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Dump the Myths, Not the Milk: Medication and Imaging Considerations for Lactating Patients in the Emergency Department

lactation myths with medications and imaging
The challenges in lactation are often compounded by outdated beliefs held by clinicians.  Most of the medications we administer in the emergency department (ED) do not warrant any interruption in expression or feeding of breastmilk. Most imaging we perform in the ED is safe in the lactating patient and likewise does not need interruption. Let us convince you to trash the phrase, “Pump and Dump” in the ED.

Most medications commonly given in the ED are safe in lactation

Evidence suggests medication transfer through breast milk is frequently overestimated, with actual infant exposure typically minimal for most medications commonly prescribed in emergency settings [1]. The majority of medications administered in the ED are compatible with continued breastfeeding or pumping without interruption [2]. The practice of “pumping and dumping” is harmful to infants and lactating adults given the many benefits of lactation [3, 4]. It can cause irreparable disruptions in supply, increased parental burden and stress, and is not medically indicated except in very rare circumstances (chemotherapeutics for example) [3, 4]. When uncertainty exists regarding medication safety during lactation, clinicians should consult evidence-based resources such as LactMed or the LactRx app [iphone] to provide informed recommendations. A brief summary table is provided below for quick reference on some common medications.

Medication ClassSafe in LactationCautions in Lactation
Analgesia
  • Acetaminophen [5]
  • Ibuprofen [6]
  • Opioids in routine doses: Oxycodone [7], Morphine [8], Hydromorphone [9],  Fentanyl [10]
  • ⚠️ Caution in very high doses or prolonged infusions of opioids
  • Data on oxycodone shows no adverse effects attributed to oxycodone in maternal doses up to 60 mg/day (~90 MME/day) [11], which is well within the range of typical short-term ED prescribing for acute pain [12]
Sedative Hypnotics
  • Propofol [13]
  • Ketamine [14]
  • Midazolam [15]
  • Safe to feed when awake
  • ⚠️ Caution in infusions and higher doses of long-acting benzodiazepines
Paralytics
  • Succinylcholine [16]
  • Rocuronium [17]
  • Safe to feed when no longer paralyzed; likely safe to feed even on infusions
Opioid Use Disorder
  • Buprenorphine [18]
  • Methadone [19]
  • Recommended to continue feeding
Antibiotics
  • Penicillins [20]
  • Cephalosporins [20]
  • Macrolides [20]
  • Metronidazole [21]
  • Doxycycline (≤21 days) [22]
  • ⚠️ Trimethoprim-sulfamethoxazole (Avoid in premature, ill or jaundiced and those with G6PD) [23]
Anti-hypertensives
  • Labetalol [24]
  • Nifedipine [25]
  • Captopril, Enalapril, Benzapril (Lisinopril—less data) [26]
  • HCTZ [27]
  • Furosemide [28]
  • ⚠️ Diuretics may decrease milk supply if dehydrated
  • ❌ ARBs (Losartan) — No safety data and other alternatives are safe [26]
Antidepressants
  • Sertraline [29]
  • Paroxetine [30]
  • Fluoxetine [31]
  • Citalopram [32]
  • Do not stop an effective antidepressant because of lactation. Risk of depression relapse outweighs the small differences in milk transfer.
  • ⚠️ Bupropion (case reports of infant seizures without causal link) [33]
  • ❌ Doxepin (case reports of infant respiratory depression, hypotonia) [34]
Anticonvulsants
  • Carbamazepine [35]
  • Valproic acid [36]
  • Phenytoin [37]
  • Lamotrigine [38]
  • ⚠️ Levetiracetam (levels can be high, monitor for somnolence) [39]
  • ⚠️ Topiramate (case reports of infant somnolence) [40]
  • ❌ Phenobarbital (Avoid due to high infant exposure and sedation risk) [41]

Most Imaging Performed in the ED is Safe in Lactation

Radiation Exposure

Radiation exposure from diagnostic imaging we typically use in the ED (CT, x-ray) is minimal and there is no need to interrupt nursing/pumping [42].

