The majority of breastfeeding moms take at least one medication while nursing. Commonly used medications during breastfeeding include pain killers, heartburn remedies, asthma medications, and medications to treat postpartum depression and anxiety. Many new moms also take herbal supplements, including galactagogues like fenugreek, during lactation.
If you are breastfeeding and/or pumping it’s really important to check that all medications and supplements you take are safe and compatible with breastfeeding.
Unfortunately, searching the internet to find answers about the safety of medications and breast milk can be very time-consuming and confusing for new mothers. Therefore, it’s essential for breastfeeding moms to have easy-to-find and accurate information as to whether or not the medications they are taking (or plan to take) are compatible with lactation.
Thomas Hale, Ph.D., is a world expert in breastfeeding medicine and the safety of medications in mothers’ breast milk. “Medications and Mother’s Milk,” Dr. Hale’s textbook, is the most comprehensive resource available for finding answers as to whether medications are safe to use during lactation. Dr. Hale classifies medications and supplements into five lactation risk categories (aka LRCs):
- L1: Compatible
“Drug which has been taken by a large number of breastfeeding mothers without any observed increase in adverse effects in the infant.”
- L2: Probably Compatible
“Drug which has been studied in a limited number of breastfeeding women without an increase in adverse effects in the infant and/or the evidence of a demonstrated risk which is likely to follow use of this medication in a breastfeeding woman is remote.”
- L3: Probably Compatible
“There are no controlled studies in breastfeeding women; however, the risk of untoward effects to a breastfed infant is possible, or controlled studies show only minimal non-threatening adverse effects.” Any newly FDA-approved medications automatically fall into this category.
- L4: Potentially Hazardous
“There is positive evidence of risk to a breastfed infant or to breastmilk production, but the benefits from use in breastfeeding mothers may be acceptable despite the risk to the infant (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective).”
- L5: Hazardous
“The risk of using the drug in breastfeeding women clearly outweighs any possible benefit from breastfeeding. The drug is contraindicated in women who are breastfeeding an infant.”
Other Resources for Medications and Breast Milk
The “Infant Risk Center” at Texas Tech University’s Health Sciences Center, which was founded by Dr. Hale, has a comprehensive website that is chock full of up-to-date information about the safety of hundreds of medications and supplements while breastfeeding. There is also an infant risk phone hotline for medical professionals to call for guidance.
The U.S. National Library of Medicine’s Drugs and Lactation Database (LactMed) is another excellent resource to use to see if medications are safe to use while breastfeeding. This website is easy to navigate and can be used by both parents and health care providers. Although LactMed’s mobile app is no longer available, the LactMed website can be accessed through the internet. MommyMeds is another helpful mobile app to check out.
Lactation Risk Categories for Commonly Used Medications
Cetirizine (Zyrtec) L2
Diphenhydramine (Benadryl) L2
Fexofenadine (Allergra) L2
Loratidine (Claritin) L1
Azithromycin (Z-pak) L2
Buproprion (Wellbutrin) L3
Fluoxetine (Prozac) L2
Paroxetine (Paxil) L2
Sertraline (Zoloft) L2
Venlafaxine (Effexor) L2
Alprazolam (Xanax) L3
Citalopram (Celexa) L2
Lorazepam (Ativan) L3
Montelukast (Singulair) L4
Cough and Cold Remedies
Guaifenesin (Mucinex) L3
Pseudoephedrine (Sudafed) L3
Cimetidine (Tagamet) L2
Famotidine (Pepcid) L1
Ranitidine (Zantac) L2
Acetaminophen (Tylenol) L1
Aspirin L3 (use only small doses)
Ibuprofen (Motrin) L1
Armour Thyroid L1
Levothyroxine (Synthroid) L1
L5 medications and supplements that need to be avoided while breastfeeding include the following: all chemotherapy agents, blue cohosh (including blue ginseng, squaw root, papoose root, yellow ginseng), DHEA, disulfiram (Antabuse), radioactive iodine, isotretinoin (Accutane), Kava-Kava, Kombucha Tea, Neomycin (if topical on the nipple), and Strontium-89 Chloride.
