're breastfeeding, consult with your doctor. And that's all we're gonna get if we're, you know lactating parent or breastfeeding mom. And they might may say that even when there isn't necessarily a problem, is that true? What what's going on with that labelling on drug boxes and leaflets?

Laura Kearney  10:24

Yeah, so the licencing information that comes with the medicine is often really overcautious. And I think we have to remember that it's a legal document as opposed to a clinical document. And so they won't look at the full evidence that's available around a medicine and breastfeeding, they won't look at the pharmacokinetics and try and work out, could it possibly get into milk or not, they will literally just rely on the information they have gathered themselves, if at all, and they're not obliged to do that. So they essentially don't want to take responsibility for the advice which is going out, they want the healthcare professional to take the responsibility for that. So consequently, the information they put on their legal document is quite unhelpful in terms of practically what do you do with that? I think that's why we thought it was very important to get involved with the patient information that's available on the NHS website, which helps to kind of counteract some of that information, which is very unhelpful, that's coming out in the medicine packets. And also, whilst we're trying to, you know, we're trying to publish really good quality information on this SPS website to help healthcare professionals navigate through what that actually means for the breastfeeding mums as well. 

Emma Pickett  11:42

Yeah. So if you're in sitting with your GP, they want to prescribe some medicine to you. And you say to your doctor, oh, I'm breastfeeding and the doctors Oh, okay, fine. Fair enough. Let me go and find out a bit more information about that. Where do doctors generally go to find out more stuff about medication? So there's a big thing called the BNF, which I'm hearing about, can you explain a bit more about what that is and where doctors are getting details from?

Laura Kearney  12:06

Yes, so the BNF definitely, I think that's where they'll turn to you first. That's the British national formulary. And, essentially, it's like the Bible of prescribing medicines. And it goes into all sorts of different advice and all sorts of different situations. But it does include advice on breastfeeding. So the BNF can be overcautious, like some of the information we're getting on the medicines packets, but, but not always, I'll put that as a caveat. Not always. But they can be overcautious. So the doctor will look there, see this overcautious message and then perhaps tell the mum that actually, it's perhaps not a good idea that she breastfeeds whilst being on this medicine. So luckily, for us, we are beginning to work with the BNF. Now we have become one of their expert advisors for the information that's going out. But obviously, this is going to take a bit of time to work through. So hopefully in time, the information should start to improve. But I think this is kind of inevitably why different advice is being issued, because the information around medicine use in breastfeeding is so poor, and there's just not much evidence around that it becomes very difficult for different people to interpret it and to actually provide that advice. And I think a lot of the time, that's why, you know, we're in the situation where we might have one resource saying one thing and another resource saying something else. 

Emma Pickett  13:38

Yeah, gosh, I do hear a lot of that different hospitals telling their patients different things. I mean, one of the things that I often hear people being told is just take 24 hours to not breastfeed, you know, after this procedure, or, you know, after the surgery, or after you've taken this medication, you know, pump and dump for 24 hours just to be on the safe side. I mean, that's something that gets thrown around so much. I mean, I'm can't I can't ask you to recall all the information about all the medications in the world. But can you think of some times where people are being told they have to pump and dump and really that that isn't required based on the evidence? And are there some times when that is a good idea?

Laura Kearney  14:14

I think this pumping and dumping thing is thrown around quite a lot, as you said as a way to manage the situation. And I think when people issue that advice, they just really don't understand what that actually means for the moment who's been told that so she may not even have got any type of equipment as as in you know, because she's she's committed to breastfeeding the May she may not be in that situation where that's even an option for her. And I think what's really sad for us as well is that we often get these requests when the mum's on the operating table or she's literally come out of theatre or she's she's already had the medicine which might have caused this concern with the with the advice that's going out so She has not even had time to think about what she's going to do in order to manage this situation. So if we do ever issue this advice, and it is actually really rare, we really don't take it lightly. So it is extremely rare that we would, because we just know that it's just not practical, it's not easy to do. And a lot of the time, it actually depends on the medicine as well. But on the odd occasions where it might be necessary, it would be for something like an overdose situation. So we might advise on an abstinence period, just to allow, obviously, the medicines to be excreted out properly. It might be accidental ingestion as well, or for some kind of extremely toxic medicine. So we're talking about things like chemotherapy and stuff like that. So. So an abstinence period might be a way that we could help a man to continue to breastfeed through chemotherapy, that those sorts of situations really do need that individual bespoke advice to kind of help manage them. But it is very, very rare that we would issue that type of advice. 

