What is the recommended treatment for acute pharyngitis in breastfeeding mothers?

Treatment of Acute Pharyngitis in Breastfeeding Mothers

For breastfeeding mothers with acute pharyngitis, penicillin or amoxicillin is the first-line treatment when Group A Streptococcal (GAS) infection is confirmed, as these antibiotics are safe during lactation and effectively eradicate the pathogen. 1, 2, 3

Diagnostic Approach

• Testing for GAS pharyngitis should be performed using rapid antigen detection test (RADT) and/or culture when symptoms suggest bacterial infection (persistent fever, tender anterior cervical lymph nodes, tonsillar exudates, absence of cough) 1
• Testing is not recommended when viral symptoms predominate (cough, rhinorrhea, hoarseness, oral ulcers) 1
• Positive RADT confirms GAS etiology and justifies antibiotic treatment 1
• A negative RADT with low risk factors for acute rheumatic fever (ARF) typically does not require antibiotic therapy 1

Antibiotic Treatment for Confirmed GAS Pharyngitis

• First-line treatment: Penicillin or amoxicillin for 10 days 1

  • These antibiotics are considered safe during breastfeeding 2, 3
  • Penicillins are excreted in breast milk in very low concentrations, posing minimal risk to the infant 3

• For penicillin-allergic patients: 1

  • First-generation cephalosporins (if not anaphylactically sensitive) for 10 days
  • Clindamycin or clarithromycin for 10 days
  • Azithromycin for 5 days
  • Most macrolides are also considered compatible with breastfeeding 3

Symptomatic Treatment

• Acetaminophen (paracetamol) is the preferred analgesic for breastfeeding mothers with pharyngitis 1, 3, 4, 5
• NSAIDs such as ibuprofen at the lower end of the recommended dosage range are also appropriate for short-term use during lactation 1, 3, 4, 5
• Aspirin should be used cautiously, with low doses (up to 100 mg/day) considered compatible with breastfeeding 3, 4
• Codeine for short-term use is generally compatible with breastfeeding, but observe infant for sedation 3, 4
• Warm salt water gargles may provide symptomatic relief, though formal studies are limited 1
• Topical agents containing local anesthetics (ambroxol, lidocaine, benzocaine) may provide temporary relief 1

Important Considerations

• Adjunctive therapy with corticosteroids is not recommended for pharyngitis 1
• When prescribing medications to breastfeeding mothers: 3, 4, 5
  • Select medications with the lowest risk to the infant
  • Use the lowest effective maternal dose
  • Time medication administration to coincide with the infant's longest sleep interval to minimize exposure

Continuation of Breastfeeding

• Temporary interruption of breastfeeding is generally unnecessary when treating pharyngitis, as most recommended antibiotics and analgesics are compatible with breastfeeding 3, 5
• The health advantages of breastfeeding to infants outweigh the potential risks of maternal medication in most cases 3, 4, 5
• Breastfeeding should continue during treatment to maintain milk supply and provide nutritional and immunological benefits to the infant 1

Follow-up Recommendations

• Routine post-treatment testing is not recommended unless symptoms persist 1
• If symptoms worsen or fail to improve within 48-72 hours, reassessment is warranted 1
• Household contacts of patients with GAS pharyngitis do not routinely require testing or empiric treatment 1