Heartburn during breastfeeding

Management of heartburn in pregnant and breastfeeding women involves lifestyle modifications, dietary modifications, non-pharmaceutical remedies and pharmaceutical drugs (1)

• lifestyle and dietary modifications to manage heartburn and dyspepsia during breastfeeding should always be tried first
• if these measures fail to manage symptoms then antacids or alginates can be tried followed by H2-receptor antagonists or PPIs if required (2)
  • is extensive experience of use of antacids during breastfeeding and they are considered first-line options for managing heartburn or dyspepsia.
    • alginates and simeticone are also considered acceptable for use during breastfeeding
  • antacids are usually aluminium, calcium, magnesium or sodium salts and are intended for short-term symptom control
    • these are all found naturally in breast milk. Additional intake of these is unlikely to affect levels in breast milk
    • antacids are considered as non-systemic therapy, and thus are a favourable first line therapy to manage GERD (gastroesophageal reflux disease) during pregnancy (1)
  • antacids, along with alginates and simethicone, have poor oral bioavailability which will limit the amount ingested by the breastfed infant
    • aluminium, calcium, or magnesium are poorly absorbed orally (1)
    • breast milk has lower levels of aluminium than cow’s milk and infant formula
  • maternal alginate absorption is limited and alginates are not significantly metabolised (1)
    • alginates are considered acceptable for use during lactation
• H2-receptor antagonists
  • can be used during breastfeeding
  • famotidine or nizatidine are preferred as smaller amounts pass into breast milk (2)
  • cimetidine is least preferred due to higher levels in breast milk and the potential for drug interactions (2)
• Proton pump inhibitors (PPIs)
  • any PPI can be used during breastfeeding, however omeprazole and pantoprazole are the PPIs of choice as they are excreted into breast milk in very small amounts and have evidence to support their use (2)
    • PPI excretion into breast milk is minimal; furthermore, stomach acid degrades PPIs (1)
      • thus, PPIs may be broken down in the infant’s stomach
        
• Use of H2-receptor antagonists or PPIs - and effect on breast milk production
  • use of H2-receptor antagonists or PPIs may lead to an increase in prolactin levels which can cause galactorrhoea in non-breastfeeding patients
  • clinical significance of this on milk production in those who are breastfeeding is unknown
    • however, where breastfeeding is established this is unlikely to have a significant effect (2)

Reference:

1. Ali RAR, Hassan J, Egan LJ. Review of recent evidence on the management of heartburn in pregnant and breastfeeding women. BMC Gastroenterol. 2022 May 4;22(1):219.
2. NHS Specialist Pharmacy Service (March 5th 2024). Treating heartburn and dyspepsia during breastfeeding