Emma Pickett  16:07

Yeah. And if if that is happening, that the dumping is about protecting milk supply, we're protecting milk production for when breastfeeding can resume. So it's not pumping and dumping to take the drugs out, which I think some people perceive it to be the case, you know, the drugs are going to leave the system through the mother's bloodstream naturally, in normal explanatory symptoms. We're dumping that milk and pumping that milk to protect milk production and lactation for the for the future. So you mentioned just a moment ago that everything is very much dependent on an individual situation. And I recall when I did speak to you, you asked lots of questions about the mum about the baby, what was happening with that individual family before you were able to give detailed information. Tell me a little bit about why that's so important to get that information about that that family? 

Laura Kearney  16:54

Yeah, so I think ideally, it's always best to know what the case is, I mean, so the information that we've published with the NHS website and on the SPS website is more about those sort of common scenarios where the situation may be more straightforward. So it's not been complicated by other things. If the scenario is a little bit more complex, and the information that we've provided on the Publish sites isn't kind of quite hitting the scenario that we're talking about, it is much better to get those details just so that we can really assess the situation properly and individually for that scenario, because there's potentially always workarounds and things that we can kind of look at. But without knowing the full case, it's very difficult to advise on that situation. So we'd want to know all the medicines the mum is taking, because often, when people first ring up, they'll decide that the other medicines are all fine. And actually, it's just this one that they want to know about that actually, we need to know about the whole picture, because there might be additive side effects that we need to think about interactions, etc. We'd want to know the doses as well, because sometimes that's important. And whether the infant is well and healthy, and whether they're taking any medicines themselves as well. And really important is actually how old the infant is because that allows us to assess one how well they're going to handle any medicines they are exposed to through the breast milk, but also the volume of milk that they're taking in because obviously, an infant who's three months old, for example, relying on breast milk, solely for their nutrition is going to be taking more volume of milk than a one year old, for example, who might be having it for sort of comfort feeds. 

Emma Pickett  18:43

Yeah, yeah. Okay, so taking that in mind, I'm going to be slightly cheeky and ask you to do a little bit of a rapid fire round, let's talk about some of the sort of common questions that do come up around medications and breastfeeding. Okay, so breastfeeding mom has a headache. What's okay to take and what should we be careful about?

Laura Kearney  19:02

So most of the sort of simple analgesics so such as ibuprofen and paracetamol are completely fine to take in breastfeeding. Most of this sort of painkillers are but where we do advise a know is with codeine. I think many people have come across this now. But we wouldn't want people breastfeeding on codeine. There has been some very rare cases of some quite serious side effects from that. So we all sort of advise to avoid that one. 

Emma Pickett  19:32

So what's the situation with aspirin? I remember my training something about rays syndrome and how babies shouldn't be exposed to aspirin because of the risk of that. Tell me a bit more about that.

Laura Kearney  19:42

I'm not sure how many people use aspirin these days as an analgesic. You can use at a much lower doses and anti platelet but yeah, that is the risk the race syndrome, and unfortunately, an infant kind of get this syndrome just exposed to very, very tiny doses. So It's not even a kind of dose related situation. So even that kind of tiny exposure to the breast milk might be enough to cause it, it seems to be more common that it happens when the infant has an infection themselves as well. So and sometimes obviously, that's quite hard to manage whether or not you know that your infant's also got an infection, or they might just be sort of a bit irritable for other reasons. So because of that risk, we would generally sort of say, it's just best to avoid it in an analgesic situation, because there are much better painkillers that we can sort of be much more assured that they're, they are sort of fine to use and breastfeeding. 

Emma Pickett  20:37

And if someone is taking it as a blood thinner, maybe on a longer term basis, it's going to depend on the individual situation is it that sometimes can be compatible with breastfeeding,

Laura Kearney  20:46

the dose is lower. So overall, that is better. But as I said, this, this risk of race syndrome is not dose related. So there is still that risk with that. But the sort of risk balance of why that might be taking the anti platelet becomes different. So it's, it's not like we can say, there's all these other things that you could use, which are which are much better, that's been used for a certain reason. And she obviously has that kind of underlying cardiovascular risk. So So yes, it can be managed, we do have to give the information out about if your baby does get a fever and how to manage that. And you know what to do in that situation. And in some cases, it's it's actually deemed that for the period of breastfeeding, the anti platelet might be stopped for that short period of time because it's a longer term gain is taking this low dose aspirin. So in some scenarios, it might actually be a case of stopping the anti platelet but again, it all will depend on the individual case, but it can be managed. 

