Safe Medication Use During Breastfeeding

OTC; used for stomach upset (dyspepsia)

The World Health Organization (WHO) considers compatible with breastfeeding; however, continue to monitor baby for side effects.²

Prescription/over-the-counter; Bayer Aspirin, Bufferin, Ecotrin, others.

In general, aspirin use is best avoided during breastfeeding. Acetaminophen or ibuprofen may be safer for pain relief.

Some expert opinion indicates that low-dose (75 to 325 mg daily) aspirin may be used as a blood thinning agent for use in breastfeeding women who require it. Monitor the infant for bruising and bleeding.¹

Avoid high-dose, long-term use of aspirin, if possible.

Found in coffee (80-150 mg per 6 ounce cup), tea, soft drinks, energy drinks, chocolate, guarana, some OTC medications.

One Starbucks Grande (16 oz) contains ~ 300 mg caffeine.

A stimulant that DOES pass into breast milk.

Excess caffeine in the mother can lead to stimulation in infants. Watch for irritability in newborn.

Avoid concentrated energy drinks, pure caffeine tablets.

Caffeine consumption of 300 mg to 500 mg per day max suggested.

Caffeine levels from breast milk may be higher in preterm infants.¹

Most cephalosporins are considered compatible with breastfeeding.^{2, 3}

Rx; broad-spectrum antibiotics for infections.

According to the American Academy of Pediatrics (AAP), in general, an antimicrobial agent is safe to administer to a lactating woman if it is safe to administer to an infant.

May interfere with gut flora in infant leading to diarrhea or thrush.

Clotrimazole (troches or topical)

Rx/OTC; used to treat yeast and fungal infections.

Poor oral bioavailability, unlikely to adversely affect the breastfed infant, including topical application to the nipples.¹

Brand name examples: Ortho Micronor, Errin, Heather, Slynd, others.

Used for birth control. Generic options may be available.

Progestin-only contraceptives are considered the hormonal contraceptives of choice during lactation, especially during the first 4 weeks postpartum.^1,6

Research has found that combination birth control pills (that also contain estrogen) don't affect milk production if started 4 weeks after delivery, as previously thought, but some doctors may still prefer progestin only pills.⁷ Combination birth control pills started within 3 weeks after delivery may also elevate risk for blood clots.¹⁶

There are no reports of adverse effects in breastfed infants with maternal use of progestin-only contraceptives.⁵

For some women, nonhormonal methods of birth control may be preferred during breastfeeding (this includes the copper IUD, condoms, diaphragm and cervical cap).

Examples: prednisone, prednisolone.

Rx; used to treat inflammation of joints and other conditions.

As reported by ToxNet LactMed (NIH) database, no adverse effects have been reported in breastfed infants with maternal use of any corticosteroid during breastfeeding.¹

OTC; Used to treat stuffy noses.

Limited systemic absorption.

Recommended over oral decongestants (such as pseudoephedrine or phenylephrine), which may inhibit milk production.¹

Rx; used for heart failure, other heart problems.

If given intravenously, avoid breastfeeding for 2 hours after dose.

Because of the low levels of digoxin in breastmilk, amounts ingested by the infant are small and would not be expected to cause any adverse effects in breastfed infants.¹

Rx; macrolide used for skin and respiratory infections.

Monitor infant for diarrhea, candidiasis (thrush, diaper rash).¹

OTC; non-drowsy antihistamine for allergies and hay fever.

Lack of sedation and low milk levels; maternal use of fexofenadine would not be expected to cause any adverse effects in breastfed infants.¹

Combined use with decongestants may lower milk production.

Rx; Used to treat yeast infections

Acceptable in nursing mothers because amounts in breastmilk are less than infant dose.¹

Rx; used to keep blood from clotting.

Not expected to be appreciably excreted into breastmilk or absorbed by the infant due to high molecular weights. No special precautions are required.¹

Rx/OTC: used for pain relief

Due to low levels in breastmilk, short action, and safe use in infants in doses higher than those found in breastmilk, ibuprofen is a preferred choice as an analgesic or anti-inflammatory agent in nursing mothers.¹

Rx; used for asthma.

No published data.

Experts agree use of inhaled bronchodilators acceptable due to low bioavailability and maternal serum levels after use.¹

Mothers with diabetes using insulin may nurse their infants.

Careful observation of increased maternal caloric needs and maternal blood glucose levels are needed.

Insulin is normally present in breastmilk. Use is acceptable.

Rx; for diabetes / elevated blood sugar; dosage required may drop up to 25% during lactation.

Insulin, including newer biosynthetic insulins (aspart, detemir, glargine, glulisine, lispro) is a protein that is inactivated and destroyed in the digestive tract of the infant if taken by mouth.⁸

OTC; used to treat constipation.

