Which analgesics are safe for a lactating (breastfeeding) mother to use for mild‑to‑moderate pain?

Safe Analgesics During Lactation

Paracetamol (acetaminophen) and ibuprofen are the safest first-line analgesics for breastfeeding mothers and can be taken immediately without interrupting nursing or discarding breast milk. 1, 2, 3

First-Line Analgesics (Completely Safe)

Paracetamol (Acetaminophen)

• Paracetamol is extremely safe during breastfeeding, as the amount transferred to breast milk is significantly less than pediatric therapeutic doses 1, 2, 3
• No waiting period is required after taking paracetamol—breastfeeding can occur immediately 1, 3
• No special monitoring of the infant is required 1
• "Pump and dump" is completely unnecessary and offers no safety benefit 1, 3

Ibuprofen

• Ibuprofen has the most reassuring safety data among all NSAIDs and is the preferred NSAID choice during lactation 1, 2, 3
• The relative infant dose is <0.38% of the weight-adjusted maternal dose, well below the 10% safety threshold 1, 4
• Extensive postpartum clinical experience shows no documented adverse effects in breastfed infants 1
• Short half-life and high protein binding limit transfer into breast milk 1
• No interruption of nursing or milk expression is required 1, 3

Multimodal Analgesia Strategy

• Combining paracetamol with ibuprofen is recommended to enhance pain control while minimizing exposure to any single drug 1, 2, 3
• Use the lowest effective dose for the shortest duration needed 1, 2, 3

Other Safe NSAIDs (Alternative Options)

Diclofenac

• Diclofenac is the second-safest NSAID after ibuprofen with established compatibility during breastfeeding 1, 2
• Small amounts detected in breast milk without adverse effects 2

Naproxen

• Compatible with breastfeeding despite longer half-life than ibuprofen 1, 2
• Widely used after cesarean section 2
• Minimal excretion in breast milk (approximately 1% of maternal plasma concentration) 1

Ketorolac

• Low breast milk concentrations without demonstrable adverse neonatal effects 2
• Compatible with breastfeeding 1

Celecoxib

• Compatible with breastfeeding, with very low relative infant dose via milk 2

Second-Line Analgesics (Use When Non-Opioids Insufficient)

Morphine

• Morphine is the preferred opioid when stronger analgesia is required 2, 3
• Transferred to breast milk in small amounts 2, 3
• Single doses pose no risk 3
• Repeated doses require infant monitoring for drowsiness, sedation, poor feeding, and behavioral changes 1, 3

Codeine

• Probably compatible with breastfeeding for short-term use 5, 6
• Use with caution due to variable metabolism and risk of infant sedation 5

Tramadol

• Should be used with caution 2
• Infant must be monitored for unusual drowsiness 2

Oxycodone

• Use with caution, especially at doses >40 mg/day 2
• Greater risk of infant drowsiness at higher doses 2

Medications to Avoid

Aspirin (Analgesic Doses)

• Aspirin should not be used in analgesic doses during breastfeeding due to risk of salicylate intoxication and neonatal bleeding 1, 2, 3
• Low-dose aspirin (up to 100 mg/day) for antiplatelet action can be used if strongly indicated 2, 5

COX-2 Inhibitors (Except Celecoxib)

• Should be avoided due to limited safety data during lactation 1, 3

Special Considerations for Young Infants

Age-Related Caution

• Extra caution is required for infants <6 weeks of age (corrected for gestational age) due to immature hepatic and renal function 1, 3
• Sensitivity hierarchy: preterm infants > neonates > young infants 1, 3
• This caution applies more significantly to opioids than to NSAIDs like ibuprofen 1

Critical Safety Points

Opioid-Specific Warnings

• Opioids should not be used as default analgesics for breastfeeding mothers—they carry significantly higher risks of infant sedation, respiratory depression, and mortality compared to ibuprofen 1
• Mothers must never co-sleep with their infant when taking sedating medications (opioids), as maternal responsiveness may be inhibited 2, 3
• Excessive maternal sedation should be monitored as an indicator of possible infant drug effects 1

Practical Dosing Principles

• Always use the lowest effective dose for the shortest duration 1, 2, 3, 6
• Infant exposure can be further reduced by avoiding breastfeeding at times of peak drug concentration in milk 6
• Regional anesthesia and local anesthetics should be encouraged to lower the need for systemic analgesics 1

Common Pitfalls to Avoid

• Do not unnecessarily discontinue breastfeeding when safe analgesics like paracetamol or ibuprofen are needed 1, 7
• Do not default to opioids when non-opioid options can provide adequate pain control 1
• Do not advise "pump and dump" for paracetamol, ibuprofen, or other compatible NSAIDs 1, 3