Emma Pickett  21:52

One of the things that we say on the national breastfeeding helpline is as on the national breastfeeding helpline, we're not able to advise directly we're not covered to talk about medications. So we will be signposting to the drugs and breast milk service and and the fact sheets online and we'll say, you know, that's where we'll send it send people and obviously there are times when people can't take ibuprofen for other health reasons whether it's a stomach condition or whatever it might be, but there's no reason why paracetamol ibuprofen can't sit alongside breastfeeding. For for most people about the sounds of it. 

Emma Pickett  22:22

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Emma Pickett  23:08

Okay, let's talk about a mum with congestion. So she's got really bad cold. She's very congested. She's got some sinus pain, what medications are probably not a great idea and what might work. 

Laura Kearney  23:19

Yeah, so we would generally advise avoiding decongestants. Some of these things which have been around for a very, very long time, we still don't actually have that much information about them in breastfeeding. And this is one of the examples of that. So they've been used for years and years and yours. But in breastfeeding, we just don't have much information about what happens but we do know that it can potentially interfere with milk production itself. So that's why we would sort of say, in these situations to avoid decongestants. Really, obviously, you can use to find paracetamol. That's fine. And we would advise using sort of more natural inhalations like Steam inhalation or menthol inhalations if something is needed.

Emma Pickett  24:05

Yeah. So I mean, the decongestants, I guess, they dry stuff up. Is it possible that they're drying stuff up in other parts of your body and they're also affecting lactation for similar reasons? I guess? If we don't know the science behind it, it's hard to understand what's happening. But I've certainly worked with moms who've taken one dose of a decongestant and really noticed their milk supply has been hit quite hard. So yeah, something to be sensitive about. I was actually in Japan last year and they don't even sell some of these decongestants in Japan. So Sudafed, and pseudoephedrine. You can't even get in Japan because they don't. They're worried about its safety. So, you know, lots of different countries have different views on these things. Yeah. What about hay fever, a man with hay fever. We're just about to come into hay fever season spring is approaching. What can we do if we're breastfeeding and we have a fever?

Laura Kearney  24:52

So generally, we would advise to go for one of the non sedating antihistamines. So that's things like Cetirizine and lemon Rata dean. And they would be fine to use as well. You can use the sedating antihistamines, but generally we would advise if he can get away with using a non sedating one that's just all around better

Emma Pickett  25:11

is the sedating problem because it may cause the baby to be more sedated. Is that the risk or we're just worried about parents not being able to act as active barons?

Laura Kearney  25:20

I think it's all of those things. Yeah. If a man was breastfeeding, and on any sedating medicines, we would always issue the advice not to bed share, because of the kind of risk of sudden infant death so for any of those, we would advise, you know, if you do need to take sedating medicine even for a short time, then then avoid bed sharing if you can for that reason. 

Emma Pickett  25:43

Okay, so last one for the rapid fire round. Mom is having a general anaesthetic in day surgery. This is these are the ones where often moms are told to pump and dump for 24 hours. What do you say when people ask about general anaesthetics?

Laura Kearney  25:55

So yeah, we would say that normally, this is fine, we would obviously want them to kind of feel that she's awakened and ready to go again. But because of the nature of the anaesthetic, they are so short lived in the body that they are got rid of pretty quickly. So as soon as the man just feel able to breastfeed, we would say that that's fine for her to go ahead, because once she's kind of got rid of the effects of the of the anaesthetic, then it most of it will have disappeared from the system, including the breast milk as well. Again, as as we've just sort of said, because she might be feeling drowsy. Still, though, for another kind of 24 hours or so afterwards. Again, we would advise just not sharing a bed with her infant during that time. That Yeah, as soon as she's ready to fit in well and ready to go again, she can breastfeed. 

Emma Pickett  26:44

Okay, thank you. I'm always a bit mystified by that one because I've never heard of anyone who's had a general anaesthetic for a caesarean section being told I can't breastfeed for the first 24 hours of their baby's life. People who breastfeed when they come out, you know, they come out of surgery, and they're well enough to breastfeed again. But yet, for some reason for day surgery, that's the message people are sometimes being given. Confusing. Thank you. Thank you for clearing that up. Okay, let's talk about antidepressants. So sometimes, when mums are breastfeeding, that will be the first time in their life that they will come across depression and be prescribed antidepressants. If there is somebody listening to this, for whom that is the case, what messages would you want them to have around antidepressants and breastfeeding? 

