Is oral clindamycin (antibiotic) safe during breastfeeding?

Oral Clindamycin and Breastfeeding Safety

Oral clindamycin can be used during breastfeeding but requires caution due to increased risk of gastrointestinal side effects in the infant, and alternative antibiotics like amoxicillin/clavulanic acid are generally preferred when clinically appropriate. 1

Primary Recommendation

The American Academy of Dermatology explicitly advises exercising caution with oral clindamycin as it may increase the risk of GI side effects in the breastfed infant. 1 This represents the most authoritative guidance on this specific question, though it does not contraindicate use entirely.

FDA Drug Label Information

The FDA label for clindamycin provides important context: 2

• Clindamycin appears in human breast milk at concentrations ranging from less than 0.5 to 3.8 mcg/mL 2
• If oral or intravenous clindamycin is required by a nursing mother, it is not a reason to discontinue breastfeeding, but an alternate drug may be preferred 2
• The label explicitly states that clindamycin has the potential to cause adverse effects on the breast-fed infant's gastrointestinal flora 2

Required Infant Monitoring

If clindamycin is used, the infant must be monitored for: 2

• Diarrhea
• Candidiasis (thrush, diaper rash)
• Rarely, blood in the stool indicating possible antibiotic-associated colitis

All breastfed infants exposed to antibiotics should be monitored for gastrointestinal effects due to alteration of intestinal flora. 1

Preferred Alternatives

When systemic antibiotics are needed during breastfeeding, consider these safer options first: 1, 3

• Amoxicillin/clavulanic acid - classified as FDA Category B and explicitly compatible with breastfeeding 1, 3
• Cephalosporins (cephalexin, ceftriaxone) - considered compatible 1
• Azithromycin - classified as "probably safe" (avoid first 13 days postpartum) 1

Clindamycin is specifically contrasted unfavorably with amoxicillin/clavulanic acid in the guidelines, with the latter being preferred due to clindamycin's increased GI risk profile. 3

Supporting Research Evidence

A 2009 systematic review examining antibiotics for MRSA infections during lactation concluded that clindamycin "appears to be relatively safe in the minimal quantities nursing infants ingest through breast milk," though the authors emphasized the need for close monitoring. 4 However, this research evidence is superseded by the more recent and specific guideline recommendations advising caution. 1

Clinical Decision Algorithm

When prescribing antibiotics to breastfeeding mothers:

1. First, determine if amoxicillin/clavulanic acid or a cephalosporin would be clinically appropriate for the infection 1, 3
2. If penicillin allergy exists, consider azithromycin or erythromycin 1
3. Only use clindamycin if no suitable alternative exists for the specific clinical indication 1, 2
4. If clindamycin is necessary, counsel the mother about GI monitoring and do not discontinue breastfeeding 2

Important Caveats

• Antibiotics in breast milk could potentially cause falsely negative cultures if the breastfed infant develops fever requiring evaluation 1
• The safety profile assumes full-term, healthy infants, standard recommended doses and durations, and exclusive breastfeeding 1
• The developmental and health benefits of breastfeeding should be weighed against the mother's clinical need for clindamycin 2