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Knowledge, attitudes and practices of health professionals and women towards medication use in breastfeeding: A review
International Breastfeeding Journal volume 6, Article number: 11 (2011)
Many breastfeeding women require and regularly take medicines, especially those available over-the-counter, and the safe use of these is dependent on the advice provided by health professionals such as general practitioners and pharmacists. The primary aim of this review therefore, was to investigate the literature relating to health professionals' and women's knowledge, attitudes and practices towards medication use and safety in breastfeeding. The limited literature that was uncovered identified that general practitioners and pharmacists have poor knowledge, but positive attitudes, and variable practices that are mostly guided by personal experience. They tend to make decisions about the use of a medicine whilst breastfeeding based on the potential 'risk' that it poses to the infant in terms of possible adverse reactions, rather than its 'compatibility' with breast milk. The decision-making process between health professionals and women is usually not a negotiated process, and women are often asked to stop breastfeeding whilst taking a medicine. Women, in turn, are left dissatisfied with the advice received, many choosing not to initiate therapy or not to continue breastfeeding. Some directions for future research have been suggested to address the issues identified in this critical area. This review is important from a societal perspective because many breastfeeding women require and regularly take medications, especially those available without prescription, and the safe use of these is dependent on the advice provided by health professionals, which is ultimately influenced by their knowledge, attitudes and practices. However, there is an absence of high quality evidence from randomised controlled trials on the safety of medications taken during breastfeeding, which naturally would hinder health professionals from appropriately advising women. It is equally important to know about women's experiences of advice received from health professionals, and whether there is consistency between recommendations made across resources on medication safety in breastfeeding, in order to gain a full understanding of the issues prevalent in this area of practice.
In July-October 2010, keywords (e.g. health professionals, doctors, nurses, pharmacists, lactation, breastfeeding, medication, medicine, knowledge, attitude/s, practice/s, behaviour/s) were used, either separately or in combination, to search databases such as Ovid, Pub Med, International Pharmaceutical Abstracts and Google Scholar. The search was restricted to articles published on primary research data, in English, and from 1990 onwards. The same keywords were used to search relevant journals such as BMC Women's Health, Medical Journal of Australia, International Breastfeeding Journal and Journal of Human Lactation. The reference lists of relevant articles retrieved from these journals were hand-searched for additional studies.
Thirty-one publications were found that were assessed for relevance to the topic area, 15 of which were not within the scope of this review - 13 that did not investigate health professionals' breastfeeding knowledge, attitudes or practices in the context of prescribing medication for women [1–13]; one that did not determine women's experiences with receiving advice from health professionals on medication use and safety in breastfeeding ; and another that was a review of primary research data .
Tables 1, 2 and 3 show the 17 publications that were critiqued [16–32]. These reported on studies that mostly used cross-sectional designs; generally had low response rates (RRs); and were undertaken in Australia, Canada, Israel, The Netherlands, USA and United Kingdom (UK), and whose findings therefore cannot be generalised to other settings.
Table 1 details 11 studies - seven that have been conducted with health professionals only [17, 18, 21, 26, 28, 31, 32] (where references 17-18 and 21 concern the same study); two with pharmacists, general practitioners (GPs) and breastfeeding women together [22, 23] (these concern the same study); another with pharmacists and breastfeeding women ; and one with endocrinologists, family physicians and women . In the four studies that involved health professionals and women [22, 23, 25, 30], only the findings on the health professionals have been detailed, and those associated with the women are shown in Table 2.
Table 2 also highlights nine studies - five with breastfeeding women alone [19, 20, 24, 27, 29]; two with breastfeeding women, pharmacists and GPs together [22, 23] (again, these concern the same study); another with breastfeeding women and pharmacists ; and one with women, endocrinologists and family physicians .
A synthesis of the evidence from these studies is presented below. Individual studies are mentioned, where appropriate, to highlight key points or compare and contrast findings between studies.
No studies were uncovered between 1990-97 on health professionals' knowledge, attitudes and practices towards medication use and safety in lactation. Most of the studies conducted from 1998-2010 are on GPs, also known as family physicians [17, 18, 21–23, 30, 31], with no representation from maternal and child health community nurses, who have an important role in this area given that they interact frequently with mothers in the postpartum and postnatal periods, but at the same time do not have prescribing rights or formal knowledge of pharmacology or medications.