IV contrast

Iodinated and gadolinium contrast agents are safe and do not require interruption of breastfeeding [43]. Read more in the American College of Radiology 2025 ACR Manual on Contrast Media (start at page 94).

In suspected pulmonary embolism (PE), CT pulmonary angiography (CTPA) is preferred over V/Q scan in lactating patients due to contrast safety (no breastfeeding interruption required), speed and availability, and high rates of indeterminate V/Q scans requiring subsequent CTPA [43, 44].

Exception: In the rare circumstance where contrast is contraindicated (such as anaphylaxis) and a radioactive tracer is indicated (V/Q scan with Tc-99m MAA), the radioactivity does warrant separation from both patient contact and milk for a period of time determined by the rate of decay of the specific agent [45]. Keep expressed milk stored appropriately until radioactivity has been able to decay then it’s safe to feed [46].

References (AMA Format)

  1. Nauwelaerts N, Macente J, Deferm N, Bonan RH, Huang MC, Van Neste M, et al. Generic workflow to predict medicine concentrations in human milk using physiologically-based pharmacokinetic (PBPK) modelling—a contribution from the ConcePTION project. Pharmaceutics. 2023;15(5):1469. doi:10.3390/pharmaceutics15051469
  2. Premer C, Caruso K. Safety profile of the most ordered medications for breastfeeding patients in the emergency department. Am J Emerg Med. 2024;80:1-7. doi:10.1016/j.ajem.2024.02.042
  3. Sachs HC; Committee On Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics. 2013;132(3):e796-e809. doi:10.1542/peds.2013-1985
  4. Meek JY, Noble L; Section on Breastfeeding. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2022;150(1):e2022057988. doi:10.1542/peds.2022-057988
  5. Acetaminophen. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  6. Ibuprofen. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  7. Oxycodone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  8. Morphine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  9. Hydromorphone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  10. Fentanyl. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  11. FDA drug label. Food and Drug Administration; 2024-2025.
  12. Zhu W, Chernew ME, Sherry TB, Maestas N. Initial opioid prescriptions among US commercially insured patients, 2012-2017. N Engl J Med. 2019;380(11):1043-1052. doi:10.1056/NEJMsa1807069
  13. Propofol. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  14. Ketamine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  15. Midazolam. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  16. Succinylcholine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  17. Rocuronium. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  18. Buprenorphine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  19. Methadone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  20. Spencer JP, Thomas S, Trondsen Pawlowski RH. Medication safety in breastfeeding. Am Fam Physician. 2022;106(6):638-644.
  21. Metronidazole. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  22. Doxycycline. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  23. Trimethoprim-sulfamethoxazole. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  24. Labetalol. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  25. Nifedipine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  26. Park K. Management of women with acquired cardiovascular disease from pre-conception through pregnancy and postpartum: JACC Focus Seminar 3/5. J Am Coll Cardiol. 2021.
  27. Hydrochlorothiazide. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  28. Furosemide. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  29. Sertraline. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  30. Paroxetine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  31. Fluoxetine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  32. Citalopram. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  33. Bupropion. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  34. Doxepin. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  35. Carbamazepine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  36. Valproic acid. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  37. Phenytoin. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  38. Lamotrigine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  39. Levetiracetam. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  40. Topiramate. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  41. Phenobarbital. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  42. Naseri M, Shahsavan M, Salahshour F, et al. Effective dose for radiological procedures in an emergency department: a cross-sectional study. Radiat Prot Dosimetry. 2020;189(1):63-68. doi:10.1093/rpd/ncaa013
  43. ACR Committee on Drugs and Contrast Media. ACR Manual on Contrast Media. American College of Radiology; 2025.
  44. Falster C, Hellfritzsch M, Gaist TA, et al. Comparison of international guideline recommendations for the diagnosis of pulmonary embolism. Lancet Haematol. 2023;10(11):e922-e935. doi:10.1016/S2352-3026(23)00181-3
  45. El-Sayed Y, Phillips Heine R, Wharton KR, eds. Guidelines for Diagnostic Imaging During Pregnancy and Lactation. American College of Obstetricians and Gynecologists; 2017.
  46. Leide-Svegborn S, Ahlgren L, Johansson L, Mattsson S. Excretion of radionuclides in human breast milk after nuclear medicine examinations: biokinetic and dosimetric data and recommendations on breastfeeding interruption. Eur J Nucl Med Mol Imaging. 2016;43(5):808-821. doi:10.1007/s00259-015-3286-0
By |2026-03-24T13:23:44-07:00Mar 26, 2026|Ob/Gyn, Radiology, Tox & Medications|
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SAEM Clinical Images Series: Perioral Facial Swelling

