Pain medications include a wide range of medications.

In general, non-opioid analgesics are not an absolute indication to pump and dump.

Opioid pain medications are commonly used postpartum and in a variety of other settings. Risks and benefits must be considered and the baby should be monitored for any medication side effects, especially with higher doses or prolonged use. Premature or very young infants are more susceptible to side effects when the lactating parent is on these medications. While the infant should be closely monitored for side effects (such as sedation or respiratory depression) with use of this class of medications by a lactating individual, many medications in this class are not an absolute indication to pump and dump and shared decision making should be used with these medications.

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

Common non-opioid pain medications include non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, gabapentin, and pregabalin among other medications. These medications are typically first-line options for management of many types of acute and chronic pain and may be valuable in reducing the need for opioid analgesics when given regularly with optimal dosing (rather than as needed dosing) (1,2). Non-opioid analgesics are generally not an absolute indication to pump and dump.

• NSAIDs (ibuprofen/Motrin, naproxen/Naprosyn, celecoxib/Celebrex, ketorolac/Toradol): Due to low lipid solubility and high protein binding, NSAIDs have limited milk transfer. These medications should be avoided if the breastfed infant has a ductal-dependent cardiac lesion (2). Unless the infant has a ductal-dependent cardiac lesion, there is no absolute indication to pump and dump.
• Acetaminophen/paracetamol/Tylenol: Milk transfer has been shown to be low (2). There is no absolute indication to pump and dump.
• Gabapentin/Neurontin: Infants should be monitored for drowsiness and insufficient weight gain with chronic use of higher doses. Low blood levels of gabapentin have been found in the breastfeeding infants of mothers taking this medication (2). While the infant should be closely monitored for side effects (such as drowsiness and insufficient weight gain) with use of this medication by the lactating parent, there is not an absolute indication to pump and dump and shared decision making should be used with these medications.
• Pregabalin/Lyrica: Infants should be monitored for drowsiness and insufficient weight gain. Low blood levels of pregabalin have been found in breastfeeding newborn infants at 48 hours postpartum of mothers taking this medication as an anticonvulsant during pregnancy and postpartum. Since there is less data available about pregabalin during lactation as compared to other non-opioid analgesics, alternatives are preferred (2). While alternatives are preferred and the infant should be closely monitored for side effects (such as drowsiness and insufficient weight gain) with use of this medication by the lactating parent, there is not an absolute indication to pump and dump and shared decision making should be used with these medications.
• Tricyclic Antidepressants (amitriptyline/Elavil, Nortriptyline/Pamelor): There has been one case report of infant sedation with low dose amitriptyline (3). The anti-cholinergic properties of tricyclic antidepressants have been observed to decrease milk production, especially with higher doses although data are limited. Nortriptyline is less anticholinergic than amitriptyline. While breastfed infants should be closely monitored for side effects (such as sedation) with use of this class of medication by the lactating individual and parents should be informed of the risk to milk production, there is not an absolute indication to pump and dump and shared decision making should be used with these medications.
• SNRIs (duloxetine/Cymbalta, venlafaxine/Effexor): The infant should be monitored for sedation and poor weight gain, especially among newborns and premature infants, as a recent case of venlafaxine toxicity in an infant has been reported and a small amount of milk transfer may occur (4). While alternative pain management options are preferred and the infant should be closely monitored for side effects with use of this class of medications by the lactating individual, there is not an absolute indication to pump and dump and shared decision making should be used with these medications.
• Low Dose Naltrexone: Reports have demonstrated very low infant blood levels of naltrexone and its metabolite beta-naltrexol with maternal doses of 50mg a day. Naltrexone is minimally excreted into breastmilk. Naltrexone dosing for chronic pain is typically very low dose, often less than 6 mg. There is no absolute indication to pump and dump.

Judicious use of opioids is generally not an absolute indication to pump and dump for most lactating individuals and their infants, but this is a class of medication with the potential for significant milk transfer and infant side effects that are more likely with larger doses or with specific opioids. Opioids can be prescribed by multiple different routes and are generally used in intravenous and oral forms in the perinatal period and perioperative setting.

