Is high dose prednisone (corticosteroid) safe for breastfeeding mothers?

High-Dose Prednisone and Breastfeeding

High-dose prednisone (>20 mg daily) can be used during breastfeeding, but mothers should delay breastfeeding for 4 hours after taking the medication to minimize infant exposure. 1

Safety of Prednisone During Breastfeeding

Dose-Dependent Recommendations

• Low-dose prednisone (≤20 mg daily):

  • Considered completely safe for breastfeeding mothers
  • No waiting period necessary before breastfeeding
  • Amount transferred into breast milk is minimal 1

• High-dose prednisone (>20 mg daily):

  • Still compatible with breastfeeding with proper timing
  • Delay breastfeeding for 4 hours after medication administration
  • Consider discarding milk collected within this timeframe 1

Transfer to Breast Milk

• Infants would ingest less than 0.1% of the maternal dose of prednisone/prednisolone
• This corresponds to less than 10% of the infant's endogenous cortisol production 1
• Nonfluorinated steroids (prednisone/prednisolone) are preferred over fluorinated ones (dexamethasone, betamethasone) for breastfeeding mothers 1

Strategies to Minimize Infant Exposure

1. Timing of medication:

   • Take prednisone immediately after breastfeeding
   • Morning dosing helps synchronize peak drug levels with the longest interval before next feeding 1
   • For doses >20 mg, wait 4 hours before resuming breastfeeding 1, 2

2. Medication selection:

   • Use nonfluorinated steroids (prednisone/prednisolone) rather than fluorinated alternatives 1
   • Consider local rather than systemic administration when possible 1

3. Monitoring:

   • Observe infant for signs of adrenal suppression (though this is rare at typical exposure levels)
   • Premature infants may require additional caution due to reduced capacity to metabolize medications 1

Important Considerations

• Maintaining maternal disease control should be prioritized, as untreated maternal disease may have greater negative impacts than minimal medication exposure through breast milk 1
• The FDA notes that "systemically administered corticosteroids appear in human milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects" 3, 4
• However, the American College of Rheumatology strongly recommends prednisone <20 mg daily as compatible with breastfeeding 1
• The benefits of breastfeeding generally outweigh the minimal risk of corticosteroid exposure, especially when appropriate timing strategies are employed 1, 2

Special Populations

• Premature infants: May have reduced capacity to metabolize medications; consultation with a pediatrician is recommended for individualized guidance 1
• Mothers requiring long-term therapy: Consider steroid-sparing agents that are compatible with breastfeeding (hydroxychloroquine, sulfasalazine) when appropriate 2

Remember that the benefits of breastfeeding are significant, and most medications, including prednisone, can be safely used during lactation with appropriate precautions 2, 5.