While some GPs have been found to be supportive of medication use during breastfeeding [18, 21, 30], others have unnecessarily advised women to cease therapy whilst breastfeeding [18, 21], or to stop breastfeeding temporarily or permanently [22, 23] as the risks associated with breastfeeding cessation were viewed to outweigh the benefits and risks of medication use . A high percentage have even advised against breastfeeding initiation . This latter and highly unfavourable situation is occurring even when there is adequate safety data to support the use of several medications whilst breastfeeding, ranging from those used to treat acute and minor ailments (e.g. ibuprofen for pain), to those prescribed for chronic and debilitating conditions (e.g. fluoxetine and sertraline for depression, propylthiouracil [PTU] for hyperthyroidism) [23, 30, 33].
Indeed, for medications such as antidepressants, the GP's decision to prescribe them should be arrived at by conducting a risk versus benefit assessment [23, 33], "taking into account factors such as the maturity of the infant, the frequency of feeds and the volume of milk consumed" . The woman's preferences for treatment must also be considered and are equally important; however, only 4% (23/590) of GPs who responded to the survey by Jones and Brown indicated that the woman would be involved in making an informed choice .
In the study by Lee et al, women who received physician advice in favour of breastfeeding were more likely to breastfeed during PTU therapy than formula feed (relative risk: 5, 95% confidence interval: 1-23) . Around 25% of endocrinologists in the same study who responded to case vignettes presented in a postal survey advised against breastfeeding during PTU treatment, but also said they would change their recommendation if the woman expressed the desire to breastfeed. Nevertheless, where a mutual decision to use medication is made, the breastfed infant should be monitored for adverse effects (e.g. sedation, failure to thrive) and if they are suspected, blood samples from the woman and the infant may be taken for laboratory analysis .
Some GPs have even been reported to use pregnancy drug categories for breastfeeding , which means that their recommendations to either continue or stop breastfeeding may be incorrect. However, GPs (and other health professionals such as pharmacists) have acknowledged that it is difficult to stop breastfeeding abruptly despite their recommendations for women to do so [22, 23].
It appears that incorrect recommendations are being made mainly because of poor self-reported  or actual [30–32] knowledge, which has been found to be influenced by frequency of contact with women [31, 32], as well as health professionals' personal or partner experience of breastfeeding their own children, although the latter may place them in a better position to handle breastfeeding and medication related problems [22, 23]. For example, in a mail survey of 265 pharmacists practicing in community pharmacies in Nebraska, United States of America (USA), it was found that for treating insomnia, 10% of the respondents recommended diphenhydramine (contraindicated in lactation), guaiphenesin (no data on safety) and dextromethorphan (might contain ethanol) for breastfeeding women . In other studies, only 34% of pharmacists  and 47% of physicians  knew that most women taking antiepileptic medicines can safely breastfeed; 66% of pharmacists and 54% of physicians thought they were unsafe or were unsure about their safety.
Similarly, in the study by Schrempp, Ryan-Haddad and Gait, some pharmacists recommended alternative, non pharmacologic treatments first, such as bran cereal or prune juice as natural laxatives for constipation; saline nasal drops, cool mist vaporiser or echinacea for colds; and dietary limitations, including eating smaller meals, for heartburn . While such recommendations are safe, reasonable and are usually trialled before prescribing medications, they work best in conjunction with pharmacological measures and may only provide temporary relief of the breastfeeding woman's symptoms. In addition, pharmacists in this study who had practiced for less than 30 years more highly valued continuing education (CE) on medication safety and use in breastfeeding than pharmacists who had practiced for more than 30 years , but were either not asked, or did not indicate, their preference(s) for formats of CE.
Poor knowledge of medication use in breastfeeding may also extend to inadequate medical history-taking skills, where important information is not gleaned from the breastfeeding woman by the health professional. Ronai et al found that 58% of pharmacists surveyed never asked women if they were breastfeeding ; however, this study was carried out with a small sample of participants. While Jones and Brown reported that 50% of pharmacists said they would ask a woman with a baby how she was feeding before prescribing an over-the-counter (OTC) medication (available without prescription) for her, many pharmacists stated that it was the responsibility of the woman to inform them that she was breastfeeding when purchasing a medication, with two pharmacists commenting that questions of this nature are too personal and cannot be asked in the pharmacy environment .
