What painkillers are safe to use during lactation (breastfeeding)?

Safe Painkillers During Lactation

Paracetamol (acetaminophen) and ibuprofen are the safest first-line analgesics for breastfeeding mothers and can be used immediately without interrupting nursing or discarding breast milk. 1, 2

First-Line Safe Options (Use Without Restriction)

Paracetamol (Acetaminophen)

• Extremely safe with no special precautions needed - the amount transferred to breast milk is significantly less than pediatric therapeutic doses 2, 3
• Breastfeeding can occur immediately after taking paracetamol with no waiting period required 1, 2
• No need to monitor the infant for adverse effects 2
• No "pump and dump" required 2

Ibuprofen

• Has the most reassuring safety data among all NSAIDs with minimal milk excretion and extensive use for postpartum pain 1, 2
• Compatible with breastfeeding with no requirement to interrupt nursing or express and discard milk 1
• Breastfeeding can resume immediately without waiting between doses and feeding 2
• Preferred over other NSAIDs due to short half-life and minimal biotransformation 4, 5

Other Safe NSAIDs

• Diclofenac is the second safest NSAID after ibuprofen according to EULAR guidelines, with small amounts detected in breast milk 1, 3
• Naproxen is widely used after cesarean section and compatible with breastfeeding, though it has a longer half-life than other options 3, 6
  • FDA labeling confirms naproxen concentration in milk is approximately 1% of maximum maternal plasma concentration 6
• Ketorolac has low levels in breast milk without demonstrable adverse effects 3

Practical Dosing Strategy

• Use the lowest effective dose for the shortest duration needed 1, 3
• Multimodal analgesia combining paracetamol with ibuprofen is encouraged to minimize need for stronger medications 1
• For short-acting NSAIDs, taking the medication at the time of breastfeeding with the next feed occurring after one half-life can further minimize infant exposure 5

Second-Line Options (Use With Monitoring)

Morphine

• Morphine is the preferred opioid if strong analgesia is required, as it transfers to milk in small amounts 2, 3
• Single doses pose no risk 2
• Repeated doses require monitoring the infant for drowsiness and poor feeding 2, 4
• Mothers must never co-sleep with their infant when taking opioids as maternal responsiveness may be inhibited 2

Other Opioids

• Codeine is probably compatible with breastfeeding, though long-term effects are not fully elucidated 4, 7
• Tramadol should be used with caution and the infant monitored for unusual drowsiness 3
• Oxycodone has greater risk of infant drowsiness at doses >40 mg/day and requires monitoring 3

Medications to Avoid

• Aspirin in analgesic doses should not be used during breastfeeding 2, 3
  • Low-dose aspirin for antiplatelet action (up to 100 mg/day) can be used if strongly indicated 3, 7
• COX-2 inhibitors should be avoided due to limited data, with the exception of celecoxib which has very low infant exposure 1, 2
  • Celecoxib is compatible with breastfeeding per some guidelines 3

Special Populations Requiring Extra Caution

Infants Less Than 6 Weeks of Age

• Extra caution required due to immature hepatic and renal function 1, 2
• Preterm infants have the highest medication sensitivity 1, 2
• However, paracetamol and ibuprofen remain safe options even in this age group 1

Infants With Jaundice

• NSAIDs like ibuprofen should be used with caution as they can displace bilirubin 1
• Large doses of aspirin should be avoided due to risk of salicylate intoxication and bleeding 1

Critical Safety Points

• There is absolutely no need to "pump and dump" with paracetamol or ibuprofen 2
• Expressing and discarding breast milk after taking these medications is completely unnecessary 1
• Breastfeeding can resume as soon as the mother has recovered from any procedure when these medications are used 2
• Clear parental education on correct dosing and intervals should be provided, with medications stored in childproof containers 1