Tramadol use while Breastfeeding
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Tramadol Levels and Effects while Breastfeeding
Summary of Use during Lactation
The excretion of tramadol into milk is low and even lower amounts of the active metabolite, O-desmethyltramadol, are excreted. With usual maternal dosage, the amount excreted into breastmilk is much less than the dose given to newborn infants for analgesia. A study in breastfed newborn infants found no adverse effects attributable to tramadol. Tramadol is unlikely to adversely affect nursing infant and is acceptable to use during breastfeeding. However, monitor infants for increased sleepiness (more than usual), difficulty breastfeeding, breathing difficulties or limpness, and contact a physician immediately if any of these occur.
In adults, tramadol has 70 to 100% oral bioavailability and is metabolized to the active O-desmethyltramadol. The capacity of preterm and newborn infants to metabolize tramadol to O-desmethyltramadol is limited.
Maternal Levels. Detectable levels (>12 mcg/L) of tramadol were found in samples of breastmilk collected 10 hours after a 50 mg maternal dose of intravenous or oral tramadol. No other clinical details or milk levels were reported.
One mother was taking oral tramadol 1800 mg daily during pregnancy and postpartum for chronic back pain. On approximately day 3 postpartum (time not specified), the breastmilk concentration of tramadol was 1.8 mg/L.
Seventy-five mothers who were 2 to 4 days postpartum provided 3 milk samples from both breasts during the 6 hours following a dose of 100 mg of oral tramadol after taking at least 4 doses. The average milk concentration of tramadol was 748 mcg/L (range 681 to 815 mcg/L) and of its active metabolite, O-desmethyltramadol, was 203 mcg/L (range 188 to 217 mcg/L). These values translate to an average infant dosage of 112 and 30 mcg/kg daily of the drug and metabolite, respectively. An exclusively breastfed infant would receive maternal weight-adjusted dosages of 2.24% of tramadol and 0.64% of its metabolite. Reanalysis of the data using a population pharmacokinetic approach yielded similar values for tramadol of 2.2% (extensive metabolizers) to 2.6% (poor metabolizers) of the maternal weight adjusted dosage. For the metabolite values were of 0.47% (extensive metabolizers) and 0.93% (poor metabolizers). The dosage excreted in milk represents a maximum of 2.6% of the proposed intravenous newborn dosage.
Infant Levels. An infant was born to a mother who as taking 1800 mg of tramadol daily for chronic back pain. By day 3, the infant was exclusively breastfeeding and a serum concentration was obtained (time not specified). The infant's tramadol serum concentration was 2 mcg/L.
Effects in Breastfed Infants
Seventy-five breastfed infants whose mothers were breastfeeding and taking tramadol 100 mg every 6 hours following a cesarean section were compared to 75 matched infants at 2 to 4 days of age. Forty-nine percent of the mothers taking tramadol and all of the control mothers were taking other opiates (primarily oxycodone) and 61% of and 58%, respectively, also were taking a nonsteroidal antiinflammatory agent (primarily diclofenac). Examination by a pediatrician revealed no difference between the groups using the Neurologic and Adaptive Capacity Score.
Effects on Lactation and Breastmilk
Tramadol can increase serum prolactin. However, the prolactin level in a mother with established lactation may not affect her ability to breastfeed.
A randomized study compared tramadol and naproxen for post-cesarean section pain. Patients received the drugs either on a fixed schedule or as needed. No difference in breastfeeding rates were seen among the groups.
Alternate Drugs to Consider
1. Allegaert K, Rochette A, Veyckemans F. Developmental pharmacology of tramadol during infancy: ontogeny, pharmacogenetics and elimination clearance. Paediatr Anaesth. 2011;21:266-73. PMID: 20723094
2. Kmetec V, Roskar R. HPLC determination of tramadol in human breast milk. J Pharm Biomed Anal. 2003;32:1061-6. PMID: 12899994
3. Hartenstein S, Proquitte H, Bauer S et al. Neonatal abstinence syndrome (NAS) after intrauterine exposure to tramadol. J Perinat Med. 2010;38:695-6. PMID: 20707626
4. Ilett KF, Paech MJ, Page-Sharp M et al. Use of a sparse sampling study design to assess transfer of tramadol and its o-desmethyl metabolite into transitional breast milk. Br J Clin Pharmacol. 2008;65:661-6. PMID: 18294329
5. Salman S, Sy SK, Ilett KF et al. Population pharmacokinetic modeling of tramadol and its o-desmethyl metabolite in plasma and breast milk. Eur J Clin Pharmacol. 2011. PMID: 21394525
6. Seitz W, Kirchner E, Schaps D, Wagner T, Hesch RD. [Endocrine reaction pattern in the course of a one-phase tramadol-N2O combination anesthesia]. Anasth Intensivther Notfallmed. 1982;17:325-31. PMID: 6297329
7. Sammour RN, Ohel G, Cohen M, Gonen R. Oral naproxen versus oral tramadol for analgesia after cesarean delivery. Int J Gynaecol Obstet. 2011;113:144-7. PMID: 21435642
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