Poster Presentation Society of Obstetric Medicine of Australia and New Zealand ASM 2015

Changing prescribing culture – a focus on codeine postpartum (#104)

Karen Whitfield 1 2 , Noor Al-Adhami 1 , Rebecca Kimble 1 3
  1. Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
  2. Pharmacy, University of Queensland, Woolloongabba, QLD, Australia
  3. School of Medicine, University of Queensland, Brisbane, QLD, Australia


To improve safety in breast fed eliminating the prescribing of codeine postpartum.

Concerns have been raised over the use of codeine products during breast feeding after the death of a neonate whose mother was prescribed codeine postpartum. High concentrations of morphine were found in the infant’s blood  attributed to the mother being a CYP2D6 ultrafast metaboliser. 1


Evidence surrounding the safety of codeine and codeine combination products in children, during the postpartum period and specifically for breast fed infants was collated. The evidence was presented to key stakeholders including obstetricians, midwives, safety and quality representatives, nurse unit managers and acute pain team representatives. Postpartum analgesia was discussed and an agreed protocol developed. Training and education sessions were undertaken to obstetric medical and nursing staff.


The evidence that was presented to key stakeholders included:

·         Reports over safety concerns surrounding the use of codeine combination products during breast feeding.

·         Guidelines about the use of codeine in children issued by international regulatory bodies (US Food and Drug Administration and European Medicines Agency).

·         Recommendations from the Australian Medicines Handbook to avoid in breast feeding 2

·         Recommendations from Hale’s Medications and Mothers Milk reporting limited data and a recent re-classification from L3 (limited data - probably compatible) to L4 (limited data - possibly hazardous). 3

Before presenting the evidence to key stakeholders and undertaking training to nursing and medical staff, more than 90% of postpartum women were prescribed a codeine containing product as part of their analgesic regimen.

Post intervention, codeine combination products have now been almost completely eliminated on medication charts for postpartum women (less than 5%).


This study highlights the impact that can be achieved when health care professionals work together to change prescribing culture to enhance patient safety. Evaluating and presenting evidence to stakeholders together with relevant training to medical, nursing and pharmacy staff are all essential to a successful outcome.

  1. Koren G, Cairns J, Chitayat D, Gaedigk A, Leeder SJ Pharmacogenetics of morphine poisoning in a breastfed neonate of a codeine-prescribed mother. Lancet 2006:19;368(9536):704
  2. Australian Medicines Handbook. Codeine – Analgesics. In: Australian Medicines Handbook. Adelaide: AMH Pty Ltd; 2015. p. 50-1.
  3. Hale T and Rowe H Medications in Mothers Milk 1992-2014 16th Ed Hale Publishing