Supporting Breastfeeding Families: The Community Pharmacist’s Role During National Breastfeeding Month
By Jesica Mills, PharmD, ND, MBA, RPh, BCES, BCLS, BCNP
August is National Breastfeeding Month, making it an ideal time for community pharmacies to highlight one of the most impactful services they already provide: helping mothers safely navigate medications while breastfeeding.
Breastfeeding parents often receive conflicting advice about medication use. Some are unnecessarily told to stop breastfeeding when prescribed new medication, while others delay treatment because they fear potentially harming their infant. Pharmacists can serve as a trusted resource to replace uncertainty with individualized, evidence-based guidance that protects the health of both mother and baby.
Whether recommending an over-the-counter product, reviewing a new prescription, helping manage a breastfeeding complication, or identifying symptoms which require referral, community pharmacists frequently have opportunities to support breastfeeding success and maternal well-being.
Start With the Right Question
One simple question can change the entire encounter:
“Are you currently pregnant or breastfeeding?”
Asking routinely helps identify patients who may need additional counseling before beginning treatment. It may also open the door to concerns the patient was hesitant to raise, including worries about medication exposure, declining milk production, postpartum mood changes, or difficulty managing an illness while caring for a newborn.
Understanding Medication Exposure Through Breast Milk
Most medications taken by breastfeeding mothers enter breast milk in relatively small amounts. For many commonly used medications, infant exposure to the medication through breastmilk is substantially lower than a therapeutic infant dose.
The clinical significance of medication exposure depends on several factors:
- Maternal dose and route of administration
- Medication half-life
- Protein binding
- Lipid solubility
- Oral bioavailability in the infant
- Timing of the dose in relation to feeding
- Infant age, gestational age, and overall health
- Whether lactation is established
- Whether the medication may affect milk production
| Medication | General Breastfeeding Compatibility | Clinical Reasoning |
| Acetaminophen | Yes | Concentrations found in milk are much lower than therapeutical doses for infants. It is considered the first-line option for pain and fever during lactation. |
| Ibuprofen | Yes | Very low milk transfer, a short half-life, and established pediatric use make ibuprofen a preferred NSAID during breastfeeding. |
| Naproxen | Usually | Short-term use is generally acceptable, but the longer half-life creates greater potential for accumulation with prolonged or repeated use. Ibuprofen is preferred when appropriate. |
| Amoxicillin | Yes | Only small amounts enter breast milk. Infants may occasionally experience loose stools, rash, or oral thrush. |
| Cephalexin | Yes | Milk exposure is low, and cephalexin is generally well tolerated. Monitor for possible diarrhea, rash, or thrush. |
| Azithromycin | Yes | Infant exposure through milk is low, and macrolides are also used therapeutically in infants. Monitor for gastrointestinal changes or thrush. |
| Nitrofurantoin | Usually | Generally acceptable for healthy, full-term infants. Avoid in infants less than one month old or with a known/suspected G6PD deficiency because of hemolysis risk. |
| Loratadine | Yes | Low milk transfer and minimal sedation make loratadine a preferred antihistamine during breastfeeding. |
| Cetirizine | Yes | Infant exposure is expected to be low, and significant sedation is uncommon. It is generally preferred over sedating antihistamines. |
| Diphenhydramine | Usually | Small, occasional doses are unlikely to cause harm. Repeated or high-dose use can cause infant sedation and may reduce milk production, especially if lactation is not well established. |
| Pseudoephedrine | Avoid if possible | Infant exposure is generally low, but even a single dose can acutely reduce milk production. Repeated use may further interfere with lactation. |
| Fluticasone nasal spray | Yes | Minimal systemic absorption after intranasal administration makes clinically significant milk exposure unlikely. |
| Albuterol inhaler | Yes | Inhaled administration produces low maternal systemic concentrations, making meaningful infant exposure unlikely. |
| Omeprazole | Yes | Milk concentrations are low, and medication reaching the infant is likely degraded by gastric acid. |
| Sertraline | Yes | Sertraline is a preferred SSRI during breastfeeding because infant serum concentrations are typically undetectable due to short half-life |
| Fluoxetine | Usually | Breastfeeding can often continue, particularly when fluoxetine was effective during pregnancy. The long half-life and active metabolite may increase infant exposure, so monitor for irritability, poor feeding, or inadequate weight gain. |
| Metformin | Yes | Very small amounts enter breast milk, and available evidence has not demonstrated clinically significant adverse effects in breastfed infants. |
| Levothyroxine | Yes | Replacement doses are compatible with breastfeeding. Treating maternal hypothyroidism helps support normal milk production. |
| Prednisone | Usually | Milk concentrations are low, and short courses are generally compatible. Doses over 40mg may require delaying breastfeeding for 3-4 hours. Individual assessment may be appropriate with prolonged, very high-dose therapy. |
Healthy, full-term, older infants can generally metabolize and eliminate medications more effectively than premature, medically fragile, or very young newborns. A medication that is reasonable for the mother of a healthy six-month-old may require greater caution when the infant is premature or only a few days old.
