Cold and Flu Medications While Breastfeeding

As cold and flu season swings into full effect, runny noses, coughing, and body aches leave many breastfeeding mothers wondering whether some quick relief from over-the-counter medications could negatively impact their breastfeeding baby. Research shows that some cold and flu medications are better than others when it comes to breastfeeding. Dextromethorphan, acetaminophen, and doxylamine succinate are common active ingredients in cold and flu syrups such as NyQuil and DayQuil along with their generic ingredients. The daytime formulation lacks doxylamine succinate but includes phenylephrine. Other common over-the-counter cold medications include diphenhydramine, pseudoephedrine, and guaifenesin. Afrin, also known as oxymetazoline, and fluticasone nasal sprays are also commonly used public. These ingredients are broken down over the next several paragraphs, along with some other common cold and cough remedies.

Dextromethorphan is a cough suppressant commonly used for treating colds in children and adults. Although most medications are transferred into breastmilk to some degree, it is unlikely that dextromethorphan would transfer into breastmilk in a large enough quantity to affect the breastfed infant, so it is generally considered safe while breastfeeding. Acetaminophen, a drug used to treat pain and reduce fever in adults and children, is compatible with breastfeeding as well. Several studies have shown that the amount secreted in breastmilk is far less than a therapeutic dose for a child¹. Ibuprofen is another fever reducer and pain medication often used during a cold and has been studied extensively. It is also considered safe for infants of breastfeeding mothers as even high maternal consumption of ibuprofen leads to very little excretion in breast milk².

A common active ingredient in the nighttime formulations is doxylamine succinate, an antihistamine that causes sedation in its users and can be used for nausea and vomiting in pregnancy¹. This drug is likely safe while breastfeeding, however data is limited. A manufacturer reported that sedation has occurred in breastfed infants whose mothers used doxylamine, so this medication should be used with caution, especially in premature infants or infants with a history of apnea. Other over-the-counter cold and flu medications may include a different antihistamine called diphenhydramine. These formulations have similar side effects of sedation, which is not ideal in a breastfeeding infant, but is not considered unsafe.

Phenylephrine is most commonly used as a nasal decongestant in adults and children, and can cause tachycardia and hypertension in sensitive individuals, although this is rare. It is generally considered safe while breastfeeding unless there has been high maternal consumption of the drug, as phenylephrine has poor oral bioavailability¹. Pseudoephedrine, another nasal decongestant commonly used to treat colds, has also shown to be secreted in breast milk in extremely low levels and is considered safe while breastfeeding³. However, studies have shown a potential decrease in late-stage breast milk production while taking pseudoephedrine⁴, so mothers struggling to produce enough milk should consider this effect before taking this medication.

Although no longer available over the counter, drugs containing codeine, including Tylenol-Codeine #3 and Tylenol-Codeine #4 are used to treat pain and cough. Codeine is an opiate medication that is converted to morphine in the body and, in adults, is addictive and can cause respiratory depression when taken in high doses. Studies have shown that very low levels of morphine are found in infants who are breastfed with maternal codeine consumption¹, so it is likely safe to consume in moderate amounts while breastfeeding. However, several cases of neonatal apnea have been reported with maternal codeine consumption and it is likely that infants under the age of 2 weeks are more responsive to this drug¹, so caution should be taken when consuming codeine while breastfeeding, especially during this time period.

Other common over-the-counter medications include Mucinex® and Robitussin®. These drugs contain the active ingredient guaifenesin, an expectorant that helps loosen phlegm in the airways and makes the phlegm easier to cough⁶. However it does not suppress coughing and the efficacy of the drug itself is uncertain. This drug is unlikely to cause side effects in a breastfeeding infant, however further studies are necessary.

Nasal sprays, including fluticasone and oxymetazoline (Afrin) are additionally used quite frequently during the cold and flu season. Fluticasone is a steroid that is used intranasally for runny noses and additionally for asthma. When using the medication as indicated, maternal plasma levels are undetectable⁵. Thus, it is unlikely that a significant amount of this drug would pass into breastmilk to affect a breastfeeding infant. Oxymetazoline is another intranasal decongestant used for runny noses. Due to the local effect of this drug, it is unlikely that significant levels of this drug would be transferred to a breastfeeding infant and is preferred over oral decongestants during breastfeeding⁷. Oxymetazoline use should be limited to 3 days to avoid rebound congestion.

