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Opioid analgesia for breastfeeding mothers

BMJ 2023; 380 doi: (Published 15 March 2023) Cite this as: BMJ 2023;380:p514

Linked Research

Maternal opioid treatment after delivery and risk of adverse infant outcomes: population based cohort study

  1. D Nicholas Bateman, honorary professor of clinical toxicology1,
  2. Thomas W Hale, university distinguished professor2
  1. 1Edinburgh Clinical Toxicology, Deanery of Clinical Sciences, Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
  2. 2Texas Tech University School of Medicine, Department of Paediatrics, Infant Risk Centre, Amarillo, Texas, USA
  1. Correspondence to: D N Bateman drnickbateman{at}

New study reports reassuring evidence on safety for infants

The benefits of breastfeeding are well known, and everything possible should be done to encourage it.1 Pain control in mothers after delivery, and in particular after caesarean section, follows a standard pain ladder approach—although the evidence base is weak for efficacy of common analgesics.23

Weak opioids such as codeine had been used for many years to manage postpartum pain. Practice changed dramatically, however, after one high profile case of an infant’s death in association with a codeine-paracetamol product in 2006, allegedly from over-expression of the enzyme P450 2D6 (CYP2D6) in the neonate, metabolising codeine ingested through breast milk to excess morphine.45 As codeine and paracetamol concentrations were unexpectedly high in the infant post mortem, reports of the case were eventually discredited and have now been retracted.67 But concern about opioids in breast milk persists among drug regulators.8

Occasional reports of drowsiness in breastfed infants associated with maternal codeine are still published, leaving mothers and their clinicians with important questions …

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