Laura Kearney  27:25

Well, in terms of the antidepressants themselves, that there are lots of them which are okay to use in breastfeeding, there will be things that the infant needs to be monitored for just in case. So there has been a few reports where infants exposed to antidepressants via breast milk have had some side effects. So we would want any mum to be monitoring their infant for that. But having said that, there are there are lots of cases. You know, the majority of the evidence is where people have taken the antidepressant fine, and the infant's been completely fine as well. And there's also beginning to be quite a bit of reassuring longer term data as well. So that early years exposure through the breast milk has that had any effect on that longer term development of that child. And there's some very reassuring data coming out on that as well. We do have some preferred antidepressants. So based on the medicine properties, there are ones which we can recommend which would be most preferable in breastfeeding. But I think one of the really important things to kind of get across is that we know that untreated depression, or depression, which isn't being treated properly can have really negative effects on both the mother and the infant as well. So it is that kind of balancing out. But it is hugely important that she does get the treatment that she needs and you know, not feel bad for asking for the help that she might need at that time.

Emma Pickett  28:51

Yeah, thank you for saying that. I think one of the things that I sometimes say to to mums who are asking these questions is that in the population of the world, a quite a big chunk of people who are suffering from depression are postnatal. So we've got quite a lot of data on this group. And quite there is unlike some drugs where you look on black men and there's like, we just don't know, there are tonnes of studies on location and antidepressants. I mean, I think perhaps your profession can be more confident talking about antidepressants than a lot of other medications. And I think some people feel uncomfortable about the theory of breast milk containing trace amounts of antidepressants, but just to reassure them that you know, they can get someone to contact you, you could go we can look at your factsheets we can look at the drugs and breast milk team fact sheets. There are so many people taking antidepressants alongside breastfeeding, and it's really helped it helping them and supporting them in their breastfeeding journey. Yeah, definitely. Thank you for clarifying that. So we've got lots of information on antidepressants and breastfeeding. I am very confused about what's happening with information on contraception and breastfeeding. So I just did, recorded a talk for the gold conference around milk production. beyond six months and talked a bit about contraception and breastfeeding and had a go at looking for some research around this. And we seem to have official guidance saying that hormonal contraception is compact compatible with breastfeeding from very early on, you know, the first few weeks, the very early stages of lactation, and then we have sort of pharmacy experts in the area of lactation who are saying no, I don't believe that's true. I don't believe the official guidance is correct. So, you know, we've got Thomas Hale, from the infant risk Centre in Texas saying, you know, some mums are fine, some completely dry up, you know, we've got the breastfeeding network on there Fact Sheets talking about it being a cause for concern that people are using hormonal contraception. So early on the on the on the breastfeed network, actually, they talk about trialling progesterone only pills before having, you know, the Depo injection or before having an implant, there seems to be a bit of a conversation going on at the moment. And it's not quite clear where to land. I mean, what do you say when you're asked about hormonal contraception?

Laura Kearney  31:00

This is a really confusing and tricky area. And as you say, there's a lot of official guidance out there, which a lot of it is all saying different things. So what on earth do you do really. So in an ideal world, non hormonal methods of contraception should be used while breastfeeding. So if we could have that as the option that that would be great. And that's what we would go for. But obviously, people would like to start contraception, and we kind of need to look at the options. So I think the concern with it all is that because it's hormonal, it can potentially interfere with the milk production itself. The evidence for all of this is actually really conflicting, and some of it is really, really old, and very poor quality as well. So the information that exists, if we had more information in it in another field, we probably wouldn't even be looking at that type of information these days. But because it's all we have, we still have to sort of take into account. I think with the oestrogen component, there is stronger evidence that that can affect the milk production. And that's why combined, hormonal contraception is advised to be avoided during breastfeeding, you know, more or less for the whole journey if possible. If a hormonal method is chosen, then I think everyone disagree that the progestogen only contraception is the preferred choice. But it's the timing of that and the type where the disagreement lies. So I think I would probably largely agree with what the breastfeeding network is saying. So if hormonal methods are required, then a suggestion only pill immediately after birth would seem like a reasonable way forward. And the first thing to try, I think, was the longer acting formulations, we don't have as much evidence or experience with them. And even though that evidence is actually coming out fairly favourable, we still don't quite know, compared to the the pedestrian only pills, how much that is actually affecting milk production and what effect those longer acting formulations might be having on the infants as well. So I think the theory is that if you delay starting those for a period of kind of six weeks or so that allows the breastfeeding to get established. And also the infant becomes sort of slightly older during that time, so they can handle anything they're being exposed to a little bit better. So at this moment in time, that's, it may be an overcautious position, but it's probably a more comfortable position to be in that those longer acting formulations are just started that that little bit time after the birth. Yeah, the sort of issue here for me is about informed decision making so so that we're actually making an active choice based on the information we do know about the risks for each type. And obviously, we don't want unwanted pregnancies. But we don't want mums to kind of think that they have to go straight back onto contraception as soon as it is feasibly possible for them to do so. And it would be good if those conversations could kind of happen before the birth so that she's in a better place to kind of read all the information take on board what she might want to do afterwards. And I think as you said that this is this is a really good example, unfortunately, of where all the poor quality evidence is really causing quite a lot of confusion and conflict within the resources. And that's leading to kind of different interpretation of the advice that's coming out. But I think working with the person's wishes, you know, for somebody, it might actually be the right thing for them to do to go on a depo straightaway. Whereas for their own sort of personal reasons. And you know, we can look at the safety of that and kind of explain the risks and where all that lie But as a kind of blanket guideline, I think, at the moment with the current evidence base going on a progesterone only pill would be would be the better thing sort of straightaway at the moment. 

