Friday, April 30, 2010


ps [added 17 November 2012]
This US FDA website gives reliable guidance on codeine ultra-rapid metabolisers.

A baby's ability to breastfeed is one of the key 'performance indicators' that I observe after birth.

The majority of my work is with women and babies who are free of medication, giving birth to healthy babies at Term. Babies behave in the normal physiological fashion when the mother takes her child to her breast, and they remain together, skin to skin, for the next couple of hours. Babies seek the breast, making licking and rooting movements and moving in a distinctive way until they are in place and can take the breast and suckle effectively. This process is known as the breast crawl.

When a woman giving birth requires surgery she is given drugs. The anaesthetist and the obstetrician will prescribe whatever they consider to be necessary.

I am concerned about the current drug of choice for postnatal pain relief, Endone.

In the past year I have worked with three women who received Endone postnatally, and I believe I have observed a strong sedative effect of the drug on two of these babies. They became quite uninterested in the breast after the first breast feed, which had been unremarkable.

Recently another client of mine had a caesarean for obstructed labour, and I talked with her and the midwife in the postnatal ward 12 hours after the birth. The analgesia ordered was Endone (for 48 hours), Panadol and Voltarin. We agreed that if she was needing Endone she would breastfeed first, then take the drug. She has progressed very well with breastfeeding, went home on the third day - in fact this baby does a little breast crawl like a pro for every feed!

I am now checking for research literature specifically on Endone (oxycodone) and breastfeeding. Other midwives have said they share my concerns. A quick Google search came up with a very clear statement: "Do not take ENDONE during pregnancy or during breastfeeding as it may cause difficulty in breathing in an unborn or newborn child." [at]

A colleague who lives in regional Victoria told me that one of the local hospitals uses Endone less than the others, and that the local GPs, who provide anaesthetic services for the hospital, are still giving spinal morphine 1mg which works so well that very few women require more than Panadol and Voltaren.

I spoke to the pharmacist at a tertiary materntiy hospital in Melbourne, and he gave me some more information. He agreed that it's a very potent opioid that has a high transfer ratio into the milk, and variation from person to person as to how they metabolize Endone into morphine substances - hence variation in effect. He said the doses given appear to be pretty hefty.

The medical justification seems to be relatively short half life - 3-6 hours; that it's only used for 48 hours, claiming that the majority of babies are not sedated, and that the amount of colostrum the baby gets is pretty negligible anyway !!. Read here breastfeeding isn't something 'we' care much about!

The Lactmed site notes that "Newborn infants seem to be particularly sensitive to the effects of even small dosages of narcotic analgesics, particularly in the first week of life."

Dr Tom Hale, a world-respected expert and author on medications and mother's milk, has a forum

Hale states that "Oxycodone is a categoryL3... moderately safe, to be used only if the potential benefit to mother justifies potential risk to baby, and it has a half life of 3-6 hrs." Potential benefit to mother justifies potential risk to baby. I wonder how many mothers are given the opportunity to consider the risk/benefit before they swallow the tablet?

A newborn infant has important work to do, including learning how to breast feed. A newborn infant who is being systematically sedated through dangerous drugs that are passing from mother's blood to mother's milk, is being put at risk of breastfeeding delay leading to dehydration, jaundice, and a subsequent cascade of interventions, each with their own package of risks. The mother, receiving powerful sedation, is also likely to experience iatrogenic (physician-induced) difficulties with bonding and establishing breastfeeding.

I have often mused on the fact that "would you like something to help with the pain?" really means "would you like me to give you a dangerous drug?" I wish I knew a friendly cartoonist.

The anaesthetists and obstetricians really need to be questioned about this.
We live in a culture of acceptance of 'doctor knows best'. Women who undergo surgery for birth place an enormous trust in their surgeons and the other medical people - we need to act in their interests and on behalf of their babies.

I would like to ask that anyone reading this blog who works in the system, and who observes any cases where the baby of a mother receiving Endone in the early postnatal days appears sedated or performs poorly at breastfeeding, please draw attention to it. Speak to the obs and anaes departments, and point out what you observe. Ask them if they are aware of other such problems. Speak to the midwife manager of the unit, and ask her if she would support an internal audit of use of Endone. Find out what application is needed to get data from the general records. How often is it prescribed? What doses? (the pharmacy should be able to tell you this) Does the hospital have a protocol for the use of Endone? (you may find this on the hospital's intranet) What is the rate of supplementation of breastfeeding babies who were born by Caesarean (all the Baby Friendly hospitals should be able to give this data easily. Feeding on discharge is recorded on the Victorian perinatal statistics, so there could be some initial comparisons done.)

And while we're on the topic, I think some midwives are telling women in early labour to take some Panadeine and go to bed. Has anyone else heard this? In that case the codeine part of the drug will be added to the opioid soup in baby's system in the early days.

This is just not good enough!


Joy Johnston said...

A midwifery student who would like to remain anonymous has written in response to this discussion:

[From my experience as a student on placement] Endone post op for C/section women is given out readily. During my 3 month placement in the post natal ward at [a busy private hospital in Melbourne] last year, I think almost every woman who had either had an instrumental birth or a C/Section was written up for Endone in her drug chart. In terms of how this affected babies, almost every baby was ‘comped’ with formula for one reason or another as this was considered normal practice. I wonder now whether it had anything to do with babies sleeping more, showing less interested in the breast etc. Also in terms of whether Panadeine is used readily, the [tertiary level maternity hospital] have a ‘standard’ approach to women presenting in spurious labour which involves the women being advised to take Panadeine Forte and Tamazepam and return home to get some sleep! We have brought this up in class over the last two years as both drugs are not recommended during pregnancy – but it seems that when labour is imminent all the standard advice and precautions go out the window! All this occurs much to the sorrow of us students who know better, but most unfortunately challenging practice would be to our detriment at this stage of our studies. Next year as Grads, it may be a different story and some of us may have the courage to stand up and question what is primarily ‘unsafe’ and not evidence based practice at some of these facilities.

