Tramadol use while Breastfeeding
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Medically reviewed on Oct 2, 2018
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 that has been given to newborn infants for analgesia. A study of breastfeeding in breastfed newborn infants found no adverse effects attributable to tramadol. Although tramadol is unlikely to adversely affect nursing infant, the U.S. Food and Drug Administration recommends against the use of tramadol during breastfeeding. If tramadol is used, 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 (M1). The capacity of preterm and newborn infants to metabolize tramadol to O-desmethyltramadol is limited.
Maternal Levels. The manufacturer reports that in the 16 hours following a 100 mg intravenous dose of tramadol, the cumulative excretion into breastmilk was 100 mcg of tramadol and 27 mcg of M1. No further details are provided.
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 (95% CI 681 to 815 mcg/L) and of its active metabolite, O-desmethyltramadol, was 203 mcg/L (95% CI 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 0.93% (extensive metabolizers) and 0.47% (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.
In a study in China, women with a scheduled cesarean section were randomized to receive intravenous patient-controlled analgesia with either sufentanil or tramadol. Postpartum prolactin levels were higher in the tramadol group (348 mcg/L) than in the sufentanil group (314 mcg/L). The onset of lactation was sooner in the tramadol group (21.4 hours) than in the sufentanil group (25.1 hours). Both of these difference were statistically significant. Note that injectable tramadol is not available in the United States.
Alternate Drugs to Consider
1. Palmer GM, Anderson BJ, Linscott DK et al. Tramadol, breast feeding and safety in the newborn. Arch Dis Child. 2018;103:1110-3. PMID: 29599166
2. United States Food and Drug Administration. FDA Drug Safety Communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. 2017;April 20. https://www.fda.gov/Drugs/DrugSafety/ucm549679.htm
3. 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
4. Kmetec V, Roskar R. HPLC determination of tramadol in human breast milk. J Pharm Biomed Anal. 2003;32:1061-6. PMID: 12899994
5. 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
6. 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
7. 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
8. 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
9. 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
10. Chi X, Li M, Mei W et al. Comparison of patient-controlled intravenous analgesia with sufentanil versus tramadol in post-cesarean section pain management and lactation after general anesthesia - a prospective, randomized, double-blind, controlled study. J Pain Res. 2017;10:1521-7. PMID: 28740418
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