Plain Language Summary: There has not been much investigation into the safety of Botox while breastfeeding. The manufacturer neither recommends against nor encourages it. From analyzing the admittedly limited data and resources available to us, we believe the risk of Botox entering your breastmilk and harming your baby is low. Ultimately, the decision must be made with your doctor’s guidance based on your own comfort level and necessity for Botox.
Breastfeeding is unmatched when it comes to providing your baby with the perfect balance of nutrients and protection. When you exclusively breastfeed for 6 months or more, as endorsed by the American Academy of Pediatrics, not only does your baby enjoy numerous benefits, but you can, too! Studies have shown that breastfeeding mothers demonstrate stronger bonding with their babies and significantly lower rates of breast and ovarian cancer. There are very few situations in which breastfeeding is not advised; for the vast majority of women, breastfeeding is a go [1]. It is expected and wise for breastfeeding mothers to wonder whether activities they’d typically not think twice about are safe for their babies. In this article, we discuss the safety of Botox while breastfeeding.
Indications and prevalence of botox use
The onabotulinumtoxinA injection, commonly known as Botox, was initially approved in the United States in 1989 and has multiple FDA-approved indications.
Patients may opt to receive intramuscular injections for management of:
- facial wrinkles
- chronic migraine
- muscle spasm
- excessive sweating
- overactive bladder
- incontinence
Botox works by preventing muscle contraction. Specifically, the toxin blocks the release of a contraction signal called acetylcholine, causing the muscle to remain in a relaxed state.
In 2020, despite COVID-19 lockdowns, 4.4 million Botox procedures were performed, making it the most frequently performed minimally-invasive cosmetic procedure in the United States - and for good reason! Its effects last for months and can drastically change one’s appearance, making it an attractive option for many postpartum mothers [2].
What does the manufacturer of Botox say?
What does AbbVie, the manufacturer of Botox, think? According to 2 forms of package inserts, “it is not known,” or rather, there is no available data on the presence of either Botox or Botox Cosmetic in breastmilk, its effects on the breastfed child, or milk production. They both advise patients to ask their doctors before starting treatment, stating that the mother’s clinical need for Botox, along with breastfeeding benefits and potential adverse effects to the infant, should be considered when making the decision to initiate treatment. This is a standard answer to reduce liability of the manufacturer, but it isn’t always helpful–or provide the evidence you need to make a decision.
Adult Side Effects of Botox
Side effects vary and are dependent on the location at which the drug is injected. Cosmetically, for example, headache along with droopy or swollen eyelids are the most commonly reported. It should be noted that both Botox and Botox Cosmetic include a warning on their package inserts regarding the “risk of distant spread of toxin effect.” They warn that it is possible for the effects of Botox to spread beyond the site of injection, producing symptoms akin to botulinum toxin, including life-threatening difficulty breathing or swallowing, from which death has occured in the past. They note that patients with certain underlying medical conditions are especially at risk.. They also advise caution with drug interactions as the effect of Botox can be increased. That being said, there is no known mechanism by which such a process can directly affect breastmilk [3,4].
Current research and ways to minimize exposure to your infant
Sometimes mothers receiving Botox injections while lactating prefer to pump and discard the breast milk collected 48 hours following treatment. There is no data regarding this “pump and dump” philosophy when it comes to Botox. When it comes to alcohol, the CDC states that this practice does NOT lower the amount of alcohol present in the breast milk, which instead depends on blood alcohol level decreasing with time [5].
Similar principles can be applied to Botox. Although there are multiple variables, such as the drug’s molecular size and ability to bind to proteins by which substances appear in breast milk, passive diffusion from the bloodstream into milk is the primary mechanism of transfer. So, how much botulinum toxin is present in the bloodstream? The variables mentioned above predict that transfer is very low (the molecule is just too big). One animal study confirms this suspicion, revealing that there is no evidence that botulinum toxin is absorbed beyond the local injection site in rats or rabbits [6]. Another review study found that although definitive recommendations regarding the safety of injectables cannot yet be made, there is minimal concern for any significant systemic absorption of Botox [7,8]. There has also been one report of a mother diagnosed with botulism who breastfed her infant throughout the duration of her illness without any problems [9].
To summarize, it is unlikely that Botox would enter your milk or harm a breastfed baby. Some women choose to wait up to 48 hours to provide their breast milk after injections, but there is no evidence to support that this helps reduce the already low risk to the infant.
Monitoring your infant while receiving Botox
While it is exceedingly rare for patients to develop botulism from Botox injections, some cases have been reported due to inappropriate injection dosage or frequency.
