Opioid Use and Lactation: Protecting the Child in the Context of Maternal Pain Care

Opioid use in the breastfeeding mother is a topic that carries a degree of controversy, with some experts reporting that short-term maternal use is usually safe [1] and others citing clear risks in ultrarapid metabolizers, in particular [2].

The decision to prescribe opioids in new mothers is fraught with unique considerations and caution against risks, given that the medications may directly impact the neonate or infant. Researchers who conducted a study of oxycodone administration following Caesarean section (N = 50) found a significant correlation between maternal plasma and milk levels (R(2) = 0.81) 24 hours after opioid administration, though they found detectable levels in the plasma of only one neonate [3]. The authors concluded that while oxycodone does accumulate in breast milk, the benefits of maternal comfort and successful initiation of breastfeeding appear to outweigh the minimal risks to neonates, though they called for careful monitoring for signs of opioid exposure, such as sedation, poor attachment, gastrointestinal symptoms, and respiratory depression [3]. In earlier publications, authors recommended against oxycodone use in breast feeding due to lack of studies on safety considerations such as excretion and repeated dosing [4,5]. Opioid therapy for chronic pain falls squarely under this umbrella as repeated dosing is a certainty. In this Ethics Forum, we welcome two esteemed experts, Dr. Ian Carroll and Dr. Priti Dalal to discuss and debate the difficult topic of opioid use in the breastfeeding mother. Here, Dr. Ian Carroll leads off the discussion with a review of the risks and a call for limits to infant opioid exposure. Dr. Dalal counters with a careful consideration of the imperative to appropriately treat maternal pain while calling for caution and an individualized approach. Where is the balance in regards to reducing maternal pain while protecting neonates and infants from harm? Can the infant risks be contained or abolished? We are pleased to present a rich discussion that sheds light on a topic that is often globally underappreciated.