What are the safe pharmacologic and non‑pharmacologic treatments for a lactating mother with a common cold, cough, and sore throat?

Safe Treatment for Breastfeeding Mothers with Cold, Cough, and Throat Pain

Breastfeeding mothers with cold, cough, and sore throat should start with saline nasal rinses and acetaminophen for symptom relief, as these are completely safe and effective first-line treatments that do not require interruption of breastfeeding. 1, 2

Non-Pharmacologic Treatments (First-Line)

• Saline nasal irrigation should be used frequently throughout the day for nasal congestion and is completely safe during lactation 1, 3
• Warm compresses to the face, steamy showers, adequate hydration, and sleeping with head elevated provide additional symptomatic relief 3
• Continue breastfeeding normally - there is no need to interrupt nursing for common cold symptoms 4, 5

Safe Pharmacologic Options

For Pain and Fever

• Acetaminophen (paracetamol) is the preferred analgesic during breastfeeding and is considered completely compatible 2, 6, 7
• Ibuprofen is also safe for short-term use and is compatible with breastfeeding 6, 7
• Low-dose aspirin (up to 100 mg/day) is acceptable, but higher doses should be avoided due to potential adverse effects in nursing infants 6, 7

For Nasal Congestion

• Intranasal corticosteroid sprays (budesonide, fluticasone, or mometasone) are safe and effective for severe nasal congestion during lactation 1, 3
• Budesonide has the most robust safety data and should be used at the lowest effective dose 1, 3
• Avoid oral decongestants - these are not recommended during lactation due to potential reduction in milk supply and infant irritability 1, 6

For Cough

• Codeine is considered compatible with breastfeeding by the American Academy of Pediatrics for short-term use as a cough suppressant 6
• Avoid combination cough products containing multiple unnecessary ingredients 6
• Many liquid cough preparations contain alcohol, which should be minimized 6

For Sore Throat (Bacterial Pharyngitis)

If bacterial pharyngitis (strep throat) is confirmed by rapid antigen test or culture:

• Penicillin V (250 mg three times daily for 10 days) is the first-line antibiotic and is safe during breastfeeding 2, 7
• Amoxicillin is equally effective and often better tolerated 2, 7
• For penicillin allergy: First-generation cephalosporins (like cephalexin) or erythromycin are safe alternatives 2, 4, 7
• Avoid erythromycin estolate formulation specifically, as it carries hepatotoxicity risk 2
• Azithromycin is acceptable but carries a very low risk of infantile hypertrophic pyloric stenosis if used during the first 13 days of the infant's life 4

Antihistamines (Use with Caution)

• Triprolidine and pseudoephedrine are considered compatible with breastfeeding by the American Academy of Pediatrics, though pseudoephedrine may reduce milk supply 6
• Loratadine or cetirizine are preferred if antihistamines are needed, as they have the most safety data 1
• First-generation antihistamines should be avoided due to sedative effects that may affect the infant 1
• Watch for paradoxical CNS stimulation in infants exposed to antihistamines through breast milk 6

Critical Timing Strategy

• Take medications immediately after breastfeeding to minimize infant exposure through breast milk 1, 6
• Use the lowest effective dose for the shortest duration necessary 6, 8
• Breastfeeding prior to medication intake further limits infant exposure 1

Antibiotics to Avoid

• Tetracyclines, fluoroquinolones, trimethoprim-sulfamethoxazole, and aminoglycosides should not be used during lactation 1, 3
• These antibiotics pose unacceptable risks to the nursing infant 1, 3

Common Pitfalls to Avoid

• Do not unnecessarily discontinue breastfeeding - most medications for common cold symptoms are compatible with nursing, and stopping breastfeeding is one of the most common but avoidable reasons for cessation 9, 5
• Do not prescribe antibiotics for viral upper respiratory infections - most colds are viral and self-limited, resolving within 3-4 days without antibiotics 2, 3
• Do not use combination cold products with multiple unnecessary ingredients when single-agent therapy is sufficient 6
• Avoid products containing alcohol when possible 6

When Antibiotics Are Actually Needed

• Only prescribe antibiotics if bacterial pharyngitis is confirmed by rapid antigen detection test or throat culture 2
• Treatment can be safely delayed up to 9 days while awaiting confirmation without increasing complication risk 2
• Most pharyngitis cases are viral and do not require antibiotics 2, 3

Monitoring

• Watch for adverse events in the breastfed infant, including irritability, insomnia from decongestants, or paradoxical CNS stimulation from antihistamines 6
• If symptoms worsen or do not improve within 48-72 hours, reevaluation is necessary 4