Notes on using antibiotics while breastfeeding
Overview
Which oral antibiotics are safe to use while breastfeeding?
Most antibiotics are okay during breastfeeding. As a rule of thumb, antibiotics that are safe to give to an infant are generally okay during breastfeeding especially since infants usually have less exposure through breast milk.
Antibiotics
Penicillins and Cephalosporins
American academy of pediatrics (AAP) considers penicillins and cephalosporins to be compatible with breastfeeding. Diarrhea, thrush, and rash have been reported. Macrolides. The AAP considers erythromycin to be compatible with breastfeeding. Because of the low levels of azithromycin and clarithromycin in breast milk and use in infants in higher doses, it would not be expected to cause adverse effects in breastfed infants. Unconfirmed epidemiologic evidence indicates that the risk of hypertrophic pyloric stenosis in infants might be increased by maternal use of macrolide antibiotics during breastfeeding.
Clindamycin
An alternate antibiotic may be preferred. However, if necessary to use oral or intravenous clindamycin while breastfeeding, monitor infant for colitis. Be aware of considerations that may guide which antibiotic to use. For example, quinolones are often thought of as a concern in kids due to cartilage and joint damage in animal studies and considered to be safe during lactation. While tetracyclines are linked to tooth staining when used in children. Point out that the calcium in breast milk might limit absorption of the small amounts of these medications by a nursing infant. And the joint damage seen in quinolone animal studies isn't proving to be a problem in kids.
Quinolones
As we say, the calcium in breast milk might reduce absorption. Avoiding breastfeeding for three to four hours after a dose of ciprofloxacin or four to six hours after levofloxacin or ofloxacin should decrease infant exposure.
- Maternal use of quinolone eye or ear drops presents negligible risk for the nursing infant.
- To substantially diminish the amount of drug that reaches the breast milk after using eye drops, place pressure over the tear duct by the corner of the eye for 1 minute or more, then remove the excess solution with an absorbent tissue.
Tetracyclines
Milk levels are low, and absorption may be limited by calcium in breast milk and protein binding. Avoid prolonged (e.g., > 21 days) or repeated exposure due to theoretical risk of dental staining. Tetracycline and doxycycline compatible with breastfeeding. Either class seems okay if there's not a good alternative, but try to avoid prolonged or repeated courses of tetracyclines.
Metronidazole
May raise questions due to cancer risks in labeling. But this hasn't been seen in nursing infants and the amount in breast milk is usually less than a therapeutic dose for an infant. If a 2 g oral metronidazole dose is needed and moms prefer to be cautious, tell them to "pump and dump" for 12 to 24 hours after the dose to limit the baby's exposure. Lower divided doses seem okay.
- Excretion into breast milk is significant (weight-adjusted infant dose may be as high as 20% of the maternal dose).
- Cases of candidal infections and diarrhea have been reported.
- Some clinicians advise deferring breastfeeding for 12 to 24 hours following maternal treatment with a single 2 g dose of metronidazole. Topical or vaginal use unlikely to be of concern.
TMP/SMX and Nitrofurantoin
Watch for Sulfamethoxazole and trimethoprim (TMP/SMX) or nitrofurantoin therapy for moms breastfeeding a newborn or any infant with a G6PD enzyme deficiency. This is due to concerns of dangerously high bilirubin levels with TMP/SMX or hemolytic anemia with nitrofurantoin.
- Alternate drugs are preferred in mothers of infants under 8 days of age, or infants with G6PD deficiency of any age.
- Sulfamethoxazole and trimethoprim should be avoided while breastfeeding a G6PD-deficient infant.
Aminoglycosides
Oral absorption of aminoglycosides is poor, and milk levels of amikacin, gentamicin, and tobramycin are far less than those achieved when treating newborn infections, so systemic effects are not expected in infants and considered to be safe during lactation. There are no human data available, but milk levels of plazomicin (U.S) are expected to be low.
Carbapenems
Known or expected to be excreted into breast milk in low levels that are not expected to cause adverse effects in breastfed infants. No reported problems in the few cases available. Imipenem-cilastatin and imipenem-cilastatin-relebactam are considered acceptable to use during breasfeeding.
Remind nursing moms using any antibiotic about possible side effects in the baby, such as diarrhea, thrush, yeast diaper rash, and skin rash. When practical, suggest that nursing moms take their antibiotic just before, or immediately after, breastfeeding or right before baby's longest sleep interval especially if the baby is exclusively breastfed.
References
- Drugs and Lactation Database (LactMed). (2006). [online] PubMed. National Library of Medicine (US). Available at: https://www.ncbi.nlm.nih.gov/books/NBK501922.
- Einarson, A. Can we use metronidazole during pregnancy and breastfeeding? [online] Available at: https://www.cfp.ca/content/cfp/46/5/1053.full.pdf
- Lee M, Bozzo P, Einarson A, Koren G. Urinary tract infections in pregnancy. Can Fam Physician. 2008;54(6):853-854.
- Bar-Oz B, et al. Use of antibiotic and analgesic drugs during lactation. Drug Saf. 2003;26(13):925-935.
