Better glycemic control in patients with diabetes can improve breastfeeding outcomes and help establish lactation by decreasing the risk of a delay in secretory activation, increasing milk production, and leading to a longer duration of breastfeeding (1, 2, 3). Even for antidiabetic medication classes with little to no data available, there is no absolute indication to pump and dump but thorough risk benefit discussions should be had regarding medications with limited data or theoretical risks to the infant. Shared decision making should include discussions regarding the biochemical properties of the medication, contribution to maternal glucose control, maternal side effects, and theoretical infant risks, among other considerations. For medications that potentially cause hypoglycemia with significant milk transfer, monitor infants and educate parents for signs of hypoglycemia (jitteriness, sedation, poor feeding, hypothermia, apnea, seizures, etc.) or physically monitor infant glucose levels if concerned.

For more detailed information and references on specific medications, please refer to Lactmed, e-lactancia, Infant Risk, or Mother to Baby.

Metformin/Glucophage has minimal transfer into breast milk and nursing children’s metformin blood levels are exceedingly low or undetectable.  There are no currently known adverse effects in breastfeeding infants.  Metformin is also used for lactating women with a history of insufficient glandular tissue to increase milk production. Based on available data, there is no absolute indication to pump and dump with metformin.

SGLT-2 inhibitors (canagliflozin/Invokana, dapaglifozin/Farxiga, empagliflozin/Jardiance) are known to be highly protein bound and not likely to be present in amounts in the breast milk that would adversely affect infants. However, due to their side effects in adults and theoretical risk of negative side effects on the developing infant kidney, manufacturers of these medications do not recommend use in the breastfeeding dyad. Due to theoretical risks to the infant and the lack of evidence in lactating individuals, alternative medications should be considered.

GLP-1 Agonists (liraglutide/Victoza, exenatide/Byetta/Bydureon, dulaglutide/Trulicity) are very large peptides and the medication concentration in breastmilk is suspected to be low. Due to the nature of being a peptide molecule, the small amount that may enter the breast milk would likely be destroyed in the infant’s gastrointestinal tract and not be absorbed by the infant. Therefore, there is no absolute indication to pump and dump with GLP-1 agonists due to low theoretical milk penetration and the likely destruction of medication that does enter breastmilk in the infant’s gastrointestinal tract.

DPP4 Inhibitor (sitagliptin/Januvia, saxagliptin/Onglyza, linagliptin/Tradjenta) have little to no data available on their use in lactating individuals. Medications in this class with a shorter half-life (sitagliptin/Januvia, saxagliptin/Onglyza) may be preferred.  Linagliptin/Tradjenta is known to be highly protein bound and not likely to be present in clinically relevant amounts in the breast milk. While data is limited, there is no absolute indication to pump and dump.

Thiazolidinediones (pioglitazone/Actos, rosiglitazone/Avandia) have little to no data available on their use in lactating individuals, but these medications are highly protein bound and not likely to be present in sufficient amounts in the breast milk to adversely affect infants. While data is limited and infants should be monitored for hypoglycemia, there is no absolute indication to pump and dump.

Sulfonylureas (glipizide, glymepiride, glyburide) have little to no data available on their use in lactating individuals, but these medications are found to be present in low concentrations in the breast milk and are not likely to be present in sufficient amounts in the breast milk to adversely affect infants. While data is limited and infants should be monitored for hypoglycemia, there is no absolute indication to pump and dump.

There are many types of insulin including insulin glargine/Lantus, insulin lispro/Humalog, insulin detemir/Levemir, Toujeo, Tresiba, NPH. All types of insulin are considered safe in breastfeeding. Insulin is present naturally in breastmilk. Levels of insulin in milk were found to be higher in women who use insulin during lactation (4). Insulin in the breast milk may lead to a decreased risk of type 1 diabetes in breastfed infants (5, 6, 7, 8).  Based on available data, there is no absolute indication to pump and dump with the use of insulin.