What are the safest corticosteroids (steroids) for breastfeeding mothers?

Safest Corticosteroids for Breastfeeding Mothers

Prednisone and prednisolone at doses below 20 mg daily are the safest corticosteroids for breastfeeding mothers, as they are minimally excreted into breast milk and are generally considered compatible with breastfeeding. 1

Preferred Corticosteroids During Lactation

Low-Dose Prednisone/Prednisolone (First-Line Choice)

• Prednisone ≤20 mg daily (or equivalent non-fluorinated glucocorticoid) is strongly recommended as compatible with breastfeeding 1
• These agents are minimally excreted into breast milk, with only approximately 10% of the maternal dose reaching the infant 1
• The American College of Rheumatology and EULAR guidelines both support low-dose glucocorticoid therapy as generally safe during lactation 1

Timing Strategy for Higher Doses

• For prednisone doses ≥20 mg daily, mothers should delay breastfeeding or discard breast milk accumulated in the 4 hours following glucocorticoid administration 1
• This timing recommendation is based on the equilibrium between prednisolone concentration in breast milk and maternal serum, which peaks within the first 4 hours after intake 1
• Infant exposure can be further minimized by timing the maternal dose to avoid breastfeeding during peak drug concentrations 2, 3

Alternative Corticosteroids

Methylprednisolone

• Methylprednisolone is also less available to the infant (10% of maternal dose), making it a reasonable alternative to prednisone/prednisolone 1
• It shares similar safety profiles with prednisone during lactation 4

Hydrocortisone

• Hydrocortisone is classified as compatible with breastfeeding and may be used when parenteral administration is necessary 1

Corticosteroids to Avoid

Fluorinated Corticosteroids (Dexamethasone, Betamethasone)

• Avoid fluorinated corticosteroids like dexamethasone and betamethasone during breastfeeding when treating maternal conditions 1
• These agents are not well metabolized by the placenta and cross more readily into fetal/infant circulation, making them appropriate for treating fetal conditions but not preferred for maternal therapy during lactation 1

Inhaled Corticosteroids (For Respiratory Conditions)

Preferred Agents

• Budesonide and beclomethasone are the preferred inhaled corticosteroids during breastfeeding due to extensive safety data 1
• Fluticasone is classified as "compatible" with breastfeeding 1
• Inhaled and nasal corticosteroid treatments are unlikely to affect breastfed infants due to minimal systemic absorption 5

Alternative Inhaled Options

• Ciclesonide and mometasone are classified as "probably safe" but have less data during lactation 1
• If a woman was well-controlled on these agents pre-pregnancy, continuation during breastfeeding is reasonable 1

Clinical Monitoring Considerations

Infant Observation

• Infants should be carefully observed for signs of hypoadrenalism if mothers received corticosteroids during pregnancy and continue during lactation 2
• Monitor for potential adverse effects including growth suppression, though this is rare with maternal low-dose therapy 2, 6

Maternal Considerations

• The lowest effective dose should always be used to maintain disease control 1, 7
• Disease control should be maintained with lactation-compatible medications, as uncontrolled maternal disease poses greater risks than appropriate corticosteroid use 1

Important Caveats

• The benefits of breastfeeding and maintaining maternal disease control typically outweigh the minimal risks of low-dose corticosteroid exposure to the infant 1, 6
• Very little systemically administered corticosteroid enters breast milk, and the dose received by the infant is generally much less than known safe doses given directly to infants 2, 6
• Individualized risk-benefit discussions should occur with each patient, but breastfeeding should be encouraged when mothers desire and are able to do so 1