In the same study, only 22% of GPs surveyed said that they would ask the mother of a 'toddler' (taken to be older than 12 months) if she was breastfeeding before prescribing medication for her [22, 23]. This is concerning, given that women may continue to breastfeed after their child turns 12 months old - the minimum age recommended in Australia  - meaning that both GPs and pharmacists may not be considering that mothers of children who are no longer newborn may be breastfeeding. Individual comments provided by GPs and pharmacists in the study by Jones and Brown "gave an impression of ambivalence to breastfeeding, particularly as the child got older and that they would advocate artificial milk formula as a substitute" .
This attitude, as seen from the woman's perspective, is reflected in the comment below, made by a mother in the study by Jones and Brown . Indeed, the World Health Organization (WHO) and United Nations International Children's Emergency Fund (UNICEF) recommend exclusive breastfeeding for six months, with introduction of nutritionally adequate, safe and appropriate complementary foods (to prevent iron deficiency) and continued breastfeeding thereafter.
"In my experience, the medical profession do not expect breastfeeding beyond 9 to 12 months. Beyond that they never ask if you are feeding and act surprised when you point it out"  (p. 553).
On the other hand, some GPs practicing in Australia have been reported to feel confident about medication use in breastfeeding women . However, despite their self-reported confidence, in a postal survey of GPs in Victoria, respondents had concerns about medico-legal issues: 76% of GPs rated the possible risk of litigation as "important/very important" . Similarly, it has been found that some pharmacists feel comfortable advising breastfeeding women and are cautious with their recommendations to them . In this study by Ronai et al, pharmacists believed that it is better to stop breastfeeding than risk exposing an infant to a potentially harmful medication . They also commented that there are contradictory and inconsistent resources available on medication use in lactation, as have GPs who have also indicated the need for a reliable internet database (that includes information on complementary medicines), or information via their software prescribing program, [17, 18, 21] instead of having to rely on pharmaceutical companies for drug information that is usually "over cautious" .
In this Victorian survey with GPs, several participants reported that advice their patients had received from community pharmacists sometimes conflicted with their own decisions, unnecessarily resulting in patient alarm . Community pharmacists in these scenarios had questioned GPs' decisions to prescribe fluconazole or metronidazole. It was also found that some GPs were referring to pharmacists at the Royal Women's Hospital (RWH), and held these pharmacists, or others working elsewhere, in high esteem:
"The pharmacist at RWH [is] excellent - gives various sources of information and good opinion re: overall management ..." (p. 5).
"Depression. Efexor [venlafaxine]. Checked with Box Hill Hospital pharmacist via phone. Got the most reliable and up to date info ..."  (p. 5).
If pharmacists, particularly those working in community settings, have insufficient knowledge and they are providing information to patients that 'challenge' GPs' decisions, this is a dilemma. If pharmacists continue providing inconsistent information and if their knowledge gaps are not met, they could potentially discredit themselves as medicine experts. Also, as some information provided by pharmacists is based on "personal decision", as demonstrated in the comment below by a participant in the aforementioned study , it could potentially be harmful to women.
"Depression. Most information is 'personal decision' i.e. no good evidence. Reasons for decision - local psychiatrist opinion, RWH pharmacist's opinion ..."  (p. 5).
These findings from the Victorian survey [17, 18, 21] should be considered in the context of having an unrepresentative sample. The invited sample had more female GPs than males (because more females in Australia are involved in shared maternity care than male GPs), the proportion of female to male respondents is higher than in the invited sample, and those who did respond probably had a greater interest in the topic than non-responders. Taken altogether, it is highly likely that the results in this survey underestimate the true situation.