Emma Pickett  35:12

Yeah. Yeah. Thanks for that. I think it is important to flag up what you just said about how we know, I think when we come from a breastfeeding support world, we imagine that breastfeeding is at the top of everyone's minds, but for some people, and unwanted pregnancy is genuinely a terrifying prospect. And even if there's information that does suggest a possible risk to supply, you know, if they've had a history of good milk supply, maybe this is their second or third pregnancy, they're pretty confident about breastfeeding, that may be a risk that they're willing to take. And as breastfeeding supporters, we just have to kind of signpost to the information and understand that there are lots of different factors here. Yeah, yes, it's super confusing. But one of the bits of research that I was looking at talked about, oh, you know, there's no problem with growth. We've looked at the babies where parents were taking contraception, growth was absolutely fine. And somebody piped up and said, Well, yes, but what was happening in those households? Maybe those those parents were breastfeeding more and more frequently through the night offering both sides, you know, using breasts compressions, maybe they were having to respond to a reduction in milk supply. And we can't necessarily say that, you know, that was a therefore a benign situation. Yeah. It just seems as though the people doing the research and the people writing the recommendations about contraception aren't necessarily talking to the rest of eating families. And I'm hoping that we get an updated protocol from the Academy of breastfeeding medicine, because we haven't had one since 2015. On this, it'd be good to see. Good to say a bit more on that. We've talked about lots of the things that do commonly come up on on your helpline. Is there anything we haven't covered? That's a sort of common query? And, and is there anything you get asked? It's been very unusual, and really, really taking you by surprise? What are some of the unusual ones you've had to?

Laura Kearney  36:47

And yeah, I think because we kind of specialise in these complex situations, our our inquiries definitely reflect that. So we do get a lot of questions about mums breastfeeding, premature infants, and sometimes they those infants are really unwell and poorly. And that becomes quite a difficult situation to manage all round. But we always try and find a solution to that. We've touched on the mental health with with the antidepressants, we also get asked a lot about anxiety, and psychotic medicines as well. And antihypertensive is another big one. Because obviously for some women, they have had preeclampsia, for example, and that treatment needs to continue after the birth. So antihypertensives is quite a big one for us as well. And then interestingly, and I think this shows how our population is changing. But we are being asked more about breastfeeding whilst on IVF therapists and also quite topical breastfeeding whilst on HRT. So they are kind of some of the sort of newer things that are coming through.

Emma Pickett  37:55

Yeah. Can I just ask you about breastfeeding on HRT, that is something I'm seeing welcome questions about what's some of the guidance around that?

Laura Kearney  38:04

Well, I think that I think that becomes even more difficult, because we've talked about all the issues, we combined contraception and the estrogens and progestogens. And those, and they're at much lower doses than the HRT. So I think for now we have, we haven't issued any kind of blanket guidance on this yet. It is in our kind of, you know, list of things to do. But I think at the moment, it would be good to get sort of individual advice on this until we've kind of you know, really looked at all the evidence very sort of deeply to come up with, you know, to see if we can come up with some advice on that. But we definitely have, you know, individually when we've looked at what people are taking in terms of the HRT they're being offered, that, you know, it is potentially possible, absolutely. But we'd want to know what the situation is with the infant and things at the time, that hopefully we should have some guidance coming on out on that, within this year. So.

Emma Pickett  39:05

Okay, thank you. We didn't talk about antibiotics when I did my rapid fire round. Are there antibiotics that aren't advisable during breastfeeding or aren't sort of first choice?