In addition to medications, over-the-counter supplements are often advertised for treating cold and flu symptoms. Zinc is one such supplement that can be applied topically or ingested. When applied topically as zinc oxide, it does has no effect on serum levels. However, when ingested as zinc salts via lozenges for cold treatment, excessive intake has shown to have negative effects on breastfeeding infants, such as lymphocyte function impairment and reduction of HDL cholesterol. Absorption of dietary zinc is twice as high during lactation than before conception, increasing the risk of excessive absorption ⁸. Thus, zinc supplementation in breastfeeding mothers should be avoided.

Vitamin C is also often advertised for cold-fighting. Although its efficacy in treating colds has not been supported, it likely is not harmful to supplement while breastfeeding. Even high levels of maternal consumption resulted in only slightly increased levels in breastmilk⁹.

An alternative to over-the-counter medications can include something much simpler: honey. According to a study in 2014, honey was more efficacious in treating cough symptoms in children than placebo and diphenhydramine, but was less efficacious than dextromethorphan¹⁰. Further studies need to be considered in adults, however. Honey should never be consumed by infants. Echinacea is an herb that has been shown to have significant antitussive effects when taken as an oral supplement¹¹. Although it is likely safe to take while breastfeeding, there have been no significant studies showing the effects of Echinacea consumption on breastfeeding infants or milk production.

Table of Common Cold Remedies:

*Avoid use early postnatally when milk levels of zinc are high.

In summary:

• Over-the-counter drugs containing dextromethorphan, acetaminophen, and ibuprofen are safe to take while breastfeeding.
• Doxylamine succinate and diphenhydramine may cause sedation in mother and breastfeeding infant and should be used with caution if the infant has a history of apnea.
• Phenylephrine is likely that it is safe while breastfeeding.
• Pseudoephedrine is likely safe while breastfeeding, but may cause a decrease in late-stage milk production so should be taken with caution in mothers struggling to produce milk.
• Cough medications with codeine should be taken with caution during breastfeeding due to the possibility of infant apnea.
• Guaifenesin is likely safe to take while breastfeeding, however its efficacy is questionable.
• Nasal sprays, such as oxymetazoline and fluticasone, are likely safe during breastfeeding due to their local absorption.
• Zinc supplementation is likely safe, but should be avoided in the early postnatal period.
• Honey may be a good alternative to medications for cough relief in breastfeeding mothers.

Erika Anderson MS4

Thomas W. Hale, Ph.D.

Teresa Baker MD

Infantrisk Center

References:

1. Hale, Thomas Wright, and Pamela D. Berens. Clinical Therapy in Breastfeeding Patients. Hale Publishing, 2010.
2. Weibert RT, Townsend RJ, Kaiser DG, Naylor AJ. Lack of ibuprofen secretion into human milk. Clin Pharm 1982; 1(5):457-458.
3. Aljazaf, Khalidah, et al. “Pseudoephedrine: Effects on Milk Production in Women and Estimation of Infant Exposure via Breastmilk.” British Journal of Clinical Pharmacology, vol. 56, no. 1, 2003, pp. 18–24., doi:10.1046/j.1365-2125.2003.01822.x.
4. Byerley LO, Kirksey A. Effects of different levels of vitamin C intake on the vitamin C concentration in human milk and the vitamin C intakes of breast-fed infants. Am J Clin Nutr 1985 Apr;41(4):665-71.
5. Anderson PO. Decongestants and milkproduction. J Hum Lact. 2000;16:294.Letter.
6. Oduwole, Olabisi, et al. “Honey for Acute Cough in Children.” Cochrane Database of Systematic Reviews, 2014, doi:10.1002/14651858.cd007094.pub4.
7. Pharmaceutical manufacturers prescribing information, 2013.
8. Pharmaceutical manufacturer prescribing information, 1996
9. Fung EB, Ritchie LD, Woodhouse LR, Roehl R, King JC. Zinc absorption in women during pregnancy and lactation: a longitudinal study. Am J Clin Nutr 1997; 66(1):80-88.
10. Findlay, Jw, et al. “Pseudoephedrine and Triprolidine in Plasma and Breast Milk of Nursing Mothers.” British Journal of Clinical Pharmacology, vol. 18, no. 6, 1984, pp. 901–906., doi:10.1111/j.1365-2125.1984.tb02562.x.
11. Barth, Anders, et al. “Antitussive Effect of a Fixed Combination of Justicia Adhatoda, Echinacea Purpurea and Eleutherococcus Senticosus Extracts in Patients with Acute Upper Respiratory Tract Infection: A Comparative, Randomized, Double-Blind, Placebo-Controlled Study.” Phytomedicine, vol. 22, no. 13, 2015, pp. 1195–1200., doi:10.1016/j.phymed.2015.10.001.