In addition, cannabis derivatives, including marijuana, pot, weed, and tetrahydrocannabinol (THC), are L4 (potentially hazardous) and all other drugs of abuse are L5 (hazardous) and need to be avoided at all costs during lactation.
What About CBD?
From a breastfeeding standpoint, is CBD considered to be as harmful as marijuana? CBD, or cannabidiol, is a substance called a phytocannabinoid that is derived from the cannabis plant. CBD does not cause a “high” due to a lack of psychoactive effects. CBD comes in many formulations, including sprays, oils, edibles, and inhaled and vaped products. It is being investigated as a possible future medical treatment for pain, anxiety, seizures, and other neurological disorders. The only current FDA-approved use of CBD is in a prescribed form as an anti-epileptic (anti-seizure) medication.
There is a lot of confusion as to whether CBD, marijuana, and cannabis are all the same thing. Hemp and marijuana both come from the cannabis plant. THC is the psychoactive substance in marijuana that causes one to feel “high.” CBD can be derived from either hemp or marijuana. Hemp comes from cannabis plants that contain no more than 0.3% THC, while marijuana-containing cannabis plants contain greater than 0.3% THC. Most of the CBD products that are sold in the United States come from hemp plants, which means that they should contain less than 0.3% THC.
The main concern with using cannabis products, such as CBD or marijuana, while breastfeeding is that we lack safety information. We do know that THC found in marijuana passes into breast milk and is metabolized by babies. THC impacts babies’ brain development and long-term studies of marijuana-exposed fetuses and babies show an association with impairments in school-aged children’s cognitive abilities, visual integration, memory, problem-solving abilities, and emotional regulation. There are also possible links between maternal marijuana usage and the later development of ADHD and hyperactivity in children. The American Academy of Pediatrics and Academy of Breastfeeding Medicine both discourage the use of marijuana and THC while breastfeeding, however, their current recommendations and protocols do not explicitly address potential risks of hemp-derived CBD (with less than 0.3% THC).
Although we don’t have evidence that CBD is, in and of itself, harmful, recent studies have shown that cannabidiol is present in mothers’ breast milk in rather large amounts. There is emerging scientific evidence in animal studies that CBD affects the brain, immune system, and reproductive system of developing fetuses. There are also increasing concerns about potentially harmful CBD product additives and contaminants that may pass into breast milk, such as heavy metals and pesticides. Per the Centers for Disease Control (CDC) website, “Some products, including cannabidiol (CBD) products, may contain other contaminants, e.g., pesticides, heavy metals, bacteria, and fungus, that could be dangerous to a mother and her infant.” In addition, there is a risk that even though a CBD product is “hemp-derived” that it could contain levels of THC greater than .3%. Because of all of these risks and unknowns about the effects of CBD, the Food and Drug Administration advises that women avoid all CBD use while breastfeeding.
Based on the current recommendations of the CDC and FDA, and until more information is available in regards to the safety of using cannabidiol while breastfeeding, lactating mothers should abstain from using any CBD-containing products. If you are breastfeeding and considering starting to use a CBD product, such as oils or edibles, please discuss this with your baby’s pediatrician. If you are already using CBD products while breastfeeding, try to cut back and limit your use and make sure to keep up to date on research about the safety of CBD during lactation. It is always better to be safe than sorry when it comes to the health and well-being of your little one(s).
Academy of Breastfeeding Medicine Clinical Protocol #21: Guidelines for Breastfeeding and Substance Use or Substance Use Disorder, Revised 2015. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378642/
Is it Safe for Mothers Who Use Marijuana to Breastfeed? CDC.gov. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/vaccinations-medications-drugs/marijuana.html
Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcome. American Academy of Pediatrics. 2018. https://pediatrics.aappublications.org/content/142/3/e20181889
Medications and Mother’s Milk. Access via HaleMeds website. https://www.halesmeds.com/
What You Should Know About Using Cannabis, Including CBD, When Pregnant or Breastfeeding. FDA.gov.