Antacids, alginates, H2-receptor antagonists or proton pump inhibitors can be used during breastfeeding. Recommendations are for full term and healthy infants.
We provide a summary of the recommendations by mechanism of action.
Antacid and alginate preparations
There is extensive experience of use of antacids during breastfeeding and they are considered first-line options for managing heartburn or dyspepsia.
Alginates and simeticone are also considered acceptable for use during breastfeeding.
Histamine (H2)-receptor antagonists
Any H2-receptor antagonist can be used during breastfeeding. Famotidine or nizatidine are preferred as smaller amounts pass into breast milk. Cimetidine is least preferred due to higher levels in breast milk and the potential for drug interactions.
Proton pump inhibitors (PPIs)
Any PPI can be used during breastfeeding, however omeprazole and pantoprazole are the PPIs of choice as they are excreted into breast milk in very small amounts and have evidence to support their use. Any PPI that passes into breast milk is likely to be degraded in the infant’s gastrointestinal tract.
Clinical considerations
Lifestyle and dietary modifications to manage heartburn and dyspepsia during breastfeeding should always be tried first. If these measures fail to manage symptoms then antacids or alginates can be tried followed by H2-receptor antagonists or PPIs if required.
Antacids are usually aluminium, calcium, magnesium or sodium salts and are intended for short-term symptom control. These are all found naturally in breast milk. Additional intake of these is unlikely to affect levels in breast milk.
Antacids, along with alginates and simethicone, have poor oral bioavailability which will limit the amount ingested by the breastfed infant.
Effect on breast milk production
Use of H2-receptor antagonists or PPIs may lead to an increase in prolactin levels which can cause galactorrhoea in non-breastfeeding patients. The clinical significance of this on milk production in those who are breastfeeding is unknown. However, where breastfeeding is established this is unlikely to have a significant effect.
Specific recommendations
The following recommendations have been grouped by mechanism of action.
Antacids and alginates
Preferred choice
Alginates can be used during breastfeeding.
Monitoring
No specific infant monitoring is usually required.
Further information
Alginates are available as combination products.
They have poor oral absorption which limits the amount the infant can absorb from breast milk.
Preferred choice
Aluminium hydroxide can be used during breastfeeding.
Monitoring
No specific infant monitoring is usually required.
Further information
Aluminium hydroxide is normally used in combination products with other antacids.
There is extensive experience of use in breastfeeding, and no side effects in breastfed infants have been reported.
Aluminium is found naturally in breast milk and does not accumulate in breast milk. Very low levels are anticipated in breast milk due to the medicine’s properties. Aluminium has poor oral bioavailability so any present in breast milk is unlikely to be absorbed by the breastfed infant.
Preferred choice
Calcium carbonate can be used during breastfeeding at recommended doses used for heartburn and dyspepsia
Monitoring
No specific infant monitoring is usually required.
Further information
There is no published evidence of use during breastfeeding, however calcium is a natural component of breast milk.
Calcium carbonate has quite poor oral bioavailability so any present in breast milk is unlikely to be absorbed significantly by the breastfed infant.
Preferred choice
Magnesium salts (magnesium carbonate, magnesium hydroxide, magnesium trisilicate) can be used during breastfeeding.
Monitoring
No specific infant monitoring is usually required.
Further information
Magnesium salts are normally used in combination products with other antacids.
There is extensive experience of use in breastfeeding with no reports of infant side effects.
Magnesium is a natural component of breast milk and does not accumulate in breast milk; low levels are anticipated in milk due to the medicine’s properties.
Magnesium has poor oral bioavailability so any present in breast milk is unlikely to be absorbed by the breastfed infant.
Preferred choice
Simeticone can be used during breastfeeding.
Monitoring
No specific infant monitoring is usually required.
Further information
Excretion into breast milk is unlikely due to the very high molecular weight. Simeticone also has poor oral bioavailability so any present in breast milk is unlikely to be absorbed by the breastfed infant.
Simeticone can be used in infants from 1 month.
Preferred choice
Sodium bicarbonate can be used during breastfeeding.
Monitoring
No specific infant monitoring is usually required.
Further information
Sodium bicarbonate is normally used in combination products with other antacids.
There is extensive experience of use in breastfeeding with no reported infant side effects.
