Breastfeeding and codeine.

Last year the FDA raised concerns about use of codeine in nursing mothers, after a two week old infant died of a morphine overdose resulting from maternal intake of codeine (in less than the amount typically prescribed). 

This issue has been in the news again this week after the release of a Canadian study documenting the same hazard.

Codeine is commonly prescribed for postpartum pain, and can be found in Tylenol 3.  When codeine is ingested an enzyme in our bodies metabolizes it into morphine.  Some mothers are "ultra-rapid metabolizers" of codeine, which means that the enzyme in their system more efficiently process codeine into morphine.  For those mothers, the amount of morphine in their milk is many times higher than others, and the concentration can be fatal to breastfed babies.

Some of us are more likely to be ultra-rapid metabolizers of codeine.  Dr. Thomas Hale, of Texas Tech University, and author of the indispensable Medications and Mother's Milk explains on his forum that the incidence ranges from 1% in Caucasians, to 10% in Greeks and Portuguese, to 29% in Ethiopians.  He also notes that at least 7-10% of Caucasians lack the metabolizing enzyme altogether, and cannot metabolize codeine to morphine, and so codeine is ineffective for these individuals.

So, what else could be used for postpartum pain?  Dr. Hale lists alternatives and guidelines for the use of strong pain killers on his forum.  You can also watch a brief FDA video on this topic.

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