Assessing pharmacy teams’ confidence on the safety of drugs in lactation

The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life, followed by partial breastfeeding for up to two years and beyond​[1]​. Around 60% of newborns in the UK and Ireland are breastfed in the first hour of life; however, this figure drops to 48.1% within the first 6–8 weeks, with less than 1% of mothers continuing to breastfeed until the age of two years or beyond​[2]​. In the UK, 80% of new mothers stop breastfeeding before they intend to, predominantly owing to lack of support and inconsistent messaging from healthcare professionals​[2,3]​. This can result in higher rates of postnatal depression, maternal guilt and trauma, demonstrating the need for healthcare professionals to improve maternal access to breastfeeding support and information​[4]​.

A survey was conducted over a two-month period (March–May 2021), using the Google Surveys application, to identify the current gaps in knowledge relating to the safety of drugs in lactation, and to understand the overall perception of breastfeeding as a public health concern among pharmacy teams in all sectors. The survey also sought to explore the methods by which further education may be delivered to pharmacy teams, with the aim of subsequently improving maternal access to breastfeeding support and information.

The survey was disseminated online, via the UK Clinical Pharmacist Association website, and via clinical commissioning groups (CCGs) within England and Scotland.

There were a total of 226 responses to the survey:

• 25.4% (n=57) were from community pharmacists;
• 46.4% (n=105) were from hospital pharmacists;
• 6.4% (n=14) were from GP practice pharmacists;
• 1.3% (n=3) were from preregistration pharmacists;
• 5% (n=11) were from pharmacists from academia, primary care, CCGs, prison, military and the pharmaceutical industry;
• 5.5% (n=12) were from community pharmacy assistants;
• 2% (n=4) were from hospital pharmacy dispensers;
• 5% (n=11) were from hospital assistant technical officers;
• 1% (n=2) were from community medicines counter assistants;
• 3.3% (n=7) were from CCG and medicines optimisation pharmacy technicians and pharmacy students.

Overall, 43.8% of all respondents (n=83 pharmacists and 15 auxiliary staff) stated that they were ‘somewhat confident, but that [they] would benefit from further education’, and 36.4% (n=74 pharmacists and 8 auxiliary staff) stated that they were ‘confident in answering questions pertaining to the safety of medicines in lactation’. However, only 20% of these respondents correctly identified the medications suitable for use in breastfeeding, and 15.2% stated that they did not know which medicines were suitable, suggesting a disparity between the perceived confidence of pharmacists and their response to queries.

In addition, 27.8% (n=63) of pharmacists did not recognise that codeine was less suitable for use in breastfeeding. Codeine is contraindicated owing to the variation in individuals of the gene responsible for codeine metabolism; individuals with duplication of the CYP2D6 gene are ultrarapid metabolisers of codeine, and produce more of the active metabolite morphine. This can affect the efficacy and side effects seen in the mother following codeine use, and the amount of codeine and its active metabolites found within the breast milk​[5]​. A total of 47.2% (n=106) of pharmacists did not recognise that aspirin is also contraindicated in breastfeeding mothers owing to the risk of Reye’s syndrome in the infant from the levels passing through breast milk. Pharmacists and technicians working within GP surgeries and hospitals performed better in this area, despite most respondents stating that they were only ‘somewhat confident’ in their clinical knowledge.

When asked about the advice they would provide breastfeeding mothers taking medications, 50% (n=113) of pharmacy staff stated that they would ‘ask the patient for time to look up the medication’ and 23% (n=52) stated that they would contact a medicines information service, or signpost the mother to a midwife, health visitor, GP or consultant. A further 4% (n=9) stated that they would recommend taking the medication after a feed, and 2% (n=4) advised ‘pumping and dumping’ breast milk while taking the medicine. Finally, 8% (n=18) stated that if they did not know whether the medication was safe in breastfeeding, they would advise the mother to avoid the medication completely or avoid breastfeeding altogether.

The British National Formulary was found to be the modal source of information for 80.4% (n=180) of respondents. The summary of product characteristics was also a main source of information for 69.2% (n=156) of respondents. Only 5.2% (n=12) had used Hale’s Medications and Mother’s Milk, 6.6% (n=15) had previously accessed LactMed and 1.5% (n=3) had used the UK Drugs in Lactation Advisory Service.

As a public health concern, 22% (n=50) of respondents were unaware of the health benefits breastfeeding can provide to new mothers, and 25% (n=56) were unaware of the health benefits for breastfeeding newborns. Just over 50% (n=120) did not correctly identify the conditions that would pose a contraindication to breastfeeding, such as phenylketonuria and galactosaemia.

Overall, 80% (n=181) 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, and 92.5% (n=209) stated they had not received any further training outside of their MPharm degree or Buttercups training. In addition, 91% (n=205) stated that they would like to see an online learning course available to all pharmacy teams, which would encompass video lectures, multidisciplinary training and further CPD articles.

Although the survey saw responses from only a small proportion of pharmacists (n=182) and pharmacy auxiliary staff (n=39), the results indicate clear gaps in knowledge regarding the safety of drugs in lactation, as well as a lack of wider understanding of breastfeeding as a major public health issue. The survey results have been used to aid discussions with expert organisations in their approach to the training of pharmacists and other healthcare professionals, and to promote available research and resources.

It is hoped that the results of this survey will also encourage pharmacists and pharmacy teams to review their own knowledge and current practices, and undertake further learning where necessary. Freely accessible materials, resources and helplines to assist pharmacists and pharmacy staff with queries relating to the safety of medicines in lactation are available:

• UK Drugs in Lactation Advisory Service;
• UK Teratology Information Service;
• Best Use of Medicines in Pregnancy leaflets;
• The Breastfeeding Network;
• The UNICEF UK Baby Friendly Initiative;
• LactMed;
• National Childbirth Trust;
• Association of Breastfeeding Mothers;
• La Leche League;
• Lactation Consultants of Great Britain.

Jessica Jones, clinical pharmacist, County Durham and Darlington NHS Foundation Trust

Read more: How to advise women on the safe use of medicines while breastfeeding