Psyllium is not absorbed from the gastrointestinal tract, so it cannot enter the breastmilk. It is acceptable to use during breastfeeding.¹

Docusate is minimally absorbed and is unlikely to be found in breastmilk. Laxatives that are completely unabsorbed may be preferred over docusate.¹

Polyethylene glycol is very poorly absorbed from the gastrointestinal tract, so it cannot enter the breastmilk in important amounts. No special precautions are required.¹

Rx; a local anesthetic.

Lidocaine is poorly absorbed by newborns. Lidocaine is not expected to cause side effects in breastfed infants.¹

OTC; non-drowsy antihistamine for allergies and hay fever.

Lack of sedation and low milk levels. Not expected to cause adverse effects in nursing infants. Some experts recommend to use at the lowest dose.

Loratadine might have a negative effect on lactation, especially in combination with a decongestant like pseudoephedrine or phenylephrine.¹

Rx; used for prevention and control of seizures in pre-eclampsia and eclampsia.

Postpartum IV use longer than 6 hours may delay onset of lactation.¹

See Summary of Use during Lactation.

Rx; used to treat high blood pressure; no special precautions needed.

Because of the low levels of methyldopa in breastmilk, amounts ingested by the infant are small and would not be expected to cause any adverse effects in breastfed infants.¹

Rx; a beta-blocker used to treat high blood pressure.

Small amounts ingested by infant; no special precautions are required.

Studies on the use of metoprolol during breastfeeding have found no adverse reactions in breastfed infants.¹

OTC; used to treat yeast infections.

Poor oral bioavailability. Unlikely to affect the breastfed infant, including topical application to the nipples, but rarely prescribed.¹

Rx; calcium channel blocker used to treat high blood pressure and angina (chest pain).

Studies on the use of metoprolol during breastfeeding have found no adverse reactions in breastfed infants.

No special precautions are required.¹

Rx; used to treat bacterial infections.

Occasionally, rash and disruption of the infant's gastrointestinal flora, resulting in diarrhea or thrush, have been reported with penicillins, but these effects have not been adequately evaluated.

Amoxicillin, penicillin G are acceptable in nursing mothers.¹

Rx; a beta blocker used to treat heart problems, high blood pressure, and infantile hemangiomas.

Low levels in breastmilk and not expected to cause side effects in breastfed infants. No special precautions are needed.¹

Elixophyllin, Theo-24, others

Rx; used to treat asthma and bronchitis.

Monitor infant for irritability, stimulation, and trouble sleeping in newborn and especially preterm infants.

Keep maternal serum concentrations in the lower part of the therapeutic range and monitor the infant for signs of theophylline side effects. Consider infant serum monitoring if needed.

Delay nursing for 2 hours (after IV dose) or 4 hours (after oral immediate-release dose) if possible. Delaying nursing may have no effect if taking long-acting forms.¹

Rx; cream used for acne; use only water-miscible cream or gel products.

Rx; replaces the thyroid hormone normally produced by your body to help regulate your energy and metabolism.

Levothyroxine is excreted into milk, but is a normal component of breast milk. Use is considered acceptable.¹

Breastfed infants should be vaccinated according to routine established schedules from the ACIP.

According to the ACIP’s General Best Practice Guidelines for Immunization in Special Situations, except for smallpox and yellow fever vaccines, neither inactivated nor live-virus vaccines administered to a lactating woman affect the safety of breastfeeding for women or their infants.

When nursing mothers cannot avoid or postpone travel to areas endemic for yellow fever in which risk for acquisition is high, these women should be vaccinated.⁹

If you are breastfeeding, you can receive a COVID vaccine as reported by the CDC. No long-term studies are available, but recent information has shown that people who are breastfeeding and have received COVID-19 mRNA vaccines have antibodies in their breastmilk, which could help protect their babies, but more data is needed to determine how protective this is for the baby.¹⁹

Rx; oral antibiotic. No special precautions are required.

Limited information indicates that oral vancomycin produces low levels in milk.

Because vancomycin is poorly absorbed when taken orally, it is unlikely to enter the bloodstream of the infant or cause side effects.¹

Rx; calcium channel blocker used for high blood pressure, angina (chest pain).

Data are limited but suggest that maternal doses of verapamil up to 360 mg daily produce detectable, but low levels in milk.

Verapamil would not be expected to cause side effects in breastfed infants, especially in infants over 2 months.¹

Rx; used to treat or prevent blood clots.

Very low milk levels occur with warfarin doses up to at least 12 mg daily.

No side effects in breastfed infants have been reported from maternal warfarin use during breastfeeding, even with a dose of 25 mg daily for 7 days.

There is a consensus that maternal warfarin therapy during breastfeeding poses little risk to the breastfed infant. No special precautions are needed.¹

captopril, enalapril (Vasotec), benazepril (Lotensin)¹

Rx; used to treat high blood pressure, kidney conditions, heart disease.

