What antibiotics are safe for use during breastfeeding?

From the Guidelines

Breastfeeding mothers can safely use antibiotics such as amoxicillin, azithromycin, and cefuroxime, as they have established safety profiles and transfer into breast milk in very small amounts. When prescribing antibiotics to breastfeeding mothers, healthcare providers typically choose medications with short half-lives and poor oral bioavailability in infants 1. The safety of an antibiotic during breastfeeding depends on factors such as the infant's age, health status, and the specific infection being treated. Some key points to consider when selecting antibiotics for breastfeeding mothers include:

• Penicillins (amoxicillin, ampicillin) and cephalosporins (cefdinir, cephalexin) are generally considered safe 1
• Macrolides (azithromycin) are also considered safe, but may pose a very low risk of hypertrophic pyloric stenosis in infants exposed during the first 13 days of breastfeeding 1
• Fluoroquinolones and chloramphenicol should be avoided due to potential risks to the infant's developing systems 1
• Mothers should always inform their healthcare provider that they are breastfeeding before starting any medication, and should watch for potential side effects in their infant such as diarrhea, rash, or changes in feeding patterns while taking antibiotics. It's worth noting that the most recent and highest quality study 1 suggests using oral amoxicillin/clavulanic acid in breastfeeding patients with hidradenitis suppurativa who require systemic antibiotics.

From the FDA Drug Label

Nursing Mothers Limited published data based on breast milk sampling reports that clindamycin appears in human breast milk in the range of less than 0.5 to 3. 8 mcg/mL. Clindamycin has the potential to cause adverse effects on the breast-fed infant's gastrointestinal flora. If oral or intravenous clindamycin is required by a nursing mother, it is not a reason to discontinue breastfeeding, but an alternate drug may be preferred Monitor the breast-fed infant for possible adverse effects on the gastrointestinal flora, such as diarrhea, candidiasis (thrush, diaper rash) or rarely, blood in the stool indicating possible antibiotic-associated colitis

• Clindamycin is not absolutely safe for breastfeeding, as it may cause adverse effects on the infant's gastrointestinal flora.
• The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for clindamycin and any potential adverse effects on the breast-fed child.
• Monitoring of the breast-fed infant for possible adverse effects is recommended 2.

From the Research

Safe Antibiotics for Breastfeeding

• The use of most antibiotics is considered compatible with breastfeeding, as long as the pharmacokinetic profile of each drug is observed to ensure the resolution of the maternal infection and the safety of the infant 3, 4.
• Penicillins, aminopenicillins, clavulanic acid, cephalosporins, macrolides, and metronidazole at dosages at the low end of the recommended dosage range are considered appropriate for use for lactating women 4.
• Fluoroquinolones should not be administered as first-line treatment, but if they are indicated, breastfeeding should not be interrupted because the risk of adverse effects is low and the risks are justified 4.
• It is essential to choose the drug that appears in the least concentration in breast milk, and all infants should be monitored for uncharacteristic symptoms and signs 5.

General Principles

• The necessity of prescribing to breastfeeding mothers should be questioned, and the advantages and disadvantages should be carefully assessed for both mother and baby 5.
• The use of drugs with short half-lives minimizes the risk of accumulation, and aiming to avoid breastfeeding when milk drug concentrations are at their peak is recommended 5.
• Advising the administration of medication immediately following a breast feed is the safest option for the baby, but this is not true for all drugs 5.

Specific Antibiotics

• Cefotaxime and Ceftriaxone have short half-lives, which minimizes the risk of accumulation in breast milk 5.
• Metronidazole is considered suitable for use during breastfeeding, but it is considered inferior for the treatment of Clostridium difficile infection 6.
• Vancomycin and fidaxomicin are considered antibiotics of choice for the treatment of Clostridium difficile infection 6.