Joy Johnston said...

Another midwife colleague has reminded me that Michel Odent argues that the use of addictive drugs in pregnancy, birth and postnatally may set up an increased likelihood that that child will become a drug addict later in life. I do not have a reference for this, but I have heard Dr Odent speaking on the topic. The primal health research site is

Joy Johnston said...

The following response is from a respected midwife who works in the breast feeding support service of a public hospital:
"The issues you speak about are very important and we need to tread that fine line between good maternal analgesia following c/s and an alert breastfeeding baby with no suckling problems. I know there is a body of research showing the potential noxious effects of post-operative analgesia upon babies in the first few days and we as clinicians have to be able to ensure there is sufficient feeding of the baby to avoid further complications developing until the baby is competently feeding at the breast. Not always easy as you know but essential nonetheless."

MeredithC said...

I have just come home from a private inner city hospital in Melbourne, 7 days post my second caesar. I was given panadol, volatarin, and endone post-op, and sent home with endone. My baby formed a good latch initially but had a very hearty appetite and I was forced to supplement before my breast milk came in. It came in on the 4th day but not in a high enough supply so I have gone home breat feeding, expressing, and topping up (with a bottle in hospital but now with a supply line). I wanted to limit the amount of supplement in hospital to boost my supply by suckling and positive feed back but was forced to continue top ups due to my baby becomeing jaundiced (but not enough to nned treatment). One of the problems I began facing, particularly by the 4th-5th day is that my baby needed to be woken for every feed and when woken (and had her nappy changed etc.) she would stay sleepy for the whole feed and I had to keep stimulating her but it was having minimal effect. I was getting quite worried coming home from hospital and thought maybe I should check up the side effects of endone in case that was making her drowsy (because her blood bilirubin levels weren't enough to explain it). I had my last dose of endone the second night before leaving hospital and since I have been home and not on the endone, my baby has now become more normal in her feeding patterns - waking properly for feeds and then going back to sleep contented. I feel she is now much more alert. I'm not sure if it is endone related but I was not warned of such possible side effects in hospital and would have opted to take it less if I had been told so.

Joy Johnston said...

Thankyou MeredithC for telling your story. I think it's very likely that your baby's difficulties with breastfeeding are directly related to Endone.

Anonymous said...

Hi there,

I just wanted to comment on this post as I am due for a c section in a few weeks (due to a placenta praevia) and I was told by the private hospital where I am due to give birth that Endone was routinely given to women after birth for pain management. I was very shocked to hear this as I had an awful reaction to the drug after taking it a year ago following a laparoscopy. I suffered from panic attacks and hallucinations and would have certainly harmed myself if I was alone. Speaking with other people who were prescribed the drug after surgery, I realised that I was not alone and quite a few people suffer side effects, that are easily dismissed by doctors as they are not physical. It took me a few weeks to recover from the drug (I was feeling very anxious after this episod) and I just can't believe that this drug is so routinely prescribed to mums and passed on to the baby via breastfeeding. I told the hospital that I preferred pain than experiencing this again - can you confirm if there is a safer alternative for the baby without knocking down the mum? I believe that every mum would rather experience a higher level of pain than taking this awful drug if they knew the side effects on the bub.

Joy Johnston said...

Hi Anonymous
You will need a plan for analgesia (pain relief) after a caesarean operation. With your history as you have described it, I suggest you ask the obstetrician and anaesthetist to prescribe pain relief that does not include codeine. This could be a patient controlled morphine drip for 12-24 hours, followed by regular doses of panadol and voltaren. You can have codeine listed as an allergy, as you understand that you have experienced an adverse reaction to it. I suggest you download a reliable article about ultra rapid codeine metabolisers and take it with you when you go to hospital for the birth of your baby. Do not take Endone, Panadeine, Panadeine Forte or other preparations with codeine. Go to if you are unsure about a drug.
All the best for the birth.

Anonymous said...

I am 37 weeks pregnant and have suffered from 32 weeks with severe back pain and cramps in my pelvis and legs, I have been in hospital every week since 32 weeks, the Midwives don't seem to interested in getting to the root f the pain and just want to hand out Endone. They wanted me to take daily for my pain relief at 2 weeks, but I refused, being allergic to opiods and having 3 children at home it was just not an option. But on reading what effect it can have on an unborn baby put me off as well. I don't understand why this drug is being used as much as it is in our local hospital, I got the feeling it was easier for the midwives to have every doped up for the night and then send you home with the stuff. I am being induced in two days and was offered a script for Endone again for pain relief which I refused. Can I complain to y local health authority, as it seems a little wrong to be pushing this drug onto pregnant women.

Joy Johnston said...

Dear Anonymous
Please speak to the doctor(s). Tell her/him your concerns about using Endone and any other narcotic drugs. The midwives can only give you what is prescribed by a doctor when you are in hospital.
It's four years since I wrote this post, and as far as I am able to discern the use of narcotics for pain management in pregnancy, labour and postnatally has not decreased.