Fluconazole Safety During Breastfeeding
Fluconazole is safe for nursing mothers and breastfeeding can continue without interruption, as it is the preferred azole antifungal for lactating women. 1
Evidence Supporting Safety
The American Academy of Pediatrics explicitly considers fluconazole compatible with breastfeeding, providing the highest level of guideline support. 1
The Infectious Diseases Society of America (IDSA) recommends that breastfeeding mothers can safely continue nursing while taking fluconazole without interruption. 1
Fluconazole is present in breast milk at low levels following a single 150 mg dose, with an estimated daily infant dose of approximately 0.39 mg/kg/day (about 13% of the recommended pediatric maintenance dose for oropharyngeal candidiasis). 2
The European Respiratory Society/Thoracic Society of Australia and New Zealand confirms that fluconazole levels in breast milk are less than the neonatal dosage, and problems have not been observed in breastfed infants from mothers treated with oral fluconazole. 1
Dosing Considerations
Single doses of 150 mg for vaginal candidiasis are safe during lactation. 1
For persistent breast/nipple thrush, higher doses can be used without interrupting breastfeeding, as the amount excreted in breast milk remains well below therapeutic infant doses even with maternal high-dose regimens. 1
A published survey of 96 breastfeeding women treated with fluconazole 150 mg every other day (average of 7.3 capsules, range 1-29) for lactation-associated candida of the breasts reported no serious adverse reactions in infants. 2, 3
Critical Distinction: Pregnancy vs. Lactation
High-dose fluconazole (400-800 mg/day) during the first trimester of pregnancy is associated with congenital malformations, but this pregnancy concern does NOT apply to breastfeeding, where fluconazole is considered safe at all doses. 1
Epidemiological studies suggest potential risk of spontaneous abortion and congenital abnormalities with 150 mg fluconazole as single or repeated doses in the first trimester of pregnancy, but these findings have limitations. 2
The teratogenic concerns are specific to pregnancy and do not translate to lactation safety. 1
Comparison with Other Antifungals
Avoid other azole antifungals during breastfeeding:
Itraconazole, posaconazole, and voriconazole should be avoided during breastfeeding due to lack of safety data and potential toxicity concerns. 1, 4
Topical options like miconazole and nystatin are classified as "compatible" with breastfeeding and may be used for localized nipple infections, though any excess cream should be removed from nipples before nursing. 1, 5
Common Pitfalls to Avoid
Do not discontinue breastfeeding when prescribing fluconazole - this is unnecessary and contradicts guideline recommendations. 1
Do not confuse pregnancy warnings with lactation safety - the FDA label includes pregnancy warnings that do not apply to breastfeeding. 2, 1
Do not substitute other azoles thinking they are equivalent - fluconazole is uniquely safe among systemic azoles for nursing mothers. 1
Caution should be exercised when fluconazole is administered to a nursing woman per FDA labeling, but this general statement is superseded by specific guideline recommendations supporting its safety. 2