I’d love to hear from the 99NICU community about your go-to references.

A few years ago, our team cared for a remarkable mother whose story reminded us how much nuance—and teamwork—breastfeeding counseling can require. She had undergone a liver transplant as a teenager and remained on lifelong anti-rejection medications. Years later, she delivered a healthy full-term baby and had a strong, heartfelt wish to breastfeed.

As you can imagine, her medications raised questions about safety and infant exposure. Instead of defaulting to “no,” our team—neonatologist, clinical pharmacist, and the mother’s own transplant specialist—reviewed each drug carefully. We dove deep into pharmacokinetics and pharmacodynamics, half-lives, peak serum times, and milk-plasma ratios. The goal was to adapt the medication schedule to support breastfeeding, rather than ask her to give up breastfeeding because of the medications.

Together, we developed a practical plan:
• She could directly breastfeed from 7 AM to 7 PM.
• She would take her immunosuppressive dose immediately after 7 PM and avoid breastfeeding until 7 AM the next morning.
• She would pump at least twice overnight to maintain supply, but this milk would be discarded.
• Her baby would receive formula as needed during the nighttime window.

With this tailored approach, she was able to partially breastfeed her baby for eight months, which meant the world to her. For us, it was a powerful reminder that with the right information—and interprofessional collaboration—we can often make breastfeeding possible even in complex medical situations. This case was one that helped me shape my personal practice when it comes to breastfeeding support and orientation. It also highlighted how important it is to have trustworthy, up-to-date resources on medication safety in lactation.

So I’m curious: what resources do you rely on to check whether a medication is compatible with breastfeeding?
Have you managed similar cases you would like to share, and what tools or references were most helpful (e.g., online databases, institutional guidelines, books, lactation pharmacology experts)?

Would love to learn from your experience!

Thanks Mariana, great topic, and an everyday question.

Our standard in Sweden is https://janusmed.se/amning, will share more later 😀

We are using https://www.embryotox.de/

We are seeing a change in practice toward allowing more medications in breastfeeding. Lately I came across an infant whose mother was on Lithium, this has been a no for us in the past, but she insisted on wanting to breastfeed, and while doing a literature search (with the help of OpenEvidence 😁). I found an article in Acta Pediatrica with a reasonable follow-up schedule.

PubMed

Lithium use during breastfeeding was safe in healthy full...

Serum lithium concentrations in breastfed infants were stabilised at barely measurable levels after the first weeks of life. Before that, concentrations higher than the mothers were found. Lithium tre

While questions about breastfeeding while taking various medications are common - and we do have a great Swedish resource that Stefan referred to above - most answers tend to be ”we don’t know” or possibly some effect.” there are only a few medications that are a clear no. For me, several immunosuppressants have fallen into that category, so hearing about your practical approach is really valuable!

Thank you for this excellent topic. I struggled with this a few days ago and came to the conclusion that we also need adequate resources within the perinatal center. At a moment we use synbase.ee and lactmed.com. OpenEvidence is very good source to find latest evidence.

I’ll add a good article reference here that will help us look at the topic more broadly

Best,

Annika

I

MOBM.pdf

I use https://www.e-lactancia.org/. Wasn't even aware of other resources listed here, thank you!

Thank you for the paper, @Annika

This is indeed an interesting topic with many unanswered questions. Lot of research required. Areas of real concern if mother is on antipsychotics or anti depressants. Any take on this

What a powerful case — thank you for sharing it. Stories like this really capture the nuance of breastfeeding counselling and the importance of moving beyond reflexive “no’s.”

One set of resources that has consistently shaped my own practice in complex situations like this is the Academy of Breastfeeding Medicine (ABM) Clinical Protocols. I find them particularly helpful because they are practical, evidence-based, and explicitly encourage individualized, patient-centred decision-making with interprofessional collaboration — exactly what you describe.

https://www.bfmed.org/protocols

A few protocols I often return to:

• ABM Protocol #21 – Breastfeeding and Substance Use / Substance Use Disorder

• ABM Protocol #18 – Use of Antidepressants in Breastfeeding Mothers

• ABM Protocol #15 – Analgesia and Anesthesia for the Breastfeeding Mother

Beyond individual drug safety, what I appreciate most about ABM protocols is their framework: assess the drug, the infant, the maternal condition, timing, and alternatives — and then adapt the plan to support breastfeeding whenever safely possible.

Your case beautifully illustrates that philosophy in action. I’d love to see more teams approach complex medication scenarios with that same curiosity and collaboration rather than default restriction.

We use https://www.e-lactancia.org/. in Argentina.

Best wishes

Hello, in Spain, www.e-lactancia.org is the most used

we use E-Lactinicia .org

Hello,

We are a human milk bank in South Africa and feed premature infants, so the issue of medications and supplements is tricky as it is commonly agreed one needs to be extra careful when the breastmilk is going to premature infants, but finding information specifically addressing this is seldom available. If anyone can recommend where we can find more information that includes the extra risks or things to be cautious about for premature infants, I would be grateful if you would share it.

We look at a variety of sources including Medications and Mothers Milk by Thomas Hale, Lactmed, e-lactancia, and information shared by other milk banks. In addition there is a helpline of pharmacists whom we can call on and they look things up on all their resources and advise and doctors and Lactation Consultants are another source of guidance.

