Breastfeeding mothers should take many precautions while using OTC medications for pain, cough, cold, and allergies.15,16 Acetaminophen is the safest OTC analgesic for nursing mothers. The amount of acetaminophen exposure in breast milk is less than concentrations observed using therapeutic doses administered to infants. If an NSAID is preferred, ibuprofen is optimal because of its short half-life and reduced systemic exposure. The lowest dose and frequency should be used. NSAIDS with a longer half-lives such as naproxen should be avoided. Aspirin use is discouraged because of the risk to the baby of Reye’s syndrome.
Saline nasal spray is the safest option for congestion.16 Oral decongestants are associated with reduced milk supply and infant irritability. If the mother requires a decongestant, pseudoephedrine is preferred over phenylephrine due to the lack of human data reports on phenylephrine, but this option should be discussed with the health-care professional. Instruct the mother to take the dose right after breastfeeding her baby and recommend that she use immediate-release formulations rather than sustained-release and combination products to minimize drug exposure. Nasal pseudoephedrine may minimize systemic concentrations. Intranasal steroids are acceptable to use while breastfeeding because the detectable amounts of these drugs found in breast milk have not been linked to harm or damage to the infant if used appropriately.
Second-generation antihistamines such as loratadine, cetirizine, fexofenadine, and desloratadine are preferred because the anticholinergic properties of first-generation agents may contribute to reduced milk supply and infant irritability.16,17 Second-generation agents are detected in small amounts in breast milk, but are associated with less sedation and milk supply reduction than first generation products such as diphenhydramine and chlorpheniramine. Loratadine and cetirizine need to be taken at the lowest possible dose, but there are no dosing restrictions for fexofenadine and desloratadine. Encourage moms to take the antihistamine dose at bedtime to minimize exposure.
Breastfeeding mothers seeking cough relief should first try nonpharmacological options, such as using a humidifier, drinking warm beverages, and remaining hydrated, due to the lack of data on other agents.11,16 There are limited published data on the excretion of dextromethorphan and guaifenesin in breast milk. These agents are unlikely to cause any harm to infants over 2 months old. Avoid any OTC antitussives/expectorant products containing alcohol to minimize potential sedation in the infant. If the mother isinstructed by her doctor to use a medication to relieve symptoms of a cough, an alcohol-free version is preferred. Codeine products should be avoided during breastfeeding because toxicity such as drowsiness, sedation, and difficulty breathing may occur. This is especially true the mother has a 2D6 enzyme mutation that results in a faster metabolic breakdown and increased opiate concentrations. Mothers with this mutation are at a greater risk of morphine toxicity when taking codeine.