No studies were uncovered in 2006 and between 2009-10 on women's knowledge, attitudes and practices towards medication use and safety in lactation. Most of the limited studies undertaken with breastfeeding women from 1990-2008 show that some were inappropriately advised by a health professional to unnecessarily cease or not even commence breastfeeding during the pharmacotherapy [20, 22, 23, 30], and if they hadn't received advice, they still had the same doubts or were more reluctant to take medications during breastfeeding than during pregnancy . Some of these findings, however, may not be relevant anymore as the work was undertaken up to 20 years ago [20, 24], and the study with women from Oslo did not have adequate representation, with a lower response rate from women living in high socioeconomic conditions than those from lower socioeconomic environments . Other work [19, 29], which includes one study that was recently conducted , is also exclusively or mostly limited to women of white ethnicity.
Regardless of these limitations, a proportion of women in some of the studies consequently stopped either breastfeeding or medication use to avoid combining the two [20, 22, 23, 27] or did not breastfeed at all , and others took a measure to minimise exposure to the child (e.g. expressing breast milk beforehand, breastfeeding just before medication intake) . However, due to dissatisfaction with the advice they received, some women either did not commence the medication that was prescribed for them or did not stop breastfeeding [20, 22, 23].
In the study by Jones and Brown, it was found that only 28% of breastfeeding women were satisfied with the advice given by their GP and pharmacist, compared to 31% who were dissatisfied [22, 23]. Moreover, 6% of women said they received conflicting advice, and of the 54% of women who had bought OTC medications in a pharmacy, only 11% were asked if they were breastfeeding by the pharmacist or pharmacy assistant [22, 23]. This study, however, involved women with a high socioeconomic status and education level who were likely to breastfeed for longer, and their responses may not represent the wider population [22, 23]. Further, the survey instrument developed in this study did not have the option of "Don't know" or "Can't remember" in order to counteract potential memory recall bias . Similarly, in the study by Merlob, Stahl and Kaplan, only 9% of women interviewed on discharge from the maternity ward were counselled by the hospital/private pharmacist and always at woman's initiative; a lesser proportion (8%) had read the information leaflet accompanying the medication .
This is concerning, as pharmacists are responsible for providing accurate medication-related advice and information to the community, and it is their duty of care to check, during this process, if a woman is breastfeeding or pregnant if she is of childbearing age. It is also unsafe for pharmacists and other health professionals to assume that breastfeeding women are not likely to consider medication use, given that Schirm et al found that 66% of all breastfeeding women had used medications; albeit less frequently than non-breastfeeding women (80%) .
Resources on medication safety in breastfeeding
In the only study that has been conducted to assess resources on medication safety in breastfeeding  (Table 3), ten different resources available to health professionals in the USA were investigated (Table 4) to evaluate 14 medications used to treat conditions such as bacterial and viral infections, hypertension, Type 2 diabetes mellitus and depression. Certainly, such resources are widely used by physicians, but less so by specialists such as endocrinologists, who prefer to conduct literature searches when unsure of the compatibility of a medicine with breastfeeding .
The advantages and disadvantages of each resource were described by Akus and Bartick, who concluded that recommendations on the safety of all of the medications in breastfeeding varied considerably, and were not based on the most recent research . Two of the sources appraised were databases used in two community pharmacy chains - Lexi-Comp and the Physician's Desk Reference - that gave an alternative recommendation for medications thought to be safe at least 75% of the time . Furthermore, these databases usually recommended early cessation of breastfeeding.
Certainly, the lack of, and inconsistency between, such information, could be an underlying and determining factor for the poor knowledge and variable practices displayed by health professionals towards medication use in breastfeeding women.
Even though all the studies reported that there is a lack of information on medication safety in breastfeeding for health professionals , and the information available is inconsistent [16, 17, 26], in the Victorian study, most GPs were confident about medication use in breastfeeding women , and in the Rhode Island study, most pharmacists felt comfortable advising breastfeeding women . This mismatch between available information, and comfort and confidence, needs to be further explored in future research. It is possible that some health professionals who have personally experienced breastfeeding have better knowledge and therefore comfort and confidence, leading to more appropriate decisions regarding breastfeeding and medication issues. However, "personal experiences cannot necessarily be generalised to patients and should not be relied upon"  (p. 28).
The lack of a uniformly accepted source of information leads to conflicting advice which can have harmful consequences for women . This can also result in public distrust, discontent , and loss of faith towards health professionals, particularly pharmacists, who are responsible for providing medication advice, and may ultimately lead to breastfeeding women seeking advice from people who are inappropriately qualified.
