Pain Medications Safe During Breastfeeding
Paracetamol (acetaminophen) and ibuprofen are the first-line analgesics for breastfeeding mothers and can be used immediately without interrupting nursing or discarding breast milk. 1, 2
First-Line Analgesics (Safest Options)
Paracetamol (Acetaminophen)
- Completely safe and compatible with breastfeeding with no requirement to interrupt nursing or express and discard milk 1, 2
- The amount transferred to breast milk is significantly less than pediatric therapeutic doses 2
- Can be combined with NSAIDs for multimodal analgesia to enhance pain control while minimizing individual drug exposure 1, 2
Ibuprofen
- The preferred NSAID with the most reassuring safety data during lactation 2
- Relative infant dose is less than 0.38% of the weight-adjusted maternal dose, well below the 10% safety threshold 2
- Extensive postpartum clinical experience shows no documented adverse effects in breastfed infants 2
- Short half-life and high protein binding limit transfer into breast milk 2
Second-Line NSAIDs (Also Safe)
Diclofenac
- The second safest NSAID option after ibuprofen with established compatibility during breastfeeding 2
Naproxen
- Safe and compatible with lactation despite longer half-life, with minimal excretion in breast milk (approximately 1% of maternal plasma concentration) 2
- Widely used after caesarean delivery in lactating patients 2
Ketorolac (IV or PO)
- Safe and compatible with breastfeeding with very low concentrations transferred to breast milk 3
- Breastfeeding can continue immediately after administration without any waiting period 3
- Substantially safer than opioid alternatives 3
Opioids (Use With Caution)
When Opioids Are Necessary
- Morphine and dihydrocodeine are the preferred opioid agents if non-opioid analgesics are insufficient 1
- Use the lowest effective dose for the shortest period of time 1
- Codeine is probably compatible with short-term use, though long-term effects are not fully elucidated 4, 5
Critical Monitoring Requirements
- Observe the infant for sedation, drowsiness, or behavioral changes; if these develop, withhold breastfeeding and seek medical advice immediately 1
- Extra caution is required for infants less than 6 weeks of age (corrected for gestation) due to immature hepatic and renal function 1
- The order of sensitivity decreases from preterm > neonates > young infants 1
- Monitor for excessive maternal sedation as an indicator of potential infant effects 1
Opioids to Avoid or Use With Extreme Caution
- Pethidine (meperidine) should be avoided for repeated administration as it negatively affects the suckling infant, unlike morphine 4, 5
- Given interindividual variation in opioid metabolism and risks in ultra-rapid metabolizers, monitoring for excessive sedation is essential 6
Medications to Avoid
Aspirin
- Avoid aspirin in analgesic doses due to risk of salicylate intoxication and neonatal bleeding 2
- Low-dose aspirin (up to 100 mg/day) is considered compatible, but higher doses require safer alternatives 5
Key Clinical Principles
Multimodal Analgesia Strategy
- Combine paracetamol with an NSAID (preferably ibuprofen) to minimize the need for opioids 1, 2
- Regional anaesthesia and local anaesthetic supplementation should be encouraged to reduce systemic analgesic requirements 1
Dosing Recommendations
- Use the lowest effective dose for the shortest duration for all analgesics 1, 2
- Take medications immediately after breastfeeding to minimize infant exposure at peak drug concentrations 4
Common Pitfalls to Avoid
- "Pump and dump" is unnecessary after taking paracetamol, ibuprofen, or other compatible NSAIDs 1, 2
- Do not default to opioids for routine pain relief; they carry significantly higher risks of infant sedation, respiratory depression, and mortality compared to NSAIDs 2
- Do not discontinue breastfeeding unnecessarily; the benefits of breastfeeding outweigh the negligible risks associated with compatible analgesics 2