Do you ever feel like the stars have aligned just for you? And not in the terrifying nine-realms-convergence kind of way; in the good, solving-your-problems kind of way. A few days ago I had started preparing a post in response to a question by Christy H. asking “aaaalll about what [you] can and can’t take while nursing, and why.” And it put me in a conundrum because it really makes more sense to talk about taking drugs in pregnancy and breastfeeding at the same time but I couldn’t justify adding in all that effort when it wasn’t what she wanted. Enter Josh C. who sent a question in on behalf of his pregnant wife wondering what drugs are safe in pregnancy. Problem solved.
Let’s lay some ground rules! ALL drugs carry some level of risk. I always recommend checking with your obstetrician or pediatrician or calling the Pregnancy Risk Line at (800)822-BABY to help you make the best decision for your situation. For the most part, I’m keeping my recommendations to over-the-counter (OTC) products as this is where I’ve seen most women asking questions and otherwise this would be the world’s longest post (it may be anyway). As a general rule of thumb older drugs are better options because they have more data on safety in pregnant or nursing women and it is usually safer to take something in the second or third trimester than it is in the first.
Let’s lay some ground rules! ALL drugs carry some level of risk. I always recommend checking with your obstetrician or pediatrician or calling the Pregnancy Risk Line at (800)822-BABY to help you make the best decision for your situation. For the most part, I’m keeping my recommendations to over-the-counter (OTC) products as this is where I’ve seen most women asking questions and otherwise this would be the world’s longest post (it may be anyway). As a general rule of thumb older drugs are better options because they have more data on safety in pregnant or nursing women and it is usually safer to take something in the second or third trimester than it is in the first.
PAIN
Acetaminophen in your go-to option for pain control during pregnancy. Using NSAIDs (aspirin, ibuprofen or naproxen) during pregnancy can cause birth defects and miscarriage. However, if you are breastfeeding you can use acetaminophen or ibuprofen for pain. In fact, ibuprofen is great at calming uterine contractions, which makes it a fantastic option in those first few days when nursing the baby sends your uterus into crazed spasms.
One note about the prescription (usually opioid-based) pain relievers often prescribed after delivery (I am not talking about the 800 mg ibuprofen prescription here): unlike ibuprofen and acetaminophen, these prescription pain relievers do come through the breast milk and can affect the baby. It is best to limit these to the first 3 to 4 days after your baby is born since the baby doesn’t drink much milk in those days. If you need to take opioid-based pain relievers at any other time while breastfeeding, try to take low doses of short-acting forms AFTER feedings to limit baby’s exposure. You will also need to watch your baby for any signs of excessive sedation—difficult to awaken, taking more frequent or longer naps, unable to stay awake through feedings, etc. (For those of you wondering, opioids also cross the placenta and can cause a serious and life-threatening withdrawal syndrome in newborns.)
One note about the prescription (usually opioid-based) pain relievers often prescribed after delivery (I am not talking about the 800 mg ibuprofen prescription here): unlike ibuprofen and acetaminophen, these prescription pain relievers do come through the breast milk and can affect the baby. It is best to limit these to the first 3 to 4 days after your baby is born since the baby doesn’t drink much milk in those days. If you need to take opioid-based pain relievers at any other time while breastfeeding, try to take low doses of short-acting forms AFTER feedings to limit baby’s exposure. You will also need to watch your baby for any signs of excessive sedation—difficult to awaken, taking more frequent or longer naps, unable to stay awake through feedings, etc. (For those of you wondering, opioids also cross the placenta and can cause a serious and life-threatening withdrawal syndrome in newborns.)
COUGH & COLD
I have several minimal risk options I offer as safe for anyone (watch out, these are all pretty revolutionary): rest, drink plenty of fluids, pump up the humidifier, use nasal saline drops or spray, drink honey lemon water and use hard candies to soothe throat irritation.
When those options aren’t enough (which is almost always), you can look a few other places for relief. Antihistamines will help dry up a runny nose and the antihistamine chlorpheniramine (Chlor-Trimeton®) has been around for awhile and has lots of good data in pregnancy. Loratadine (Claritin®) and cetirizine (Zyrtec®) also look to be safe in the second and third trimesters and they usually cause less drowsiness. Unfortunately, the case is not so simple for breastfeeding moms. Anything that can stop your body from producing one fluid (e.g. mucus) can also slow production of other fluids (e.g. breast milk). While someone who has been breastfeeding twins for 6 months and pumping enough extra milk to start a dairy may not notice a huge difference, new moms who are still establishing their milk supply will want to be more cautious. Also, antihistamines can come through in the breast milk and infants are very sensitive to their effects. If possible, take the antihistamine after the baby’s bedtime feeding to minimize exposure. You’ll also want to monitor the baby for signs of excess antihistamine exposure such as sedation or irritability and decrease your use if necessary.