Laura Kearney  39:16

Yes, there are definitely lots of antibiotics that you can take, which are completely fine. So the penicillins A lot of the kaffir sporrans they're not used quite so much these days. But all of those essentially are fine, but there are some antibiotics where we need to be a little bit more cautious with so if I went back to the pharmacy first scheme, for example, one of the indications that you can go and get help with from your community pharmacist is UTI. So urinary tract infection, one of the medicines to treat that is nitrofurantoin that you won't be able to get that kind of supply see the pharmacy first scheme but nitrofurantoin can be used in breastfeeding this Just a few more bits and pieces that you need to think about in terms of the monitoring. So that's probably best that you go to the GP to get that one sorted. Some of the other sort of tetracycline antibiotics that we sort of talked about. Again, it's not that you can't have them during breastfeeding, there's just a few sort of things to consider and think about if that is the, the antibiotic that has been prescribed for you. But I think in terms of antibiotics, it, this becomes a little bit more of a trickier situation to manage, because we often don't have the choice to say, actually use this one because the antibiotics obviously geared towards the infection if there's any current resistance in that infection, as well. So it's more about managing the situation with the medicine that's been prescribed in those scenarios. 

Emma Pickett  40:49

Okay. Do you get questions about alcohol to people phoned the helpline to ask about alcohol? 

Laura Kearney  40:55

Surprisingly, no, not really. So I don't know if this kind of does reflect the nature of our service, perhaps answering those quite complex inquiries. But I think also, there is some really good guidance on there about it as well. So the NHS website gives some good guidance, as does the breastfeeding network. And I think, generally, people hopefully know that they can enjoy a drink if they want to moderation if they feel like doing so. But we would say that if you can avoid breastfeeding, ideally, for two to three hours after you've had a drink, just to make sure that it's kind of cleared out of the system, it is quite rapidly cleared out. So. So that's that's fine. But just to sort of take that precaution.

Emma Pickett  41:42

Okay. And presumably, with older babies, that's perhaps less less of a concern and less of an issue. But it's not necessarily your place to say that so. And it just took about one to two units of alcohol once or once or twice a week. And I know that drinking alcohol isn't a barrier to being a milk donor, for example. So we should we shouldn't want parents to feel they have to abstain completely that isn't that isn't evidence based. Yeah, difficult to get information about that if you're a parent, but the rest of your networks a good place to start. What about recreational drugs? You've mentioned overdoses? And I'm guessing that sometimes includes I don't know, recreational is probably not the right word. What word do you use to describe drugs being used for non medical purposes?

Laura Kearney  42:21

Yeah, it's a Yeah, I know what where do you use substances of abuses is often a term that's used as well. And yes, we definitely get asked about this. Cannabis is probably our biggest one that we get asked about that. The next one after that would be ketamine, actually. So generally, we don't advise obviously breastfeeding whilst people are taking these substances. And the reason for that is because these substances are not regulated in any way. When we are assessing a situation with a normal medicine, I'd say a medicine that's gone through all the proper approval processes, etc. We have good data on how that that medicine might be handled in the body, which helps us to kind of assess that in terms of how much might get across into breast milk, and how the infant might therefore handle that medicine. But when it comes to things, which haven't been regulated in any way, then that type of information is even more difficult to get ahold of. And certainly there are no sort of good studies that have really looked at these substances in breastfeeding as well, there are some, but we're talking about even less information that we would normally have available to us. So therefore, it becomes really, really difficult to formulate good quality advice. And in addition to that, even though someone might say that they're taking cannabis, or ketamine, or heroin, or whatever it is, these products are quite often adulterated with other things that we just don't know what they are. So the risk to the infant just becomes greater and greater and greater. So the blanket sort of statement is no, these are not a good idea during breastfeeding at all. But we certainly have had situations where we've been, we have been able to kind of manage a very individual situation and kind of come up with a way forward. And that might be introducing some of these abstinence periods, these wash out periods that we've talked about. But, you know, generally we would say that it's not a good idea. Really. 

Emma Pickett  44:34

Yeah. You mentioned that there's work to be done in certain areas, like, you know, we need a bit more information around contraception, we could do with a bit more information around HRT, are there any areas where you think, gosh, if I had an infinite amount of money, this is where I would be pointing all the researchers in the world to look at this area of drugs and breast milk. Is there any real gaps that we have that we really need to fill? 