Further research is required to determine whether this situation is currently occurring, as well as to scope, to a greater extent, what the educational needs of women from a range of ethnic and socioeconomic backgrounds are with respect to medication use in breastfeeding. In particular, in-depth studies are required to understand the views of women who are considering taking medicines which are regarded as risky, such as antidepressants [19, 29]. Similarly, women's views about the use of other substances by breastfeeding women, such as tobacco, alcohol and caffeine, as well as illicit drugs, needs to be looked into.
At this stage however, as a result of the inconsistent information available for all stakeholders, pharmacists and other health professionals seem to be relying on their own personal experience (or a lack of it), resulting in variable practices that may mean recommending the cessation of breastfeeding and thus being overly cautious. Consequently, the infant would be deprived of the benefits that breast milk confers on growth, development, health and nutrition. Women who stop breastfeeding may perceive themselves as not being a 'good mother' which can negatively affect their self-esteem.
However, even if consistent and better quality information did become available, health professionals need to be rigorously trained on communicating with breastfeeding women via the identification, through further educational research, of continuing education formats they prefer e.g. didactic or flexible delivery methods such as online education programs. Indeed, in the study by Jones and Brown, GPs and pharmacists indicated that they would prefer a distance learning package on this topic, whereas pharmacists were more enthusiastic about interprofessional workshops ; however, this work was done 10 years ago. More recently, Long and Montouris reported that physicians preferred web-based or didactic material , but a more in-depth investigation in to health professionals' current educational needs in this area is required.
Health professionals also need to actively seek information about the breastfeeding status of women, then consider the risk of damage from the medications and the effects of the illness itself, as well as the risks of not breastfeeding, on both the woman and the baby prior to prescribing. Finally, health professionals have an obligation to extensively and adequately inform breastfeeding women about the safety of medications and their possible side effects, and to provide alternative options in circumstances where medications cannot be used, or if the mother chooses not to initiate therapy, so that more women are satisfied with the advice given to them.
The limited literature available indicates that health professionals have poor knowledge, as well as positive attitudes and variable practices that are mostly guided by personal experience, towards medication use in breastfeeding women. In turn, women are left dissatisfied with the advice provided by health professionals. Further research is needed to investigate this phenomenon. Resources available for health professionals on medication safety in lactation also need to be reviewed and updated to remove inconsistencies and reflect recent evidence as well as the experiences of expert practitioners in this area.
SH graduated from Monash University (BPharm(Hons) in 2001 and PhD in 2007) and was appointed to the position of Lecturer in 2009 at the Faculty of Pharmacy and Pharmaceutical Sciences. She is an Early Career Researcher in Pharmacy Practice with research experience and expertise in professional practice, education and medication safety and use, particularly in the area of palliative care service delivery in the primary care setting.
SH also has a strong research interest in women's health, and has recently worked on a collaborative project investigating the knowledge and attitudes of women, and the knowledge and practices of pharmacists, towards the emergency contraceptive pill that is available from pharmacies in Australia without prescription. She is currently involved in a project that will result in the production of weight management guidelines specific to women for pharmacist use in Australia, and looks forward to designing a project that will investigate gaps in Australian pharmacists', GPs' and women's knowledge, attitudes and practices towards medication use and safety in lactation.
United Nations International Children's Emergency Fund
United States of America
Royal Women's Hospital
World Health Organization
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This literature review was undertaken for the purposes of an undergraduate elective that was offered at the Bachelor of Pharmacy course at Monash University, Australia. The authors declare that there are no sources of funding to acknowledge.
The authors declare that they have no competing interests.
SH conceived the research question to be addressed via this literature review, for the purposes of an undergraduate elective that was offered in the Bachelor of Pharmacy course at Monash University, Australia during July-October 2010. ND, an undergraduate student at Monash University, conducted the literature review, then drafted a report that was submitted for assessment by SH and the unit coordinator of the research elective. SH acted as ND's supervisor for the research elective and prepared the manuscript based on the report she produced. Both authors have read and approved the final manuscript.
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Hussainy, S.Y., Dermele, N. Knowledge, attitudes and practices of health professionals and women towards medication use in breastfeeding: A review. Int Breastfeed J 6, 11 (2011) doi:10.1186/1746-4358-6-11
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