If you need a decongestant you can use pseudoephedrine (Sudafed®) after the first trimester (it can cause fetal malformations if taken early in pregnancy). The other decongestant, phenylephrine (Sudafed PE®, etc.), carries the same level of risk but it doesn’t work nearly as well so I don’t recommend it. These can both also be used for breastfeeding moms but with some of the same concerns as the antihistamines in that the decongestants can decrease milk supply and cause irritability in the nursing baby. The nasal decongestants like oxymetazoline (Afrin®) are absorbed from the nose into the bloodstream so I wouldn’t recommend them in pregnancy but they are a valid option in breastfeeding moms.
Coughing? This is one area where there aren’t any great options. I can’t recommend the expectorant guaifenesin (Mucinex®) or the cough suppressant dextromethorphan (Delsym®) because, while they are fairly safe in pregnancy and breastfeeding, their efficacy is questionable at best. This is another prime example of just a little risk outweighing zero benefit. If you are opt to take a cough product, watch out for alcohol in the syrup products (this goes for pregnant and breastfeeding moms). Also, if you happen to have some prescription codeine syrup lying around, DON’T use it. Codeine doesn’t work well and can cause serious problems for babies before and after birth.
So what about those immune boosters like Airborne®? Out of curiosity I googled Airborne® and breastfeeding/pregnancy to see what popped up and I got a lot of results talking about how the goldenseal in Airborne® causes brain damage in babies (this goes for pregnancy and breastfeeding). While goldenseal can cause fetal brain damage, there is no goldenseal in Airborne®. I checked out all of the ingredients actually contained in Airborne® and my biggest concern actually comes from the vitamin C. If you follow the package dosing directions you will exceed the recommended limit of 2000 mg of vitamin C per day which will put your baby at risk for upset stomach and osmotic diarrhea (i.e. their bum will be on fire and it will be sad). In addition, many of the herbal ingredients (e.g. echinacea, forsythia, Chinese vitex, etc.) have limited to no data on their safety in pregnant or nursing women which means I would have to expect a significant benefit to recommend them. There is some data on echinacea’s efficacy showing it has a modest benefit in shortening the length of a cold (think 5 days instead of 6)—I will let you decide how the risks and benefits weigh out for you.
When those options aren’t enough (which is almost always), you can look a few other places for relief. Antihistamines will help dry up a runny nose and the antihistamine chlorpheniramine (Chlor-Trimeton®) has been around for awhile and has lots of good data in pregnancy. Loratadine (Claritin®) and cetirizine (Zyrtec®) also look to be safe in the second and third trimesters and they usually cause less drowsiness. Unfortunately, the case is not so simple for breastfeeding moms. Anything that can stop your body from producing one fluid (e.g. mucus) can also slow production of other fluids (e.g. breast milk). While someone who has been breastfeeding twins for 6 months and pumping enough extra milk to start a dairy may not notice a huge difference, new moms who are still establishing their milk supply will want to be more cautious. Also, antihistamines can come through in the breast milk and infants are very sensitive to their effects. If possible, take the antihistamine after the baby’s bedtime feeding to minimize exposure. You’ll also want to monitor the baby for signs of excess antihistamine exposure such as sedation or irritability and decrease your use if necessary.
If you need a decongestant you can use pseudoephedrine (Sudafed®) after the first trimester (it can cause fetal malformations if taken early in pregnancy). The other decongestant, phenylephrine (Sudafed PE®, etc.), carries the same level of risk but it doesn’t work nearly as well so I don’t recommend it. These can both also be used for breastfeeding moms but with some of the same concerns as the antihistamines in that the decongestants can decrease milk supply and cause irritability in the nursing baby. The nasal decongestants like oxymetazoline (Afrin®) are absorbed from the nose into the bloodstream so I wouldn’t recommend them in pregnancy but they are a valid option in breastfeeding moms.