Rather than automatically recommending that breastfeeding be interrupted, pharmacists should evaluate the specific medication, dosage, treatment duration, infant characteristics, and availability of safer alternatives.
Reliable Lactation Resources
Package labeling is often conservative because pregnant and breastfeeding patients have historically been underrepresented in clinical trials. Pharmacists should consult lactation-specific references rather than relying solely on product labeling.
Useful resources include:
- Drugs and Lactation Database, or LactMed
- Academy of Breastfeeding Medicine clinical protocols available in a variety of languages
- InfantRisk Center
- Hale’s Medications & Mothers’ Milk
As a resource from the National Library of Medicine, LactMed provides information about medication concentrations in breast milk, estimated infant exposure, reported adverse effects, effects on milk production, and possible therapeutic alternatives. InfantRisk Center is a resource through the Texas Tech University Health Sciences Center founded by Dr. Thomas Hale. In addition to a pharmacology laboratory and study publications, the center staffs a call center for healthcare providers. Hale’s Medications & Mothers’ Milk is a paid subscription that includes herbal, prescription, OTC, and street drugs.
Common Medication Questions During Breastfeeding
The following chart provides general guidance for healthy, full-term infants. Recommendations may differ for premature newborns, medically fragile infants, patients using high doses or prolonged treatment, and infants with conditions such as glucose-6-phosphate dehydrogenase deficiency.
Clinical pearl: “Avoid if possible” does not automatically mean breastfeeding must stop. It means another medication may be a better first choice, especially when lactation is not firmly established or the patient is already experiencing low supply.
Pharmacists should also caution patients against multi-symptom cold and flu products. Combination products may expose the mother and infant to unnecessary ingredients and make it harder to identify which ingredient is responsible for sedation, irritability, or reduced milk production. Selecting a single-ingredient product targeting the patient’s primary symptom is generally preferable.
Galactagogues and Low Milk Supply
Questions about increasing milk supply are common. Products marketed as “lactation supplements” may contain fenugreek, moringa, goat’s rue, blessed thistle, fennel, or combinations of several herbs. Sunflower lecithin is also frequently marketed to breastfeeding families, although it is used primarily to reduce recurrent plugged ducts rather than directly increase milk production.
Evidence supporting herbal and prescription galactagogues remains limited, and product quality, dosage, and ingredient consistency may vary by manufacturer or even lot from the same manufacturer. “Natural” does not necessarily mean effective or free of adverse effects. Herbal products may cause allergic reactions, gastrointestinal symptoms, changes in blood glucose, drug interactions, or adverse effects in the infant.
Before recommending a galactagogue, pharmacists should encourage patients to assess how completely milk is being removed during pumping or feeding, and the underlying cause of the perceived low supply. Milk production is largely driven by frequent and effective removal of milk. Common contributors of low milk production or unsuccessful removal include:
- Ineffective latch or positioning
- Infrequent feeding or pumping
- Scheduled feeds that do not reflect infant hunger cues
- Inadequate breast emptying
- Incorrect pump flange size
- Ineffective or poorly maintained pump equipment
- Supplementation without corresponding pumping
- Infant tongue or oral-motor dysfunction
- Maternal pain, illness, severe stress, or exhaustion
- Certain medications, particularly pseudoephedrine and estrogen-containing products
- Prior breast surgery or insufficient glandular tissue
Hormonal and Endocrine Causes of Low Milk Supply
Several hormonal and endocrine conditions can interfere with the initiation or maintenance of milk production. The most clinically relevant include:
Hypothyroidism
Inadequately treated hypothyroidism may contribute to delayed lactogenesis or low milk production. Patients with symptoms such as persistent fatigue, constipation, cold intolerance, dry skin, or difficulty establishing supply may benefit from thyroid evaluation. Postpartum thyroiditis should also be considered when thyroid symptoms develop following delivery.