Laura Kearney  44:54

Yeah, I mean, I suppose the COVID pandemic really sort of highlighted Um, that we just don't have a good process in terms of managing. When a new medicine comes onto the market. What do you do with that if a breastfeeding person needs to have that medicine, and yet, the COVID pandemic was a really horrible example of that, because all these new medicines were coming out medicines that had been used for other indications, which were all of a sudden being used in the general population for this, and there just wasn't any information on their use and breastfeeding. I mean, luckily, we were in a situation where they were regulated. So we had a lot of the drug properties to work from and things but you know, people were not touching these with a bargepole. And just would not issuing any type of advice in breastfeeding at all. So that we sort of did, we managed to, some get some advice on that. The world of breastfeeding does not receive much research attention at all. And I think it probably goes without saying that almost every single medicine that we look at, we need more information on it. Because we're kind of working in a very evidence poor area, having to extrapolate from other medicines we might know a little bit more about. So I think if we could have better evidence on how these medicines are getting across into milk, and also the infant as well, that would be great. But I think somehow we need to come up with a sort of simulated model. So we're not like relying on actual breastfeeding women being kind of donating their milk and being tested. If we could sort of simulate this in some way. That'd be absolutely great. 

Emma Pickett  46:34

Which should be possible come on AI, some sort of clone system, I don't know, people can consent to have a clone created, let's make a Black Mirror episode about this. And maybe we'll get some attention into this area. So obviously, there are lots of people out there who are being told they can't breastfeed alongside taking certain medications. They're not getting access to your service. They're not finding the drugs and breast milk service. They're just ending breastfeeding. How do you keep motivated knowing that that's the case? How do you not end up chaining yourself to the to the railings of 10 Downing Street? Because you're fighting this good fight all the time? And how do you manage to sort of stay positive? 

Laura Kearney  47:11

Now there's a thought maybe that's what I should do tomorrow? Yeah. Yeah, a bit seriously. As we all know, anyone who works in this area, this area is super challenging. And I know that medicines, and breastfeeding represents a really small piece of the jigsaw puzzle of challenge that anyone is facing when they're working in this area. And there's not enough funding, there's not enough research, as we've just said, breastfeeding is not supportive as the massive public health intervention that it is. And it's not embedded in policy, and it's not in education. And we are constantly having conversations with others that why why does this matter? Why does this matter so much? And why are we doing this, but it's important, and it does sometimes feel that you are banging your head against a brick wall. But there is hope. And I do see change. And we do chip away. And slowly and surely we are trying to make a difference. And the sort of Aston University project that we've been working on is a small win. So for the first time, you know, we are we are giving some undergraduate education in this area, which is, which is amazing for our kind of service to be doing that. Although we are only a small piece of the entire jigsaw. I think knowing that we are saving breastfeeding journeys on a daily daily basis is kind of worth all the fight for us.

Emma Pickett  48:27

Yeah, definitely. I mean, I can hear the differences you're making and the positive work, you know, does it just yeah, there's so much good stuff going on. I definitely feel this is an area where we can perhaps feel more positively than we can about lots of other areas of breastfeeding support. I mean, and thank you on behalf of breastfeeding families and the people that support them, I want to say thank you for the work that you do. Because you get that breastfeeding matters, you understand that telling somebody, oh, you know, just don't breastfeed for a day or so is impossible. That's a mountain for a breastfeeding family. And you and you really get that and understand that. And, you know, I'm gonna want to sort of make a summarising comment here. But you know that it sounds as though there are very few cases where somebody genuinely would have to end breastfeeding. And there is no alternative. I mean, you mentioned, chemotherapy is maybe one of those cases where someone would have to stop breastfeeding for a while. But it doesn't sound like you often have to have that conversation with people. Is that a fair summary? 

