Proton Pump Inhibitors Safe for Breastfeeding
Omeprazole and lansoprazole are the preferred PPIs during breastfeeding, with omeprazole having the most robust safety data showing minimal secretion into breast milk (peak concentrations <7% of maternal serum levels). 1
First-Line Recommendations
Omeprazole is the best-studied PPI in breastfeeding women and should be considered first-line. A case study demonstrated that peak omeprazole concentrations in breast milk were only 58 nM (3 hours post-ingestion), representing less than 7% of the peak maternal serum concentration (950 nM at 4 hours), indicating minimal secretion and negligible infant exposure. 1
Lansoprazole represents an acceptable alternative with comparable safety profile to omeprazole, though with less published breastfeeding-specific data. 2, 3
Clinical Decision Algorithm
When selecting a PPI for breastfeeding women:
- Start with omeprazole 20 mg daily as the evidence-based first choice given documented minimal breast milk transfer 1
- Consider lansoprazole if omeprazole is ineffective or not tolerated, as it has longer duration of action and similar safety expectations 2
- Avoid pantoprazole as first-line despite theoretical advantages (less cytochrome P-450 interaction), as breastfeeding safety data are insufficient 2, 4
Pharmacokinetic Rationale
PPIs are generally compatible with breastfeeding due to:
- High protein binding reduces free drug available for milk transfer 5
- Acid lability means any PPI reaching the infant's stomach would be rapidly degraded in gastric acid, minimizing systemic infant absorption 5
- Poor oral bioavailability in the formulations that might reach breast milk further limits infant exposure 4
Practical Considerations
Timing of doses can further minimize infant exposure: Take the PPI immediately after breastfeeding to maximize the interval before the next feeding, allowing peak maternal serum (and milk) concentrations to decline. 1
Duration of therapy matters less than drug selection: Short-term or chronic PPI use appears equally safe with omeprazole, as the minimal transfer remains constant. 1, 5
Common Pitfalls to Avoid
- Do not unnecessarily discontinue breastfeeding when PPIs are needed—the benefits of breastfeeding outweigh the negligible risks from omeprazole exposure 6
- Do not assume all PPIs have equal breastfeeding data—omeprazole has the strongest evidence, while newer agents lack adequate study 1, 5
- Do not use esomeprazole preferentially over omeprazole without specific indication, as the enantiomer lacks dedicated breastfeeding studies despite similar expected behavior 7