Captopril, enalapril and benazepril can appear in breast milk. However, amounts ingested are small and would not be expected to cause any adverse effects in breastfed infants.

No information is available for lisinopril; an alternative may be preferred.¹

Reported as possibly safe or cautious use advised. Monitor infant closely for side effects¹:

• phenytoin (Dilantin), fosphenytoin
• carbamazepine (Tegretol)
• lamotrigine
• levetiracetam
• ethosuximide
• gabapentin
• oxcarbazepine
• phenobarbital
• primidone
• valproic acid

Do not use, or use with extreme caution, and monitor infant as recommended by a healthcare provider¹:

• felbamate (do not use)
• zonisamide (alternative drugs are preferred)

Rx; used for seizures and mood disorders. Pregnant and breastfeeding women with epilepsy should always consult their health care provider about appropriate seizures medications.

Check individual drugs as certain medications can be hazardous to nursing infants, while others may be more safe.

Some medications may lead to side effects in the infant such as drowsiness, feeding difficulties and poor weight gain.

Treatments for epilepsy are often used in combination. Use of two or more seizure drugs may lead to worsened or unexpected side effects.

Measurement of an infant serum level might help rule out toxicity if there is a concern. Monitor for developmental milestones.¹

Nonsedating antihistamines are usually preferred; most are not expected to cause side effects in infants.¹

• loratadine
• fexofenadine
• desloratadine

Sedating antihistamines are alternatives for short-term, low dose use.¹

• diphenhydramine (Benadryl)
• chlorpheniramine

OTC/Rx; Some antihistamines may reduce milk supply (especially when used with a decongestant) and cause infant drowsiness or fussiness.

If sedating, use lowest dose possible and take at bedtime after last feeding.

generic only

Rx; used to treat tuberculosis

The CDC and other expert groups state that breastfeeding should not be discouraged in women taking isoniazid.

Nursing mothers who are taking isoniazid should take 25 mg of oral pyridoxine daily.

Give the once-daily dose to the mother before the infant's longest sleep period to decrease dose that infant receives.

Monitor infants for rare instances of jaundice.¹

Imuran

Rx; used to suppress the immune system following organ transplants; can be used for inflammatory bowel disease or lupus.

Most experts consider breastfeeding during azathioprine to be acceptable. May want to monitor complete blood count with differential, and liver function tests in exclusively breastfed infants.¹

Long-term follow-up for effects such as cancer in children have not been performed.

Avoid breastfeeding for 4 to 6 hours after a dose.

Aplenzin, Wellbutrin XL

Rx; for depression, seasonal affective disorder, smoking cessation.

Clinical data is lacking; case report of possible seizure in partially breastfed 6-month-old; another drug may be preferred.¹

Monitor infant closely if combined with an SSRI. Watch for vomiting, diarrhea, jitteriness, or sedation; consider monitoring infant levels.¹

Cleocin

Rx; Used to treat abdominal and vaginal infections; topical for acne.

Oral or IV product may alter infants gastrointestinal flora leading to diarrhea, thrush, or rarely blood in stool; consider alternative.¹

Topical agents unlikely to cause infant side effects.

phenylephrine, pseudoephedrine (Sudafed)

OTC; Used to treat congestion associated with colds or allergies.

May cause irritability in the infant; often interferes with or reduces milk supply - do not use if lactation not well established.

A single dose of pseudoephedrine decreases milk production acutely and repeated use seems to interfere with lactation. Mothers with newborns whose lactation is not yet well established or in mothers who are having difficulties producing sufficient milk should not receive pseudoephedrine.¹

Limited information on oral phenylephrine so alternatives may be preferred.

Phenylephrine nasal spray or ophthalmic drops are less likely to lower milk production.

Diflucan

Rx; antifungal.

Fluconazole is acceptable in nursing mothers because amounts excreted into breastmilk are less than the neonatal fluconazole dosage.¹

• cimetidine (Tagamet HB)
• nizatidine (Axid AR)
• famotidine (Pepcid AC)

OTC; used to treat stomach acid reflux/heartburn.

Famotidine may be preferred.

Cimetidine may inhibit hepatic enzymes leading to drug interactions.¹ WHO states to avoid cimetidine as no long-term data on side effects.²

Ranitidine (Zantac) was found to break down to a cancer-causing chemical and has been removed from the U.S. market.

Trandate

Rx; used for high blood pressure.

Caution with preterm babies; other agents may be preferred.

Levels of labetalol are low in breastmilk. No special precautions are required in most fullterm infants.

Labetalol may predispose nursing mothers to Raynaud’s phenomenon of the nipple.¹

Microzide

Rx; diuretic for high blood pressure.

Doses of 50 mg daily or less are acceptable during lactation; higher doses may decrease milk production.¹

Ativan

Rx; used to treat anxiety, seizure disorders.

