Just before the first UK lockdown in 2020, I welcomed my beautiful baby daughter into the world. I learned very quickly that being a new mother is hard, even with the support of family and friends, baby classes and playdates. And being a new mother isolated in the throes of a global pandemic is an altogether different experience entirely.
I found myself thankful that as a pharmacist I possessed some level of paediatric knowledge. I’m no expert in neonatology, but I know the difference between meningitis and measles, teething and tantrums. This level of understanding put my mind at ease just a little in those trying first few months. But I realise how difficult this time of life must be for women with no medical knowledge and lack of support.
One evening I saw a post from a local mother who, after being given a diagnosis of cancer, was desperately trying to source donor breastmilk for her newborn daughter. I wondered why this mother needed the milk. Why couldn’t she breastfeed? Was she worried about the effects her medication would have on her baby?
As a profession, we are responsible for protecting the public from the harmful effects of their medicines. Why then, are we not taught how to protect newborn babies? Or how to support mothers throughout their breastfeeding journey? I believe it is our responsibility to provide accurate and up to date information to empower patients to make the best possible decisions for themselves and their families, including breastfeeding mothers.
Pharmacists are perfectly placed to provide support, information and education to new mothers on the safety of medicines in breastfeeding, but we are vastly undervalued and receive very little in terms of education surrounding this topic.
I recently conducted a short survey, designed to assess pharmacists’ perception of breastfeeding and to explore the current gaps in knowledge relating to the safety of drugs in lactation which may cause pharmacists to advise premature cessation of breastfeeding. I also wanted to explore the methods by which further education may be delivered to pharmacy teams, with the aim of improving maternal access to breastfeeding support and information.
The results highlighted a startling lack of pharmacists’ knowledge surrounding the safety of drugs in breastfeeding. Of 218 respondents to the survey, only just over a third of pharmacists felt confident in answering questions relating to the safety of medicines in lactation, and over forty percent reported that they were ‘somewhat confident’, but that they would benefit from further education.
However, only one-fifth of respondents correctly answered the clinical questions asked. For example, over a quarter of pharmacists did not recognise that codeine was unsafe to use in breastfeeding, and almost half did not recognise that aspirin is also contraindicated in breastfeeding. A further 15 percent stated they did not know the answers. This suggests a disparity between the perceived confidence of pharmacists and their actual knowledge.
Pharmacists and technicians working within GP surgeries and hospitals performed better in this area, despite the majority of these respondents stating that they were only somewhat confident in their clinical knowledge of drugs in lactation.
The BNF was found to be the most frequently used source of information, with over 80 percent of respondents stating that this would be their choice of resource. The Summary of Product Characteristics was also a key source of information for nearly 70 percent of pharmacists in the survey. Only five percent of pharmacists had used Hale’s Medications and Mother’s Milk as a reference, just over six percent had previously accessed LactMed, and only 1.5 percent had used the UKDILAS service; these respondents were pharmacists with academic or clinical specialties.
When asked about the advice they would give to breastfeeding mothers taking medication, half the respondents stated that they would ask the patient for time to look up the medication. Given that the most used resource used was the BNF, it is unlikely that this ‘quick check’ would yield reliable results for breastfeeding mothers.
Around a quarter of respondents stated that they would contact an MI service, or signpost the mother to a midwife, health visitor, GP or consultant. Four percent stated that they would recommend taking the medication after a feed, and two percent advised ‘pumping and dumping’ breastmilk whilst taking the medicine. Worryingly, four percent said that they would advise the mother to avoid the medication, and a further four percent stated they would advise that the mother avoid breastfeeding altogether.
Further education around the safety of drugs in lactation may help to reduce the number of mothers advised to stop breastfeeding unnecessarily due to their medicines, and may allow mothers to take important medicines such as analgesics without needing to worry about the risk to their baby.
Benefits of breastfeeding
Around a fifth of respondents were unaware of the health benefits that breastfeeding can provide to new mothers, and a quarter were unaware of the health benefits for breastfeeding newborns. Around half of pharmacists stated they did not know the conditions that would pose a contraindication to breastfeeding, although a similar percentage correctly identified the current World Health Organisation guidance regarding the duration of breastfeeding.
