Benefit should outweigh risk

US FDA pregnancy category: Not formally assigned a pregnancy category

Comments: Prolonged use of opioids during pregnancy can result in physical dependence in the neonate; women should be advised of the risk of neonatal abstinence syndrome and ensure that appropriate treatment will be available.

Codeine has been shown to be embryolethal and fetotoxic in the hamster, rat, and mouse at doses of approximately 2 to 4 times the maximum recommended human dose. Maternally toxic doses (7 times the maximum recommended human dose) were associated with evidence of resorptions and incomplete ossification, including meningioencephalocele and cranioschisis. In the rabbit model, embryotoxicity and fetotoxicity were not observed. Codeine rapidly crosses the placenta. Neonatal codeine withdrawal has occurred even in infants whose mothers were taking codeine at cough suppressant doses for as little as ten days prior to delivery. The Collaborative Perinatal Project monitored 65 first trimester exposures to brompheniramine. Malformations were reported in 10 infants, a statistically significant association. In another 6509 live births, 172 mothers were exposed to Dimetapp (brompheniramine, phenylephrine and phenylpropanolamine). Five infants were born with congenital abnormalities resulting in a somewhat higher frequency than normal. There are no controlled data in human pregnancy.

Chronic use of opioids may cause reduced fertility; it is unknown whether these effects are reversible.

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Use is not recommended

Excreted into human milk: Yes (codeine) Yes (phenylephrine) Unknown (brompheniramine)

Comments: Breastfeeding is not recommended when taking codeine due to the risk of serious adverse reactions in breastfed infants.

The US FDA recommends against use of prescription codeine pain and cough medicines in breastfeeding women. This is due to serious reactions in breastfed infants including excess sleepiness, difficultly breastfeeding, or serious breathing problems that could result in death. The US FDA is considering regulatory action for OTC combination cough and cold products containing codeine.

Codeine is present in breast milk and for women with normal codeine metabolism (normal CYP450 2D6 activity) the amount of codeine secreted is low and dose-dependent; however, in women who are ultra-rapid metabolizers of codeine (those with a specific CYP2D6 genotype) higher-than-expected serum levels of morphine, codeine's active metabolite, may be present in their breast milk which may lead to dangerously high serum morphine levels in their breastfed infants. In most cases, a person's specific CYP2D6 genotype is unknown. Several small series and 1 small retrospective study suggest that codeine may be causative in episodes of apnea, bradycardia, and cyanosis in the first week of life. A death of a breastfeed infant due to respiratory depression has been reported; the mother was found to be a CYP450 2D6 ultrarapid metabolizer

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