Is prednisone (corticosteroid) safe to use during breastfeeding?

Prednisone Safety During Breastfeeding

Prednisone is generally safe to use during breastfeeding, with doses under 20 mg daily considered compatible with breastfeeding, while doses of 20 mg or higher require discarding breast milk obtained within 4 hours after medication administration. 1

Safety Guidelines for Prednisone During Breastfeeding

• Prednisone at doses less than 20 mg daily (or equivalent nonfluorinated glucocorticoid) is strongly recommended as compatible with breastfeeding 1
• For prednisone doses of 20 mg daily or higher, women should delay breastfeeding or discard breast milk accumulated in the 4 hours following glucocorticoid administration 1
• The American College of Rheumatology strongly recommends this approach to minimize infant exposure while maintaining maternal treatment benefits 1

Pharmacokinetic Considerations

• Systemically administered corticosteroids do appear in human milk but in very low concentrations 2, 3
• The relative infant dose (RID) for methylprednisolone (similar to prednisone) is approximately 0.71% of the weight-adjusted maternal dose, which is well below the generally accepted safety threshold of 10% 4
• Corticosteroid levels in breast milk peak shortly after administration and decline rapidly, which is why discarding milk for 4 hours after higher doses is recommended 4

Potential Concerns and Monitoring

• Theoretical concerns include potential growth suppression, interference with endogenous corticosteroid production, or other untoward effects in the infant 2, 3
• However, clinical evidence suggests that at recommended doses, these risks are minimal compared to the benefits of breastfeeding 5
• For short-term use (such as during an acute flare of disease), the risk to the infant is particularly low 1

Clinical Recommendations

• Maintain disease control with lactation-compatible medications, including prednisone at appropriate doses 1
• For women requiring higher doses of prednisone (≥20 mg daily):
  • Time medication administration to be immediately after breastfeeding 6
  • Discard milk produced in the 4 hours following administration 1
  • Resume breastfeeding after the 4-hour window 1
• For women requiring long-term corticosteroid therapy, the lowest effective dose should be used to minimize infant exposure 7

Balancing Maternal and Infant Needs

• The benefits of breastfeeding generally outweigh the potential minimal risks of prednisone exposure at recommended doses 8
• Effective treatment of the mother's condition is a priority for both maternal and infant well-being 5
• Women with rheumatic and musculoskeletal diseases should be encouraged to breastfeed if they desire and are able to do so, while maintaining disease control with compatible medications 1

Important Caveats

• Individual factors such as infant age, maternal dose, frequency of administration, and duration of therapy should be considered 7
• Collaboration between rheumatologists, primary care physicians, and pediatricians is recommended when managing breastfeeding women on corticosteroid therapy 1
• Alternative anti-inflammatory medications such as NSAIDs may also be considered compatible with breastfeeding for short-term use if appropriate for the maternal condition 6, 7