From the Guidelines
Propranolol is generally considered safe during breastfeeding, with the most recent and highest quality evidence supporting its use in lactating women. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, beta blockers, such as propranolol, are considered safe for use during breastfeeding, with metoprolol being the preferred agent. The guideline recommends monitoring the neonatal heart rate when using beta blockers during lactation.
The relative infant dose of propranolol is estimated to be less than 1% of the maternal dose, which is well below the 10% threshold of concern. Propranolol is also used in infants directly for certain conditions, which further supports its safety profile. However, it's essential to monitor the breastfed infant for potential side effects, such as drowsiness, lethargy, poor feeding, or slow heart rate, although these are rare.
Some key points to consider when using propranolol during breastfeeding include:
- Using the lowest effective dose possible
- Monitoring the breastfed infant for potential side effects
- Extra vigilance may be warranted for mothers taking higher doses (greater than 80mg daily), especially with premature infants or newborns under 2 months who may have reduced ability to metabolize the medication
- Consulting with a healthcare provider before making decisions about medication during lactation, as individual circumstances may vary.
It's also important to note that the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure 1 recommends propranolol as a preferred beta blocker for use during lactation, along with labetalol. Additionally, the 2019 clinical practice guideline for the management of infantile hemangiomas 1 and the 2015 diagnosis and management of infantile hemangioma: executive summary 1 provide further support for the safety of propranolol during breastfeeding.
From the FDA Drug Label
Propranolol is excreted in human milk. Caution should be exercised when propranolol hydrochloride extended-release capsules are administered to a nursing woman Lactation Safety: Propranolol is excreted in human milk, and caution should be exercised when administering it to a nursing woman 2.
- Key Consideration: Caution is advised due to the presence of propranolol in human milk.
- Clinical Decision: Use propranolol with caution in nursing mothers, as the potential risk to the infant cannot be ruled out.
From the Research
Lactation Safety with Propranolol
- The safety of propranolol during lactation has been studied, and the results suggest that it is safe for breastfeeding mothers to take propranolol 3.
- A study published in the Postgraduate Medical Journal found that the milk:plasma ratio of propranolol was less than 1, and the estimated daily intake of propranolol in breast milk by the infant was about 3 micrograms 3.
- The study concluded that there appears to be no reason to advise women receiving propranolol to avoid breastfeeding 3.
- Other studies have focused on the use of propranolol during pregnancy, but have not specifically addressed lactation safety 4, 5, 6.
- One study compared the pharmacokinetics of propranolol and other beta blockers in elderly hypertensive and young healthy subjects, but did not address lactation safety 5.
- Another study compared the effects of different beta blockers, including propranolol, on survival after acute myocardial infarction, but did not address lactation safety 6.
- A study on metoprolol, a different beta blocker, discussed its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy, but did not address lactation safety with propranolol 7.