The patient is a 40-year-old male with no significant past medical history who presents to the Emergency Department with perioral rash and swelling. He had been in his normal state of health the day before and woke up in the morning with an itchy rash around his mouth. He denies lip, tongue, or intraoral swelling, throat itching or sensation of throat swelling, trouble swallowing, or swelling or itching of any other part of his face. The rash has not changed locations nor has it spread beyond the perioral area. He noted a similar episode once or twice before in his life, which had improved with taking diphenhydramine. He denies the presence of a rash or itching on any other part of his body, wheezing, shortness of breath, GI symptoms, or dizziness. He denies any exposure to new foods or medications, and he has not been exposed to ACE inhibitors nor ARBs. He has no other complaints at this time.

 

Vitals: BP 141/97; HR 88; R 19; T 98.2°F; O2 sat 98% on room air.

General: Awake and alert, no distress, speaking in a clear voice.

HEENT: As shown in the images provided. There is no oropharyngeal swelling. There is no stridor.

Respiratory: Clear to auscultation, no wheezes.

Skin: There is no rash or swelling elsewhere on the patient’s body.

Non-contributory

The patient has been dyeing his facial hair.

Para-phenylenediamine.

Upon further questioning, the patient admitted to applying an “instant hair dye shampoo” to his facial hair the day before presentation. Review of the product ingredients revealed para-phenylenediamine. He later recalled that his previous episodes of peri-oral swelling had occurred after exposure to the same product. Para-phenylenediamine can be found in commercial black and dark brown hair dyes, as well as in henna tattoos. Reactions can range from local erythema and contact dermatitis to bullous dermatitis and significant edema in severely affected patients. Symptoms may appear similar to angioedema and may only be distinguished after careful history identifies hair dye or henna exposure. Initial management is to remove the offending dye or henna with thorough washing. Topical steroids or a short course of oral steroids can be used for severe symptoms. Prevention of exposures in sensitized individuals remains the most important tenet of care. Hair dyes recommend consumers test the dye on a small patch of skin prior to using it, which has been proven to help identify those who will develop a reaction.

Take-Home Points

  • Para-phenylenediamine is a compound found in henna and hair dye that is commonly responsible for adverse skin reactions, but may be under recognized when used for facial hair.

  • Allergic contact dermatitis from this compound may show a range of clinical skin findings and sometimes may mimic angioedema.

  • Mukkanna KS, Stone NM, Ingram JR. Para-phenylenediamine allergy: current perspectives on diagnosis and management. J Asthma Allergy. 2017 Jan 18;10:9-15. doi: 10.2147/JAA.S90265. PMID: 28176912; PMCID: PMC5261844.
  • Krasteva M, Cristaudo A, Hall B, Orton D, Rudzki E, Santucci B, Toutain H, Wilkinson J. Contact sensitivity to hair dyes can be detected by the consumer open test. Eur J Dermatol. 2002 Jul-Aug;12(4):322-6. PMID: 12095875.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2026-03-10T21:10:56-07:00Mar 16, 2026|Allergy-Immunology, SAEM Clinical Images, Tox & Medications|
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