Coughing? This is one area where there aren’t any great options. I can’t recommend the expectorant guaifenesin (Mucinex®) or the cough suppressant dextromethorphan (Delsym®) because, while they are fairly safe in pregnancy and breastfeeding, their efficacy is questionable at best. This is another prime example of just a little risk outweighing zero benefit. If you are opt to take a cough product, watch out for alcohol in the syrup products (this goes for pregnant and breastfeeding moms). Also, if you happen to have some prescription codeine syrup lying around, DON’T use it. Codeine doesn’t work well and can cause serious problems for babies before and after birth.
So what about those immune boosters like Airborne®? Out of curiosity I googled Airborne® and breastfeeding/pregnancy to see what popped up and I got a lot of results talking about how the goldenseal in Airborne® causes brain damage in babies (this goes for pregnancy and breastfeeding). While goldenseal can cause fetal brain damage, there is no goldenseal in Airborne®. I checked out all of the ingredients actually contained in Airborne® and my biggest concern actually comes from the vitamin C. If you follow the package dosing directions you will exceed the recommended limit of 2000 mg of vitamin C per day which will put your baby at risk for upset stomach and osmotic diarrhea (i.e. their bum will be on fire and it will be sad). In addition, many of the herbal ingredients (e.g. echinacea, forsythia, Chinese vitex, etc.) have limited to no data on their safety in pregnant or nursing women which means I would have to expect a significant benefit to recommend them. There is some data on echinacea’s efficacy showing it has a modest benefit in shortening the length of a cold (think 5 days instead of 6)—I will let you decide how the risks and benefits weigh out for you.
GASTROINTESTINAL
Nausea and/or vomiting becomes an issue at some point for almost every pregnant woman ever. I want to give a shout out here for the elusive mid-day nap—a little extra rest can make a difference. You’ll also want to eat smaller, more frequent meals full of bland foods (I love saltine crackers) and stay hydrated. I love these recommendations because they are obviously only going to be possible for about 1% of women (that is a scientific statistic I made up).
What else is there? My first recommendation is to start taking vitamin B6 (aka pyridoxine) at 10 to 25 mg three to four times a day. B6 helps with nausea and it is super safe—no regrets here. As you need more help you can add on doxylamine (Unisom® TABLETS) at 12.5 to 25 mg three times a day. Doxylamine has great safety data in pregnancy and I think it works wonders. My only caution would be that it will make you super sleepy. When I took doxylamine 12.5 mg and 25 mg of B6 at bedtime I slept a TON (slept in to 8 or 9, 2-hour nap in the afternoon and wanted to go back to bed at 7 or 8) the next day. You have been warned. Doxylamine is an antihistamine so the same breastfeeding warnings apply as I mentioned in the cough and cold section above.
For those women who need more help, you can add on dimenhydrinate (Dramamine®) or get a prescription for promethazine (this is what I see most women and OBs opt for). These both carry the same warnings as antihistamines for breastfeeding women. Finally, your doctor can also prescribe ondansetron (Zofran®). While this option causes the least sleepiness, it also carries a few more risks (small risk of cleft palate or heart defects in the baby if taken in the first trimester and a small possibility of heart arrhythmia in the mom) but severe nausea and vomiting can also be very dangerous so this is something to weigh out with your OB if you are concerned. I have seen a lot of women take ondansetron without incident and I feel the small risk is worth the benefit if you are truly unwell. As always, you’ll want to take the smallest effective dose for the shortest time period possible.
Some women may want to try ginger as a more natural option and it is a great, safe option for nausea. Unfortunately, I found the ginger flavor very unappetizing when I was pregnant so you’ll probably want to look for a capsule form. The anti-nausea dose for ginger is 250 mg four times daily.
The next big issue most pregnant women face is heartburn. Some of this can be relieved by sleeping with the head of the bed elevated, eating small frequent meals, and eating less food at bedtime. Calcium carbonate (Tums®) is your next go-to and it is really safe as long as you take less than 5000 mg per day. The aluminum hydroxide/magnesium hydroxide combination (Mylanta® or Maalox®) is another great option. If you are tired of eating chalk, omeprazole (Prilosec®) has been used in pregnant women and appears fairly safe but does have a slightly increased risk of infant heart defects. Breastfeeding mothers can also use ranitidine (Zantac®).
