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Women who are breastfeeding can have pain due to many different causes: post-partum pain after episiotomy or
Cesarean section, nipple pain from early breastfeeding, headaches, pain from injuries or other causes.
Maternal pain causes stress and may cause problems with decreased oxytocin release and subsequent milk
letdown.
See also:
Hormones involved in breast development and breastfeeding
.
Consequently pain in breastfeeding mothers should be treated. Non-pharmacologic methods such relaxation
techniques can be used. Use of acetaminophen and ibuprofen are safe and effective in breastfeeding women.
When pain does not respond to routine measures listed above, oral codeine and hydroxycodone have been used in
many many breastfeeding mothers around the world without infant problems. Occasional cases of infant
sedation have been reported but appear to be dose related. In 2006, an infant death at age 13 days was
reported. The mother was taking a codeine preparation for episiotomy pain. The infant was reported to have
decreased breastfeeding and periods of lethargy starting at 7 days of age. The post-mortem blood
concentration of morphine in the infant's blood was very high and thought to be responsible for the death.
The mother had reported sleepiness and constipation on the oiginal dose of codeine and had decreased her dose
in half. Evaluation of the mother showed that she had a variant of the gene CYP2D6 that caused her to be an
ultra-rapid metabolizer of codeine to morphine. There has been debate in the medical literature about this
case and whether codeine was the cause of the infant's death
(
Koren, 2006
,
Ferner, 2008
,
Bateman, 2008
.
The FDA recently published a Public Health Advisory on the use of codeine by breastfeeding mothers. Because
people don't know how they metabolize codeine, the FDA urged physicians to use the lowest dose of codeine that
is effective and use it for the shortest period of time necessary. The FDA recommends that breastfeeding
mothers monitor themselves and their infant while taking codeine. If the mother or infant becomes sleepy
while taking codeine or the infant has decreased feeding, they need to contact their physician for urgent
assessment (
FDA, 2007
).
Further study on the issue of codeine metabolism, maternal and infant toxicity, and the genetic varient of
ultra-rapid metabolizer is underway.
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