Is Morphine safe while breastfeeding?

Effects on the breastfed infant

In a term infant with unexplained apnea and bradycardia with cyanosis while hospitalized in the first week of life, the measured plasma morphine in the infant was 1.2 mcg/L. The measurement was taken 108 hours after the mother's last dose of morphine and no morphine was detected in her milk. The mother's dose was not reported.[ 13 ] Breastfed newborns of mothers using intravenous PCA morphine for postcesarean analgesia were more alert and better oriented after postpartum day 3 than infants of mothers using intravenous PCA meperidine and nonbreastfed control infants. There was no difference in newborn respiratory rates. The authors stated that the mothers of nonbreastfed infants had greater parity than the breastfeeding mothers which, combined with a presumed lower desire to breastfeed, may have contributed to the lower behavioral and alertness scores in the nonbreastfed newborns.[ 7 , 14 ] A study of pregnant women being treated for opiate dependency with slow-release oral morphine at a clinic in Vienna were followed as were their newborn infants. Compared to infants who were not breastfed (n = 91), breastfed infants (n = 21) had lower average measures of neonatal abstinence, lower dosage requirements of morphine (5.23 mg vs 8.75 mg), shorter durations of treatment for neonatal abstinence (10.2 vs 18.1 days) and shorter hospital stays (19.7 vs 31 days).[ 15 ] A search was performed of the shared database of all U.S. poison control centers for the time period of 2001 to 2017 for calls regarding medications and breastfeeding. Of 2319 calls in which an infant was exposed to a substance via breastmilk, 7 were classified as resulting in a major adverse effect, and one of these involved morphine. A one-month-old infant was exposed to fentanyl, morphine, oxycodone, and unspecified benzodiazepines. The infant was admitted to the intensive care unit and described as being agitated and irritable and having tachycardia, confusion, drowsiness, lethargy, miosis, respiratory depr

Effects on milk supply

Morphine can increase serum prolactin.[ 20 ] However, the prolactin level in a mother with established lactation may not affect her ability to breastfeed. A national survey of women and their infants from late pregnancy through 12 months postpartum compared the time of lactogenesis II in mothers who did and did not receive pain medication during labor. Categories of medication were spinal or epidural only, spinal or epidural plus another medication, and other pain medication only. Women who received medications from any of the categories had about twice the risk of having delayed lactogenesis II ( 72 hours) compared to women who received no labor pain medication.[ 21 ] A randomized, blinded study in 250 women receiving a cesarean section at term compared the effects on breastfeeding of postpartum intrathecal morphine 300 to 500 mcg to a control group who received a non-opiate for pain. Systemic morphine or meperidine could be given to control mothers for severe breakthrough pain. All mothers also received midazolam 2 mg after cord clamping and oxytocin. At 2 months of age, there was no difference in the breastfeeding rates between the two groups, although infant weight gain was about 5% lower in the spinal morphine group.[ 22 ] A prospective study in an Australian hospital compared mothers who received epidural fentanyl analgesia, subcutaneous morphine or neither during labor and delivery. When controlled for labor induction, instrumental delivery and special care nursery admission, no difference was seen between the 3 groups in breastfeeding rates at discharge or at 6 weeks postpartum.[ 23 ] A multicenter, prospective cohort study in Hong Kong of 1277 women who gave birth found that women who received epidural analgesia with either fentanyl or morphine had no decreased frequency breastfeeding in the first hour compared to mothers who did not receive epidural analgesia. All epidural injections were combined with a local anesthetic, but the exact dosages were not giv

Levels in milk

Morphine is metabolized to inactive morphine-3-glucuronide (60%) and to active morphine-6-glucuronide (10%). Morphine has an oral bioavailability of about 30% in adults. Morphine-6-glucuronide has an oral bioavailability of about 4% but can probably be converted back to morphine in the infant's gut and absorbed as morphine. The plasma clearance of morphine is prolonged in very young infants compared to older infants and children. Usual therapeutic intravenous doses of morphine in infants are 10 mcg/kg/hour or 50 to 100 mcg/kg as a single dose. Usual single oral doses of morphine in infants are 100 to 500 mcg/kg. Maternal Levels. Five lactating mothers who were at least 1 month postpartum were given 1 to 2 doses of either epidural 4 mg or parenteral (intravenous or intramuscular) 5 to 15 mg morphine every 4 to 6 hours for postoperative analgesia. Milk samples were taken from each mother 10 times over the 8 hours after her dose. The peak milk level after epidural morphine was 82 mcg/L and occurred 30 minutes after a second dose. The peak milk level after parenteral morphine was about 500 mcg/L and occurred about 45 minutes after a single 15 mg (10 mg intravenous plus 5 mg intramuscular) dose. The half-life in milk was about 3 hours.[ 5 ] Using the peak milk levels from this study, an exclusively breastfed infant would receive 75 mcg/kg daily. Six women who received epidural morphine 5 mg for labor analgesia had their initial colostrum sampled postpartum (range 24-100 hours after epidural). Morphine was undetectable ( 0.6 mcg/L) in 4 of the women. The peak morphine level was 4.5 mcg/L and was measured 28 hours after the epidural dose.[ 6 ] Considering the small amount of colostrum consumed by the infant, based on the peak level in this study, an exclusively breastfed infant would only receive a negligible amount of morphine from a maternal epidural 5 mg morphine dose for labor analgesia. Five mothers who had undergone cesarean section delivery at term were given intrav

Alternatives LactMed lists

• Butorphanol
• Celecoxib
• Diclofenac
• Flurbiprofen
• Fentanyl
• Hydromorphone
• Ibuprofen
• Indomethacin
• Naproxen
• Piroxicam