From the Guidelines
Breastfeeding is generally safe for mothers taking tuberculosis (TB) medications, as the small concentrations of these drugs in breast milk do not produce toxicity in the nursing newborn. Most first-line TB drugs, including isoniazid, rifampin, ethambutol, and pyrazinamide, are compatible with breastfeeding as they pass into breast milk in small amounts that are not harmful to infants 1. The benefits of both treating the mother's TB and continuing breastfeeding outweigh potential risks, as proper TB treatment prevents transmission to the infant, while breastfeeding provides essential nutrition and immunity.
Key considerations for breastfeeding mothers with TB include:
- Continuing their complete TB treatment regimen while breastfeeding, which typically includes isoniazid (300mg daily), rifampin (600mg daily), ethambutol (15-25mg/kg daily), and pyrazinamide (20-25mg/kg daily) for the initial 2-month intensive phase, followed by isoniazid and rifampin for an additional 4 months 1
- Administering pyridoxine supplementation (25 mg/day) to prevent peripheral neuropathy, as recommended for all women taking INH who are either pregnant or breastfeeding 1
- Ensuring the infant receives prophylactic isoniazid (10mg/kg daily) for at least 6 months if the mother has active TB, along with pyridoxine (vitamin B6) supplementation 1
- Taking medications immediately after breastfeeding to minimize drug concentration in milk at the next feeding
- Regular pediatric follow-up to monitor the infant for any adverse effects or TB symptoms
It is essential to note that while breastfeeding is safe, the drugs in breast milk should not be considered effective treatment for active tuberculosis or latent tuberculosis infection in a nursing infant 1. Therefore, prophylactic measures, such as isoniazid, should be taken to protect the infant from TB. Overall, the most recent and highest quality study 1 supports the safety of breastfeeding for mothers taking TB medications, and this practice should be encouraged to promote the health and well-being of both the mother and the infant.
From the Research
Breastfeeding Safety with TB Medication
- Most antituberculosis drugs appear to be safe for use with breastfeeding, with minimal concentrations excreted in breast milk 2
- The American Academy of Pediatrics (AAP) considers isoniazid, rifampin, ethambutol, streptomycin, kanamycin, and cycloserine to be compatible with breastfeeding 2
- However, there is limited data on the safety of pyrazinamide, ethionamide, and capreomycin during breastfeeding 2, 3
- Breast milk does not contain Mycobacterium tuberculosis bacilli, and only minor, non-toxic quantities of drugs pass into breast milk, making it safe for women with drug-susceptible TB to breastfeed once they are no longer infectious 3
Drug Exposure via Breast Milk
- Infants may be exposed to antituberculosis drugs via breast milk, but the existing data lacks a critical review of published studies 4
- A systematic review of antituberculosis drug concentrations in plasma and milk found that most studies had limitations in sample collection, quantity, timing, and study design 4
- Concerns for potential adverse effects in breastfed infants could be ruled out for bedaquiline, cycloserine/terizidone, linezolid, and pyrazinamide, but adequate studies are needed to cover the scenario in treated mothers, breast milk, and infants 4
General Considerations
- Untreated tuberculosis in pregnancy poses a significant threat to the mother, fetus, and family, and supervised treatment is especially helpful in encouraging adherence 5
- All first-line drugs (isoniazid, rifampicin, ethambutol, and pyrazinamide) have an excellent safety record in pregnancy and are not associated with human fetal malformations 5
- Pyridoxine (vitamin B6) should be added to the drug treatment of tuberculosis in all pregnant women taking isoniazid 5