Symptoms commonly occurring 2-6 days after injection usually include:
- headache
- dizziness
- insomnia
- fatigue
- blurred vision
- eye opening difficulty
- slurred speech
- dysphagia
- bucking
- constipation
Even though to date there have been no reports of breastfeeding babies diagnosed with botulism after their mothers received Botox injections, it may be wise to monitor your baby regardless, looking out for lethargy, irritability, swallowing difficulty, breathing difficulty, and droopy eyelids [10].
Are there any Botox alternatives?
For mothers who express reservations about using cosmetic Botox while breastfeeding, there are less-invasive alternatives available that may produce similar results. Wrinkles appear when aging skin loses collagen and produces less hyaluronic acid. For many, the adoption of a hyaluronic acid serum into their skin care routine can produce immediately visible plumping effects due to its water-attracting chemical structure. Further, ensuring adequate hydration and incorporating antioxidant-rich fruits and vegetables in the diet may address the skin concerns at play in a healthful and safe way.
Here are some ways you can keep your skin looking its best:
- Hyaluronic acid serum
- Drinking enough water for your body
- Adding a large variety of fruits and vegetables to your diet, especially vitamin C
- Using a chilled jade roller on the skin
- Regular sheet masking
- Always wearing sunscreen (even if it’s cloudy!), floppy hats, and avoiding tanning beds
- Wearing sunglasses
For those using Botox for migraine management, one may consider over the counter pain medications in breastfeeding-safe dosages. For those using Botox to treat muscle problems, gentle massage and stretches can be used for short-term relief.
Conclusion
The risks to a breastfed infant in a mom who receives Botox injections is low. Because there is such minimal research done on the safety of Botox while breastfeeding, the decision to receive injections ultimately remains one to be discussed between yourself and your team of doctors. Your comfort level and desire/necessity for Botox will be variables influencing that choice. No matter what you decide, we sincerely applaud you for taking the time to research this matter and wish you the very best during your breastfeeding journey and beyond.
References:
- Gartner LM, Morton J, Lawrence RA, Naylor AJ, O’Hare D, Schanler RJ, Eidelman AI. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005;115:496–506. [PubMed] [Reference list]
- American Society of Plastic Surgeons. American Society of Plastic Surgeons unveils covid-19's impact and pent-up patient demand fueling the industry's current Post-Pandemic Boom. American Society of Plastic Surgeons. https://www.plasticsurgery.org/news/press-releases/american-society-of-…. Published April 27, 2021. Accessed January 15, 2022.
- BOTOX Cosmetic (onabotulinum toxin A) [package insert]. Madison, NJ: Allergan; 2021.
- BOTOX (onabotulinum toxin A) [package insert]. Madison, NJ: Allergan; 2010.
- Alcohol. Centers for Disease Control and Prevention. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/v…. Published February 9, 2021. Accessed January 15, 2022.
- Tang-Liu DD, Aoki KR, Dolly JO, de Paiva A, Houchen TL, Chasseaud LF, Webber C. Intramuscular injection of 125I-botulinum neurotoxin-complex versus 125I-botulinum-free neurotoxin: time course of tissue distribution. Toxicon. 2003 Oct;42(5):461-9. doi: 10.1016/s0041-0101(03)00196-x. PMID: 14529727.
- Lee KC, Korgavkar K, Dufresne RG Jr, Higgins HW 2nd. Safety of cosmetic dermatologic procedures during pregnancy. Dermatol Surg. 2013 Nov;39(11):1573-86. doi: 10.1111/dsu.12322. Epub 2013 Oct 29. PMID: 24164677.
- Trivedi MK, Kroumpouzos G, Murase JE. A review of the safety of cosmetic procedures during pregnancy and lactation. Int J Womens Dermatol. 2017;3(1):6-10. Published 2017 Feb 27. doi:10.1016/j.ijwd.2017.01.005
- Middaugh J. Botulism and breast milk. N Engl J Med. 1978 Feb 9;298(6):343. doi: 10.1056/nejm197802092980620. PMID: 622098.
- Bai L, Peng X, Liu Y, et al. Clinical analysis of 86 botulism cases caused by cosmetic injection of botulinum toxin (BoNT). Medicine (Baltimore). 2018;97(34):e10659. doi:10.1097/MD.0000000000010659
- Bozzo P, Chua-Gocheco A, Einarson A. Safety of skin care products during pregnancy. Can Fam Physician. 2011;57(6):665-667.
