What painkillers are safe for a lactating (breastfeeding) woman to use?

Safe Painkillers During Breastfeeding

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

First-Line Analgesics (Safest Options)

Paracetamol (Acetaminophen)

• The amount transferred to breast milk is significantly less than pediatric therapeutic doses, making it completely safe. 1
• Breastfeeding can occur immediately after taking paracetamol with no waiting period required. 2
• No infant monitoring is needed when mothers use paracetamol. 2

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

Ibuprofen is the preferred NSAID with the most reassuring safety data:

• Used extensively for postpartum pain and considered safe during lactation. 1
• No requirement to interrupt nursing or express and discard breast milk. 2
• The Association of Anaesthetists recommends ibuprofen as the first-line NSAID choice. 2

Other safe NSAIDs (in order of preference):

• Diclofenac: Second safest option after ibuprofen, with small amounts detected in breast milk and extensive safe use during lactation. 1, 2
• Naproxen: Safe despite longer half-life; widely used after caesarean section with no interruption of breastfeeding needed. 1, 2
• Ketorolac: Low levels in breast milk without demonstrable adverse effects in neonates; compatible with breastfeeding. 1, 3
• Celecoxib: Very low relative infant dose via milk; breastfeeding may continue. 1

Aspirin should be avoided in analgesic doses; only low-dose aspirin (≤100 mg/day) for antiplatelet action is acceptable if strongly indicated. 1, 4

Opioid Analgesics (When Stronger Pain Relief Needed)

Morphine is the opioid of choice if strong analgesia is required:

• Transferred to breast milk in small amounts. 1
• Single doses cause no detrimental effects to infants. 1
• Morphine patient-controlled analgesia (PCA) after caesarean section shows low transfer with no neurodevelopmental delays. 1
• Use the lowest effective dose for the shortest time possible. 1
• Monitor infants for excess sedation, respiratory depression, drowsiness, and poor feeding. 1, 5

Codeine: Probably compatible with breastfeeding for short-term use, though long-term effects are not fully elucidated. 4, 6

Avoid pethidine (meperidine): Repeated administration negatively affects the suckling infant, unlike morphine. 4, 6

Critical Safety Considerations

Timing and Dosing Strategy

• Use the lowest effective dose for the shortest duration. 1, 2
• Multimodal analgesia combining paracetamol and NSAIDs is encouraged to minimize need for opioids. 2, 7
• To further reduce infant exposure, avoid breastfeeding at times of peak drug concentration in milk. 6

Special Populations Requiring Extra Caution

• Infants less than 6 weeks of age (corrected for gestation) have immature hepatic and renal function; extra caution is warranted with any medication. 3, 2, 7
• Preterm infants have the highest medication sensitivity and require heightened vigilance. 2, 7

When Using Opioids

• Never co-sleep with the infant when taking any sedating medication, as natural maternal responsiveness may be inhibited. 7
• Monitor for withdrawal symptoms in breastfed infants when maternal opioid administration is stopped or breastfeeding is discontinued. 5
• Watch for unusual drowsiness, poor feeding, or decreased responsiveness. 1, 7

Anesthetic Agents (For Procedures)

All standard anesthetic agents are compatible with breastfeeding:

• Propofol, thiopental, etomidate: No waiting period required before resuming breastfeeding. 1
• Volatile agents (sevoflurane, isoflurane, desflurane): Cleared by exhalation; no precautions needed. 1
• Midazolam: Can resume breastfeeding as soon as recovered from procedure. 1
• Neuromuscular blockers (rocuronium, vecuronium, atracurium): Poor oral bioavailability; safe with no nursing interruption required. 7

Common Pitfalls to Avoid

• Do not unnecessarily interrupt breastfeeding or advise expressing and discarding milk when using paracetamol or NSAIDs—this is completely unnecessary. 2
• Do not use aspirin in analgesic doses during breastfeeding due to risk of salicylate intoxication and bleeding in neonates. 1, 2
• Do not prescribe repeated doses of pethidine—morphine is superior for repeated dosing. 4, 6
• Do not undertreat pain out of fear—most analgesics are safe, and mothers should not have to choose between pain relief and breastfeeding. 4