Education and training
Overall, 80 percent of respondents stated that they felt pharmacists and pharmacy teams were not currently well equipped or trained to answer queries relating to the safety of drugs in lactation. Over 90 percent of respondents had not received any further training outside of their MPharm degree or Buttercups training relating to the safety of drugs in lactation.
Although the survey saw responses from only a relatively small number of pharmacists (n=179) and pharmacy auxiliary staff (n=39), the results suggest that there are gaps in pharmacists’ knowledge regarding the safety of drugs in lactation, as well as a lack of wider understanding of the potential benefits of breastfeeding to mothers and babies.
Overall, 80 percent stated that they felt pharmacists and pharmacy teams were not currently well equipped or trained to answer queries relating to the safety of drugs in lactation.
The results of the survey will be used to inform the creation of educational materials tailored to pharmacy professionals, in collaboration with other experts in the field. Further data is required to understand how pharmacists’ knowledge may differ depending on length of time registered and the sector in which they work. It may also be beneficial to investigate the perception of breastfeeding in other healthcare professions, such as medics, nursing staff and dentists, to further improve maternal access to breastfeeding support, given that the current NICE guidance on Maternal and Child Nutrition (PH11) recommends “as part of their continuing professional development, train health professionals, including doctors, dietitians and pharmacists, to promote and support breastfeeding, using BFI training as a minimum standard.”
It is hoped that the results of this survey and the subsequent production of learning resources will enable pharmacists to better support mothers throughout their breastfeeding journey. Where possible these learning resources should be freely available to all pharmacy staff in all sectors and should empower teams to signpost accordingly. These resources should also allow pharmacy staff to recognise any contraindications to breastfeeding by providing current, evidence-based information on the safety of drugs in lactation, thus avoiding premature cessation of breastfeeding in cases where this may be preventable.
Within the UK and Ireland, government statistics indicate that around 60% of mothers breastfeed their baby within an hour of giving birth. However, by 6-8 weeks post-birth this figure has dropped to just under 50 percent. Less than one percent of mothers are still breastfeeding when the child is age two or beyond. Furthermore, around 80 percent of mothers stop breastfeeding before they intend to.
Whether this happens due to conflicting advice from healthcare staff, or due to a new health diagnosis is not known, but with the correct education and training, pharmacy professionals can be instrumental in improving maternal access to breastfeeding support, care and information. We can help to increase the rates of breastfeeding within the UK, and we can help to protect breastfeeding where mothers have chosen to do so.
- The UK Drugs in Lactation Advisory Service (Specialist Pharmacy Service) provides evidence-based information and practical advice on the use of medicines during breastfeeding.
- The UK Teratology Information Service (UKTIS) provides healthcare professionals with evidence-based information on foetal risk following pharmacological and other potentially toxic pregnancy exposures.
- BUMPS (Best Use of Medicines in Pregnancy) is a public-facing website offering a library of openly available, patient-focussed information sheets to complement the scientific reviews that UKTIS produces for health care providers.
- The Breastfeeding Network is an independent source of support and information for breastfeeding women and others. The site has easy to access factsheets on common medications in lactation.
- The Unicef UK Baby Friendly Initiative is transforming healthcare for babies, their mothers and families in the UK, as part of a wider global partnership between the World Health Organization (WHO) and Unicef. Unicef enables public services to better support families with feeding and developing close, loving relationships, ensuring that all babies get the best possible start in life.
- The National Childbirth Trust is the UK’s largest parent charity. The charity’s mission is to support parents through the first 1000 days, from the beginning of pregnancy through to a child’s second birthday.
- The Association of Breastfeeding Mothers are a group of trained volunteers dedicated to supporting breastfeeding mums and their families.
- La Leche League is a non-governmental, nonprofit organisation that organises advocacy, education and training related to breastfeeding to help mothers to breastfeed through mother-to-mother support, encouragement, information, and education, and to promote a better understanding of breastfeeding as an important element in the healthy development of the baby and mother.
- Lactation Consultants of Great Britain is a registered charity working to improve the health and wellbeing of families through advocacy and expert breastfeeding care.
The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.