Polyendocrine Metabolic Ovarian Syndrome (PMOS) and Insulin Resistance
PMOS, formerly known as Polycystic Ovarian Syndrome (PCOS), is associated with androgen excess, insulin resistance, and irregular ovulation. These hormonal and metabolic abnormalities may interfere with normal breast development during pregnancy or the initiation of milk production after delivery. Not every patient with PMOS will experience low supply, but it should be considered when other signs are present.
Diabetes and Poor Glycemic Control
Preexisting diabetes and gestational diabetes have been associated with delayed onset of copious milk production. Women with gestational diabetes may take longer for their colostrum to change to milk production, especially if the baby was separated after birth to monitor for low blood sugar. Insulin plays a role in mammary gland function, and significant insulin resistance or poor glycemic control may negatively affect lactation. Both hypoglycemia and hyperglycemia can lead to lower breast milk volume of up to 50%.
Pituitary Dysfunction and Inadequate Prolactin Production
Prolactin is essential for milk synthesis. Pituitary injury following severe postpartum hemorrhage, sometimes called Sheehan syndrome, can result in inadequate prolactin production and failure of lactation. A history of major blood loss, hypotension, inability to produce milk, persistent weakness, low blood pressure, absent menstruation, or other symptoms of pituitary hormone deficiency warrants urgent medical evaluation.
Other pituitary disorders or prior pituitary surgery may also interfere with prolactin secretion.
Retained Placental Tissue
Placental delivery produces the rapid decline in progesterone that helps trigger secretory activation and the onset of milk production. Retained placental fragments may prolong progesterone exposure and delay lactogenesis. Persistent or heavy postpartum bleeding, uterine pain, fever, or failure of milk production requires prompt obstetric evaluation.
New Pregnancy
Hormonal changes during a subsequent pregnancy commonly reduce milk production, even when feeding or pumping patterns remain unchanged. Pregnancy should be considered when an established supply declines unexpectedly and the patient has pregnancy symptoms or a delayed menstrual period. New mothers may still conceive in the post-partum phase before menstruation resumes.
Estrogen Exposure
Estrogen-containing contraceptives may reduce milk production in some patients, particularly when introduced early postpartum or before milk supply is established. The timing, dosage, patient risk factors, and need for contraception should be evaluated with the patient’s obstetric provider.
Identifying and treating an underlying hormonal problem is more appropriate than simply adding a supplement. Galactagogues should never replace an evaluation of maternal health, infant feeding, and effective milk removal.
Supporting Common Breastfeeding Concerns
Community pharmacies can also support breastfeeding families by stocking products such as:
- Milk storage bags
- Nursing pads
- Hydrogel cooling pads
- Purified lanolin
- Nipple-protection products, such as nipple shields
- Manual pumps and pump accessories
- Correctly sized pump flanges
- Breastfeeding-compatible prenatal vitamins
- Infant vitamin D drops
- Oral rehydration products
- Hot and cold breast therapy packs
Product placement can serve as a conversation starter, but recommendations should remain individualized. Painful feeding, recurrent plugged ducts, nipple trauma, or persistent supply concerns should not be managed solely through product sales.
Mastitis: Supportive Care and Referral
Inflammatory mastitis may present with localized breast pain, redness, swelling, and systemic symptoms. Current management emphasizes continued physiologic breastfeeding, rest, hydration, and appropriate anti-inflammatory therapy rather than aggressive breast massage or attempts to completely “empty” the breast.
