How to Manage Postpartum Pain Medications While Breastfeeding Safely

After giving birth, pain is normal-whether you had a vaginal delivery or a C-section. But if you're breastfeeding, choosing the right pain medication isn't just about feeling better. It’s about keeping your baby safe. Many new parents still hear outdated advice like "pump and dump" after taking any medication. That’s no longer necessary-and in some cases, it’s harmful. The key is knowing which drugs are safe, which to avoid, and how to time them right.

Start with the Safest Options: Acetaminophen and Ibuprofen

The first line of defense for postpartum pain should be acetaminophen and ibuprofen. Both are considered safe during breastfeeding, with very little passing into breast milk. Acetaminophen transfers at just 0.1-1.0% of the maternal dose, and ibuprofen at 0.6-0.7%. These levels are so low that they rarely, if ever, affect the baby. The American College of Obstetricians and Gynecologists (ACOG) and the Academy of Breastfeeding Medicine both list these as first-choice pain relievers for nursing mothers.

You can take them together. In fact, alternating them every 3 hours gives better pain control than using one alone. For example: take acetaminophen at 8 a.m., ibuprofen at 11 a.m., acetaminophen at 2 p.m., and so on. This keeps pain managed without overloading your system or your baby’s. Michigan OPEN’s 2022 guidelines even suggest replacing the first three oral NSAID doses after a C-section with IV Toradol (ketorolac) for faster, more effective relief-without compromising safety.

Avoid Codeine and Tramadol Completely

These two opioids are not safe for breastfeeding. The FDA issued strong warnings in 2017 for codeine and 2018 for tramadol, stating that breastfeeding is not recommended during treatment with either. Why? Because some mothers are "ultra-rapid metabolizers." Their bodies convert codeine into morphine-and tramadol into its active form, M1-much faster than normal. About 1 in 100 Caucasian women fall into this group, and they have no way of knowing unless they’ve had genetic testing.

The results can be deadly. In multiple documented cases, infants developed extreme drowsiness, trouble breathing, or even died after their mothers took standard doses of codeine or tramadol. One 2012 FDA report linked codeine to infant deaths after mothers took just 30 mg. Tramadol has similar risks. Even a single dose can be dangerous. The American Society of Health-System Pharmacists now advises against codeine for breastfeeding mothers regardless of pain level. There’s no safe workaround. Skip them entirely.

If You Need an Opioid, Choose Morphine

Not all opioids are created equal. If acetaminophen and ibuprofen aren’t enough, and you need something stronger, morphine is the safest option. It transfers into breast milk at low levels, and infants absorb less than 1% of what’s passed through milk. That’s because morphine doesn’t get absorbed well in a baby’s gut. Other opioids like hydrocodone, oxycodone, and fentanyl do transfer more and carry risks of infant drowsiness or breathing problems.

Studies show morphine has a relative infant dose (RID) of 8-10%, which is considered low-risk. Oxycodone’s RID is similar but comes with more reported cases of infant sedation. Fentanyl is also used in hospitals right after delivery, but it’s only recommended for short-term use because it can cause temporary breathing suppression in newborns. Always use the lowest effective dose for the shortest time-no more than 4-6 days.

Timing Matters: Take Medication After Feeding

Even safe medications can build up if you take them at the wrong time. For any opioid, take it right after you finish breastfeeding-not before. That gives your body time to break down the drug before the next feeding. Peak levels in breast milk happen 1-2 hours after you take the pill. If you take it before a feed, your baby gets the highest dose.

For example: if you feed at 7 p.m., take your pain pill at 8 p.m. Then wait until 11 p.m. or midnight for the next feed. This simple timing trick cuts your baby’s exposure by more than half. Intermountain Health recommends this approach for all opioid use during breastfeeding. Don’t guess-plan ahead.

Watch for Warning Signs in Your Baby

Even with safe medications, you need to stay alert. Monitor your baby for signs of oversedation:

• Excessive sleepiness (hard to wake for feeds)
• Difficulty latching or sucking
• Weak cry
• Slow or shallow breathing
• Constipation or poor feeding

These signs can appear within hours-or be delayed for up to 24 hours. If you notice any of these, stop the medication and call your doctor. The Breastfeeding Network advises keeping a close watch for at least 24 hours after each dose. Babies under two months are especially vulnerable because their livers and kidneys can’t process drugs as efficiently.

What About Naproxen or Indomethacin?

These are NSAIDs like ibuprofen, but they’re not recommended for breastfeeding. Naproxen stays in your system longer and builds up in breast milk over time. At 24-hour concentrations, it can reach 1.5-2.0% of the maternal dose-higher than ibuprofen. Indomethacin has been linked to kidney issues and bleeding in newborns. Stick with ibuprofen. It clears faster, transfers less, and has decades of safety data.

Don’t Panic About Anesthesia or Short-Term Use

Some mothers still worry that anesthesia or a single dose of pain medicine means they must stop breastfeeding. That’s outdated. The Academy of Breastfeeding Medicine updated its guidelines in 2021 to remove all "pump and dump" recommendations after anesthesia. Studies show that less than 1% of most anesthetics enter breast milk. You can nurse right after waking up. No need to wait 24 hours. The same goes for short-term opioid use-if you’re using morphine or oxycodone correctly, your baby is not at risk.

What’s Next? Genetic Testing and Better Tools

In the future, we might see routine genetic testing for CYP2D6 metabolism before prescribing opioids. Mayo Clinic researchers published a 2023 study showing it’s possible to identify ultra-rapid metabolizers before they’re given codeine. But right now, it’s not standard practice. Until then, the safest rule is simple: avoid codeine and tramadol. Use acetaminophen and ibuprofen first. If you need more, choose morphine, time it right, and watch your baby closely.