Laura Kearney  49:21

Yeah, I think that is a fair summary. And just to sort of say that within the team as well, and many of us have been on our own breastfeeding journeys and also struggled with those. So I think, you know, we really get it we really understand what telling someone that they can't breastfeeding how absolutely devastating that can be. And I think the way that we try and look at it is that, you know, instead of trying to look for all this evidence to say, yes, it's safe, yes, it's safe. Yes, it's safe. We're actually trying to almost kind of turn it on its head and start with a we're gonna say that this is okay. And actually, we're looking for some really good evidence of why this is not going to be the case. because a lot of the time, people say you can't breastfeed because they're worried about the theoretical risks of the medicines in the breast milk, but they're not actually taking on board or the actual proper evidence base benefit to the mum and the infant of what that breast milk exposure can do. So it's really about sort of getting that balance. Absolutely. Right. And on that on that tone, then yes, it is very rare that we would advise that breastfeeding isn't compatible. And then there are times when we do and, as we said, chemotherapy can be extremely toxic. And a lot of the drugs which are used for that can hang around in the body for a long time. And with the intensity of the kind of repeat cycles that people have to go through. It does sometimes make even, you know, wash out periods and things and the sustaining of that breastfeeding, just absolutely impossible. And fortunately, we've also talked about some medicines which might affect milk production themselves and why they're not advisable. Another example, where we would say no is with a drug called metronomic acid. So this is a strong painkiller, which belongs in the same group as ibuprofen. But it can cause some quite nasty side effects in adults, and the concern is that those side effects might also happen in infants as well. So, you know, we're lucky in that kind of group of medicines that actually we can advise an alternative to that. So often, it is about altering the medicine to fit in with breastfeeding. So another example would be some anticoagulant, some oral anticoagulants are not recommended and breastfeeding. So we would advise switching to one that is, and it's the same for some medicines in hypertension, as well. So some of those aren't advisable. But you know, we can offer alternative to switch to ones which might be better and safer within breastfeeding. But sometimes, again, it's not actually just due to the medicine, it's about the circumstance. So we had a mother the other day, who was on around 25 medicines. And she was trying to feed an unwell infant as well. And so unfortunately, in that situation, it was just too risky for her to go ahead. Because if something did go wrong, there's just no way that we would have been able to tease out out of that list of 25, which one might have been the culprit? And how would we kind of monitor and resolve that if something did actually happen? On the whole, we do try and ensure that there's some sort of workaround option. And we'll I think, as you found with your experience with this, we do try and clearly explain what those risks are, and how we've come up with that advice or what the limitations of that advice are. So another sort of example, is methotrexate, which is quite a nasty, toxic drug, we don't say that it's absolutely contraindicated in breastfeeding. But for a lot of women, the advice that we do issue about its conditions of use just might be too much, because there is a lot of monitoring for the infant, which includes taking blood samples in the infant as well. And so even though were saying that, you know that this is the workaround option, and these are can be the conditions if you breastfeeding, for a man that just might personally just be the cut off for them that you know, they just don't want to sort of go down that route. We are constantly looking for ways in which we can manage the situation better. And sometimes that might be with part feeding as well, which is better than no breast milk at all. 

Emma Pickett  53:28

When you say part feeding or do you mean that somebody? If there's the depending on the half life of the drug, for example, you might take the drug at a certain time of day and then not breastfeed immediately afterwards? Is that the sort of thing you mean?

Laura Kearney  53:38

No, it might actually be to sort of introduce mixed feeding with the with the sort of formula and breast milk which, again, that's the type of advice that we would not sort of issue lightly because of all the interference with kind of a good gut flora. And, you know, there is obviously evidence that that kind of mixing can sometimes be detrimental as well. But sometimes a woman is so sort of determined that she wants to breastfeed in some manner that, you know, if we can reduce the dose essentially, that the infant is being exposed to because they're not relying on breast milk solely, then then that is one of the ways that we can sort of suggest that breastfeeding might be able to continue, but it might be in a more sort of 50% pattern as opposed to 100%. Okay. And the other thing is as well that, as I say, because we work as a team, if we ever come across a situation where we are advising No, we always get it double checked with each other. So that's kind of, you know, the situation we're in that we do value breast milk so much that the no decision has to be double checked. 

Emma Pickett  54:51

Yeah, well, thank you. Thank you, Laura can hear I can hear how passionate you are about this and are very carefully you take this and how responsibly You take this and I'm very, very grateful for that. And I'm very, very grateful for your service as well. Thank you. So in the show notes, then we will put a link to the fact sheet information, we will explain how people can get in touch with you and contact you if they are a breastfeeding support or a breastfeeding support professional. And thank you very much, Laura, for all the information you've given today. I really appreciate it and good luck with your ongoing work and Aston University. Three cheers for Aston for taking on board your training. I do hope that other pharmacy training and other universities will also take you on board as well. And so if anyone is involved in university education and wants to get in touch with you from a training perspective, they can do that too. 

Laura Kearney  55:39

Yeah, definitely. 

Emma Pickett  55:40

Thanks, Laura. I really appreciate your time today.

Laura Kearney  55:42

Thanks so much, Emma. It's been really nice talking to you.

Emma Pickett  55:49

Thank you for joining me today. You can find me on Instagram at Emma Pickett IBCLC and on Twitter @MakesMilk. It would be lovely if you subscribed because that helps other people to know I exist. And leaving a review would be great as well. Get in touch if you would like to join me to share your feeding or weaning journey, or if you have any ideas for topics to include in the podcast. This podcast is produced by the lovely Emily Crosby Media.