For those of you lucky enough to add constipation to your list of woes start out by increasing your fiber and fluid intake and getting more exercise (even just walking). You can add in the fiber/psyllium products (Citrucel®, Metamucil®, etc.) as needed but do so slowly and drink plenty of water. Docusate stool softener is my next recommendation, followed closely by polyethylene glycol (Miralax®). Up to this point all of these options carry little to no risk for pregnant or nursing mothers. The stimulant laxatives, senna and bisacodyl, would be my last choice and should be used sparingly.
Simethicone (Gas-X®) is also safe in pregnancy and while breastfeeding (it does not leave the stomach) but bismuth subsalicylate (Pepto-Bismol® and Kaopectate®) is NOT.
As a final note, remember to get your vaccines! You are the first line of defense for your baby. Pregnant women should not get live vaccines but this primarily means you won’t be getting the nasal flu vaccine (it’s a nasty experience anyway).
I want to give a shout out here to Pharmacist’s Letter. They produce fantastic information for pharmacists and other health professionals to help make medication decisions easier. They provided a lot of the information in this post and they have always been one of the first places I looked to answer patient’s medication questions.
What else is there? My first recommendation is to start taking vitamin B6 (aka pyridoxine) at 10 to 25 mg three to four times a day. B6 helps with nausea and it is super safe—no regrets here. As you need more help you can add on doxylamine (Unisom® TABLETS) at 12.5 to 25 mg three times a day. Doxylamine has great safety data in pregnancy and I think it works wonders. My only caution would be that it will make you super sleepy. When I took doxylamine 12.5 mg and 25 mg of B6 at bedtime I slept a TON (slept in to 8 or 9, 2-hour nap in the afternoon and wanted to go back to bed at 7 or 8) the next day. You have been warned. Doxylamine is an antihistamine so the same breastfeeding warnings apply as I mentioned in the cough and cold section above.
For those women who need more help, you can add on dimenhydrinate (Dramamine®) or get a prescription for promethazine (this is what I see most women and OBs opt for). These both carry the same warnings as antihistamines for breastfeeding women. Finally, your doctor can also prescribe ondansetron (Zofran®). While this option causes the least sleepiness, it also carries a few more risks (small risk of cleft palate or heart defects in the baby if taken in the first trimester and a small possibility of heart arrhythmia in the mom) but severe nausea and vomiting can also be very dangerous so this is something to weigh out with your OB if you are concerned. I have seen a lot of women take ondansetron without incident and I feel the small risk is worth the benefit if you are truly unwell. As always, you’ll want to take the smallest effective dose for the shortest time period possible.
Some women may want to try ginger as a more natural option and it is a great, safe option for nausea. Unfortunately, I found the ginger flavor very unappetizing when I was pregnant so you’ll probably want to look for a capsule form. The anti-nausea dose for ginger is 250 mg four times daily.
The next big issue most pregnant women face is heartburn. Some of this can be relieved by sleeping with the head of the bed elevated, eating small frequent meals, and eating less food at bedtime. Calcium carbonate (Tums®) is your next go-to and it is really safe as long as you take less than 5000 mg per day. The aluminum hydroxide/magnesium hydroxide combination (Mylanta® or Maalox®) is another great option. If you are tired of eating chalk, omeprazole (Prilosec®) has been used in pregnant women and appears fairly safe but does have a slightly increased risk of infant heart defects. Breastfeeding mothers can also use ranitidine (Zantac®).
For those of you lucky enough to add constipation to your list of woes start out by increasing your fiber and fluid intake and getting more exercise (even just walking). You can add in the fiber/psyllium products (Citrucel®, Metamucil®, etc.) as needed but do so slowly and drink plenty of water. Docusate stool softener is my next recommendation, followed closely by polyethylene glycol (Miralax®). Up to this point all of these options carry little to no risk for pregnant or nursing mothers. The stimulant laxatives, senna and bisacodyl, would be my last choice and should be used sparingly.
Simethicone (Gas-X®) is also safe in pregnancy and while breastfeeding (it does not leave the stomach) but bismuth subsalicylate (Pepto-Bismol® and Kaopectate®) is NOT.
As a final note, remember to get your vaccines! You are the first line of defense for your baby. Pregnant women should not get live vaccines but this primarily means you won’t be getting the nasal flu vaccine (it’s a nasty experience anyway).
I want to give a shout out here to Pharmacist’s Letter. They produce fantastic information for pharmacists and other health professionals to help make medication decisions easier. They provided a lot of the information in this post and they have always been one of the first places I looked to answer patient’s medication questions.
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