Hi all,

I am a neonatal and pediatric pharmacist from Israel, and I regularly provide consultations on drugs and breastfeeding in our NICU and obstetrics wards. I am delighted to see this discussion and the dyad-centered approach, which strives to take into account both mother and infant considerations and wishes to make an educated decision backed by careful risk management. This is without a doubt the right course of action!

I will share the resources I am aware of and often use, and even though some have already been mentioned, perhaps this list may be useful as a convenient and accessible collection for your practices and everyday needs:

1. Lactmed - An American, NIH-sponsored, freely available resource. Comprehensive and regularly updated.

2. E-lactancia - A Spanish resource, available in English and Spanish, freely accessible. It should be noted that it also provides information on exposures other than pharmaceuticals (some food supplements, phytotherapy).

3. MotherToBaby - An American resource powered by The Organization of Teratology Information Specialists (OTIS). They offer a vast collection of fact sheets for various exposures, including pharmaceuticals but many other exposures as well. While this is patient-oriented information, it may still be useful for professionals to observe the approach of OTIS to exposure with scarce evidence.

4. Hale's Medications & Mothers' Milk - a well-known, long-standing American resource by Thomas Hale and Kaytlin Krutsch. Available digitally (to paying subscribers) and in print, this collection provides evidence summaries for many exposures (mostly pharmaceuticals, but not solely). One of its highlights is the pharmacokinetic data table that accompanies each monograph, which is very helpful for a quick observation, before diving into the evidence. It also contains some appendices that are worth checking out (drugs that may alter the taste of human milk and more).

5. InfantRisk Center - This is the teratology information center in Texas Tech University that produces Hale's Medications & Mothers' Milk, and its online website and community offers additional resources and articles that may complement the book. I suggest checking out the forums, where patients and professionals may ask questions on exposures during breastfeeding and the InfantRisk team responds to them, and the breastfeeding page, which contains many articles on all kinds of exposures during breastfeeding.

6. Academy of Breastfeeding Medicine - This American medical society publishes protocols on various topics related to breastfeeding, some include exposure to certain drug groups.

7. Breastfeeding Medicine - This Journal, published by the Academy of Breastfeeding Medicine and Mary Ann Liebert, offers a myriad of peer-reviewed papers, protocols and publications on breastfeeding. Some material is open access, others require subscription access. It is possible to search the journal page for drug name/family and retrieve appropriate publications. This journal also features publications by Philip O. Anderson, who is also involved in Lactmed. His publications include summaries for various drug families in breastfeeding.

8. Guidelines for anaesthesia and sedation for patients who are breastfeeding - This open-access British publication, which was originally published in 2020 and very recently revised and updated, includes a lot of information on many drugs used for analgesia and sedation in breastfeeding women. Be sure to check out the supporting information, the appendices offer much useful information (including more resources), basic terminology and more.

9. SPS (Specialist Pharmacy Service) "Safety in Breastfeeding" topic - This NHS-supported service has a lot to offer about drugs and pharmacy skills in general, and there is a topic about "Safety in Breastfeeding" that serves as a collection of articles about pharmacotherapy during breastfeeding in general, as well as dedicated articles for certain drugs/drug groups (e.g., antihistamines, GLP-1 receptor agonists, contrast agents, oral anticoagulants, and more).

10. Pharmacokinetics sections in drug labels and general drug databases - When all else fails, one may try to make an educated "guess" about the amount of drug that may pass into breastmilk according to PK parameters, e.g., low bioavailability of injectables, high molecular weight of biological products etc.

This list is not complete, but provides a collection of trusted resources for healthcare professionals. I was also happy to see the paper @Annika shared, not only because I was a co-author on this paper, but also because I believe this review captures the 'modern' approach to drug exposure during breastfeeding and provides a holistic view of this topic that may allow NICU professionals to provide preterm infants with human milk that is SO important to them. So I do recommend reading it and applying our suggestions in your practices as you see fit.

* A word on OpenEvidence - this is an excellent tool, the most trustworthy AI platform for medical information currently available. However, one should note that in questions about drugs, it often relies on information from FDA drug labels, which - as we know - often provide no safety information for exposure during pregnancy and/or breastfeeding, or even recommend against use of the drug in question. Therefore, always check the sources for OE answer, and if it relies on the label, do check in any of the other sources I listed above.

Thank you for raising this topic, and I do hope this will contribute to better care for breastfeeding mothers and infants.

Edited February 24Feb 24 by Dotan S
Added no. 9 - SPS "Safety in Breastfeeding" topic.

The primary resources for checking medication compatibility with breastfeeding are LactMed, Hale's Medications and Mothers' Milk, and MotherToBaby, all of which are recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.

LactMed is the most comprehensive and authoritative free resource, published by the National Library of Medicine and continuously updated. It is available online at https://www.ncbi.nlm.nih.gov/books/NBK501922/ and through mobile applications

1. Technical Report: Breastfeeding and the Use of Human Milk. Pediatrics. 2022. Meek JY, Noble L. Guideline

2. Optimizing Support for Breastfeeding as Part of Obstetric Practice. American College of Obstetricians and Gynecologists (2018). 2018. Susan D. Crowe, Lauren E. Hanley

3. Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant: Clinical Report. Pediatrics. 2026. Parker MG, Stellwagen L, Miller ER, et al