Motherisk News: Motherisk Advisory for Codeine Use During Breastfeeding

1) A large number of women are treated for pain following caesarian section or episiotomy.

• It is important to treat effectively postpartum pain.
• Codeine is widely used for postpartum pain, mostly in combination with acetaminophen. Tylenol 3 is the most common codeine-acetaminophen combination in clinical use.
• Recent research from Motherisk suggests that codeine may not be safe for all breastfed infants, as in a minority of cases it may cause central nervous system (CNS) depression and apnea.
• A minority of mothers may convert in their bodies more codeine to morphine, putting the baby at risk of these side effects or even death.
• Infants appear to be more sensitive to the effects of narcotic opioids (such as morphine) than older children or adults.

2) The following are suggested guidelines for safe use of medications that contain codeine: They are based on the available scientific data.

• In most cases - there is consistency between CNS depression in the mother and the baby. If the mother is CNS depressed (e.g., somnolent, groggy) - the baby should be examined by a physician for signs of CNS depression.
• In any case where the baby is not fed well, does not get up to be fed, does not gain weight, or shows limpness- s/he should be examined by a physician.
• CNS depression in the baby appears to worsen after 4 days, probably due to accumulation of morphine with more breastfeeding. If possible - codeine should not be used for longer than 4 days. If pain still necessitates codeine - an attempt should be made to decrease the dose, and/or switch to non-codeine pain killers (such as NSAIDs).
• The women who convert more codeine to morphine have a duplication of the gene encoding for cytochrome P450 2D6. This genetic predisposition can be detected by genetic test. This test, although not available in most hospitals, is available on the market.
• While in North America codeine is widely used, 9 randomized studies comparing codeine to different nonsteroidal anti-inflammatory agents (NSAIDs) in laparatomy (abdominal surgery), have failed to show codeine to be superior in pain relief.

If you have further questions, call Motherisk at (416) 813-6780.