Both sodium and bicarbonate are natural components of breast milk. Bicarbonate does not accumulate in breast milk.
H2-receptor antagonists
Preferred choice
Famotidine can be used during breastfeeding.
Monitoring
As a precaution, monitor the infant for diarrhoea, constipation, irritability, drowsiness or rash.
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
There is limited published evidence of use during breastfeeding. Very small amounts pass into breast milk. No side effects have been reported in a breastfed infant.
Preferred choice
Nizatidine can be used during breastfeeding.
Monitoring
As a precaution, monitor the infant for diarrhoea, constipation, irritability, drowsiness or rash.
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
There is limited published evidence of use during breastfeeding. Very small amounts pass into breast milk. No side effects have been reported in a breastfed infant.
Use with caution
Cimetidine can be used with caution during breastfeeding, but famotidine or nizatidine are preferred.
Monitoring
Monitor the infant for diarrhoea, constipation, irritability, drowsiness or rash.
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
Cimetidine passes into breast milk in moderate amounts, although no side effects have been reported in breastfed infants.
However because of the higher passage into breast milk and the theoretical potential for interactions due to hepatic enzyme inhibition, cimetidine is not the preferred H-2 receptor antagonist to use during breastfeeding.
Proton pump inhibitors
Preferred choice
Omeprazole can be used during breastfeeding.
Monitoring
As a precaution monitor for constipation, diarrhoea, sickness, poor sleeping, irritability or rash.
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
There is limited published evidence of use during breastfeeding. Omeprazole passes into breast milk in very small amounts and any that does is likely to be degraded in the infant’s gastrointestinal tract.
No side effects have been observed in breastfed infants.
Omeprazole can be used therapeutically in young infants. Doses used will be much higher than the amounts the infant may be exposed to via breast milk.
Preferred choice
Pantoprazole can be used during breastfeeding.
Monitoring
As a precaution monitor for constipation, diarrhoea, sickness, poor sleeping, irritability or rash.
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
There is limited published evidence of use during breastfeeding. Pantoprazole passes into breast milk in very small amounts and any that does is likely to be degraded in the infant’s gastrointestinal tract. No side effects have been observed in breastfed infants.
Use with caution
Esomeprazole can be used with caution during breastfeeding, but omeprazole or pantoprazole are preferred
Monitoring
As a precaution, monitor for constipation, diarrhoea, sickness, poor sleeping, irritability or rash.
Further information
There is limited published evidence of use during breastfeeding. Very small amounts pass into breast milk and any that does is likely to be degraded in the infant’s gastrointestinal tract. No side effects have been observed in breastfed infants.
Use with caution
Lansoprazole can be used with caution during breastfeeding, but omeprazole or pantoprazole are preferred
Monitoring
As a precaution, monitor for constipation, diarrhoea, sickness, poor sleeping, irritability or rash.
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
There is no published evidence of use during breastfeeding. However, lansoprazole is not expected to pass into breast milk in significant amounts and any that does is likely to be degraded in the infant’s gastrointestinal tract.
Side effects in breastfed infants are therefore not expected.
Lansoprazole can be used therapeutically in young infants. Doses used will be much higher than the amounts the infant may be exposed to via breast milk.
Use with caution
Rabeprazole can be used with caution during breastfeeding, but omeprazole or pantoprazole are preferred.
Monitoring
As a precaution, monitor for constipation, diarrhoea, sickness, poor sleeping, irritability or rash.
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
There is no published evidence of use during breastfeeding. However, rabeprazole is not expected to pass into breast milk in significant amounts and any that does is likely to be degraded in the infant’s gastrointestinal tract.
Side effects in breastfed infants are therefore not expected.
Patient Information
The NHS website provides advice for patients on the use of specific medicines in breastfeeding.
Recommendations are based on published evidence where available. However, evidence is generally very poor and limited, and can require professional interpretation. Assessments are often based on reviewing case reports which can be conflicting and lack detail.
If there is no published clinical evidence, assessments are based on: pharmacodynamic and pharmacokinetic principles, extrapolation from similar drugs, risk assessment of normal clinical use, expert advice, and unpublished data. Simulated data is now increasingly being used due to the ethical difficulties around gathering good quality evidence in this area.