Patients should avoid deep massage, excessive pumping, and repeated heat since these measures worsen inflammation. Cold packs and an appropriate NSAID may help reduce pain and edema when not otherwise contraindicated.
Prompt medical evaluation is appropriate when symptoms are severe, the patient appears acutely ill, or when an abscess is suspected. If symptoms fail to improve in 24-48 hours or include a fever, there may be an accompanying bacterial infection. Breastfeeding can usually continue during mastitis and during treatment with commonly selected antibiotics.
Knowing When to Refer
Pharmacists should recommend an evaluation by an obstetric provider, pediatrician, primary care clinician, or International Board-Certified Lactation Consultant when a patient reports:
- Poor infant weight gain
- Fewer wet diapers or signs of dehydration
- Persistent nipple trauma, bleeding, or severe feeding pain
- Inability to establish or maintain milk production
- Suspected tongue-tie or oral-motor dysfunction
- Recurrent plugged ducts or breast inflammation
- Breast redness, fever, or systemic symptoms
- A breast mass that does not resolve
- Symptoms of infant sedation, poor feeding, or respiratory depression after maternal medication administration
- Persistent or heavy postpartum bleeding
- A history of severe postpartum hemorrhage with failure of milk production
Pharmacists should also remain attentive to postpartum mental health. Persistent sadness, panic, intrusive thoughts, severe anxiety, inability to sleep even when the infant sleeps, feelings of hopelessness, or difficulty functioning warrant prompt referral. Thoughts of suicide or harming the infant require immediate emergency intervention.
Building a Breastfeeding-Friendly Pharmacy
Independent pharmacies can strengthen their role in maternal and infant health by forming relationships with:
- Local lactation consultants
- Obstetric and midwifery practices
- Pediatric offices
- Birthing centers and hospitals
- Postpartum therapists and mental health professionals
- Women, Infants, and Children (WIC) programs
- Community parenting and breastfeeding support groups
Pharmacies may also consider staff education, breastfeeding-resource displays, private counseling areas, prenatal medication reviews, breast-pump support, and postpartum medication consultations.
The goal is not to pressure every family to breastfeed or imply that breastfeeding outcomes reflect parental effort. Feeding decisions are personal and may be influenced by medical conditions, mental health, infant needs, access to support, work demands, prior trauma, and individual preference. Pharmacists can provide evidence-based support while respecting each family’s goals and circumstances.
The Pharmacist’s Opportunity
Community pharmacists often see postpartum patients more frequently than other healthcare professionals. A prescription pickup or over-the-counter consultation may be the first opportunity for someone to recognize that a mother is struggling with medication fears, low milk production, breast pain, exhaustion, or postpartum anxiety or depression.
A thoughtful medication review may prevent unnecessary interruption of breastfeeding. Especially in the upcoming cold and flu season, recognizing pseudoephedrine as a potential cause of declining supply may solve a problem before it escalates. Identifying symptoms of retained placental tissue, pituitary dysfunction, mastitis, or postpartum depression may prompt care that protects both mother and infant.
Pharmacists do more than determine whether a medication is “safe.” They translate evidence into practical guidance, identify safer alternatives, explain what to monitor, and connect families with additional care when needed.
During National Breastfeeding Month and throughout the year, community pharmacies have an opportunity to become trusted, accessible sources of compassionate support for breastfeeding families.
References
- National Library of Medicine. Drugs and Lactation Database (LactMed). National Center for Biotechnology Information.
- Academy of Breastfeeding Medicine. Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Production.
- Academy of Breastfeeding Medicine. Clinical Protocol #18: Use of Antidepressants in Breastfeeding Mothers.
- Academy of Breastfeeding Medicine. Clinical Protocol #36: The Mastitis Spectrum.
- Hale TW, Krutsch K. Medications & Mothers’ Milk.
- InfantRisk Center. Clinical resources regarding medication use during pregnancy and lactation.
- Greenberg, Victoria R. “Glycemic Patterns and Breastfeeding With Type 1 or Type 2 Diabetes.” Diabetes Spectrum, vol. 38, no. 4, 2025, pp. 407–413. PubMed Central, https://pmc.ncbi.nlm.nih.gov/articles/PMC12620739/.