• Oral Opioids (oxycodone/Roxicodone, hydrocodone, codeine, tramadol/Ultram): Infants should be monitored for side effects such as sedation or respiratory depression with any opioid use. The newborn’s exposure to opioids via breast milk increases greatly as the mother’s milk volume increases, so families and healthcare teams should be especially vigilant about infant sedation during the first 1-2 weeks (2). Hydrocodone or oxycodone are preferred over codeine and tramadol.
  • Oxycodone & hydrocodone: Oxycodone and hydrocodone remain the primary options for short courses of oral opioids for acute pain. As with any opioid use for any pain issue, these should be given at the lowest effective dose and for the shortest necessary time. LactMed suggests a maximum dose of 30 mg/24 hours in divided doses for each of these medications. Infants should be monitored for side effects (such as sedation, difficulty breathing, respiratory depression, or limpness) and should be cared for by a responsible adult not under the influence of opioids (2). While infants should be closely monitored for side effects, there is not an absolute indication to pump and dump if daily doses are kept to less than 30 mg total.
  • Morphine & hydromorphone: Infants should be monitored for side effects and cared for by a responsible adult not under the influence of opioids (2). While infants should be closely monitored for side effects, there is not an absolute indication to pump and dump with the use of morphine or hydromorphone.
  • Codeine & tramadol: The FDA issued a “black box warning” in 2017 against the use of codeine and tramadol in breastfeeding mothers, owing to interindividual variation in metabolism of these pro-drug medications that could result in a relative overdose of their respective active analgesic metabolites morphine and o-desmethyltramadol (2). Alternative medications are preferred in lactating individuals.
  • Methadone: Doses less than 100mg per day are recommended for lactating individuals. If choosing a new medication for pain control, alternatives are preferred, as infants who are were not exposed to methadone during pregnancy have a higher risk of sedation than those who were exposed in utero. Neonates exposed to methadone in utero have significantly lower rates of neonatal withdrawal symptoms if breastfed by the parent taking methadone. Alternative pain management options are preferred if new treatments are being started. Infants should be closely monitored for side effects with the use of methadone by lactating individuals, but there is not an absolute indication to pump and dump for parents who have been on methadone previously.
  • Buprenorphine: There is low oral bioavailability in infants, with low urine and serum levels in breastfed infants. Watch for sedation in very young or premature infants. While infants should be closely monitored for side effects such as sedation with the use of this medication by a lactating individual, there is not an absolute indication to pump and dump.
• Intravenous Opioids (fentanyl, morphine, and hydromorphone): The parent might consider pumping and saving milk in certain situations if high doses of medications are needed and the infant is at risk of developing side effects. While infants should be closely monitored for side effects such as sedation, there is not an absolute indication to pump and dump. For more information, see the section on Anesthesia.
  • Fentanyl: Fentanyl exhibits low milk transfer and extremely low oral bioavailability, so it is likely the safest opioid to use perioperatively (1, 2). When continuous Fentanyl drips are used (such as in the ICU setting), the risks of infant sedation and side effects may be higher so shared decision making should be utilized with a thorough risk benefit discussion of the options and infants should be monitored closely for any side effects if milk pumped in patients on continuous Fentanyl drips is used. While infants should be closely monitored for side effects such as sedation, there is not an absolute indication to pump and dump.
  • Morphine & hydromorphone: Caution should be used with high doses in the operating room or postoperatively. Generally, once the lactating parent is awake enough to pump or feed the baby, breastfeeding can resume if the infant is not at risk of side effects, such as a preterm infant (1, 2). While infants should be closely monitored for side effects such as sedation, there is not an absolute indication to pump and dump.
  • Other IV opioids: Other medications such as remifentanil, sufentanil, and nalbuphine may also be used during anesthesia, and their intra-operative use should not preclude breastfeeding once the mother is awake and alert (1, 2). While infants should be closely monitored for side effects such as sedation, there is not an absolute indication to pump and dump.