What analgesics are safe for breastfeeding mothers?

Safe Analgesics During Breastfeeding

Paracetamol (acetaminophen) and NSAIDs such as ibuprofen and diclofenac are the safest analgesics for breastfeeding mothers and should be considered first-line options. 1, 2

First-Line Analgesics

Non-Opioid Options

• Paracetamol (acetaminophen): Considered very safe during breastfeeding as the amount transferred to breast milk is significantly less than the pediatric therapeutic dose 1, 2
• Ibuprofen: Has been used extensively for postpartum pain and during lactation with minimal transfer into breast milk 1, 2
• Diclofenac: Small amounts detected in breast milk; has been used extensively during lactation and is considered safe 1
• Naproxen: Despite having a longer half-life than diclofenac, it's widely used after cesarean section and is compatible with breastfeeding 1
• Celecoxib: The relative dose that infants are exposed to via milk is very low, making it compatible with breastfeeding 1
• Ketorolac, parecoxib: Low levels detected in breast milk without demonstrable adverse effects in the neonate 1

Second-Line Analgesics (Use with Caution)

Opioid Options

• Morphine: Transferred to breast milk in small amounts; recommended as the opioid of choice if strong analgesia is required 1
• Codeine: Considered compatible with breastfeeding for short-term use as a cough suppressant 3
• Tramadol: Use with caution and observe the infant for unusual drowsiness 1
• Oxycodone: Greater risk of drowsiness in doses > 40 mg/day; should be used with caution 1

Analgesics to Avoid

• Aspirin: Should not be used in analgesic doses during breastfeeding. Low-dose aspirin for anti-platelet action (up to 100 mg/day) can be used if strongly indicated 1, 4
• Dipyrone: Safer alternatives should be considered 4
• Pethidine (meperidine): Repeated administration affects the suckling infant negatively 5

Practical Recommendations

Dosing Considerations

• Use the lowest effective dose for the shortest time possible 1, 4
• For opioid analgesia, if required, use the lowest effective dose for the shortest time possible 1
• Time medication administration after breastfeeding to minimize infant exposure 4

Monitoring

• When using tramadol, observe the infant for unusual drowsiness 1
• With oxycodone doses > 40 mg/day, monitor for increased risk of drowsiness in the infant 1
• If repeated doses of morphine are used, monitor the infant for adverse effects 1

Special Considerations

• Avoid co-sleeping with the infant when taking sedating medications, as maternal natural responsiveness may be inhibited 1
• For most analgesics, no interruption of breastfeeding is necessary 6, 4
• When choosing between analgesics, consider the infant's age and health status - younger or premature infants may be more susceptible to adverse effects 5

Algorithm for Analgesic Selection in Breastfeeding Mothers

1. Start with non-opioid analgesics:

   • First choice: Paracetamol (acetaminophen) 1, 2
   • Second choice: Ibuprofen or diclofenac 1, 2

2. If additional pain relief is needed:

   • Add short-term morphine for severe pain 1
   • Consider tramadol with careful infant monitoring 1

3. For long-term analgesic needs:

   • Prefer short-acting agents without active metabolites (e.g., ibuprofen) 5
   • Avoid aspirin in analgesic doses 1, 4

By following these recommendations, breastfeeding mothers can receive adequate pain relief while minimizing potential risks to their infants.