Lorazepam has low levels in breastmilk, and a short half-life compared to some benzodiazepines.

It is safely given directly to infants, and would not be expected to cause infant problems. Most reports do not list sedation in infants at normal maternal doses.¹

Anaprox, Aleve, Naprosyn

OTC/Rx; used for pain relief.

However, because of naproxen's long half-life and reported serious adverse reaction in a breastfed newborn, other NSAIDs (i.e., ibuprofen) or acetaminophen may be preferred while nursing a newborn or preterm infant.¹

generic only

Rx; used to treat anxiety.

Low levels in breast milk. Oxazepam is not expected to cause side effects in breastfed infants with usual maternal doses.

No special precautions are required; however, short-term use is always preferred.¹

Rx; used to treat heartbeat irregularities.

Limited data suggests that maternal doses of quinidine up to 1.8 grams daily produce low levels in milk.

Not expected to cause side effects in breastfed infants, especially if the infant is older than 2 months.

Consider measurement of serum levels to rule out infant toxicity if there is a concern; monitor exclusively breastfed infants closely.¹

• ciprofloxacin (Cipro)¹
• levofloxacin (Levaquin)¹
• moxifloxacin (Avelox)^{1 -}may be preferable to use a fluoroquinolone with safety data

Rx antibiotic

Due to serious side effects in patients, the FDA has stated that this class is not suitable for common conditions such as sinusitis, bronchitis, and uncomplicated urinary tract infections. However, if clinically appropriate, short-term use of ciprofloxacin and levofloxacin appears to be acceptable in nursing mothers. No information is available on the use of moxifloxacin during breastfeeding.

Recommendations now state this class should be reserved for more serious infections when possible.

Monitor infant for possible effects on the gastrointestinal flora, such as diarrhea or candidiasis (thrush, diaper rash).

Fluoroquinolones have traditionally not been used in infants because of concern about adverse effects on the infants' developing joints. However, studies indicate little risk.

If prescribed in a nursing woman, avoiding breastfeeding for 3 to 4 hours after a dose to help decrease the exposure of the infant.

Ophthalmic preparations pose little risk to a nursing baby.¹

SSRIs

Mothers taking an SSRI postpartum may have more difficulty breastfeeding, although this might be a reflection of their disease state. Lactation support may needed.¹

• paroxetine (Paxil)
• sertraline (Zoloft)

Rx; used to treat depression, postpartum depression.

Most authoritative reviewers consider paroxetine or sertraline preferred antidepressants during breastfeeding.¹

Paroxetine: has not been detected in serum of most infants that were tested. Occasional mild side effects such as insomnia, restlessness and increased crying have been reported in breastfed infants.¹

Sertraline: weakly active metabolite norsertraline (desmethylsertraline) has been detected in low levels infants; preterm infants with impaired metabolism may accumulate the drug and demonstrate symptoms similar to neonatal abstinence.¹

Most newer antidepressants produce very low or undetectable plasma concentrations in nursing infants. Shorter half-life agents may be preferred.

Aldactone

Rx; used to treat high blood pressure

Spironolactone appears to be acceptable during breastfeeding.¹

Intense diuresis (treatment for fluid retention) can suppress lactation but it is unlikely that spironolactone alone is potent enough to cause this effect.¹

Imitrex

Rx; used to treat migraines

Sumatriptan has low oral bioavailability with low milk levels. Sumatriptan would not be expected to cause any adverse effects in most breastfed infants

Experts suggest to withhold breastfeeding for 8 hours (12 hours from manufacturer). This may be helpful in preterm infants.¹

Sumatriptan would not be expected to cause any side effects in most breastfed infants.

Tetracyclines

• tetracycline
• doxycycline

• Achromycin V (tetracycline)
• Vibramycin, Oracea, Monodox, others (doxycycline)

Rx; antibiotic may be used to treat acne or UTI, Lyme disease.

Available literature indicates unlikely to be harm (i.e., teeth-staining) with short-term use of tetracycline or doxycycline during lactation because milk levels are low and absorption by the infant is inhibited by the calcium in breastmilk.¹

Doxycycline use in children under 8 years is now considered acceptable in courses up to 21 days.¹

As a precaution limit to short-term use and avoid repeat treatments.

Monitor for altered intestinal tract flora (diarrhea, thrush, diaper rash).

Rx; used for depression and sleep.

Limited data shows that trazodone milk levels are low.

Not expected to cause side effects in breastfed infants, especially if older than 2 months or when doses of 100 mg or less are used at bedtime for sleep.¹

• imipramine (Tofranil)
• nortriptyline (Pamelor)

Rx; used to treat depression.

Some experts consider imipramine or nortriptyline the TCAs of choice for nursing mothers, if a TCA must be used. Low milk levels and few side effects reported in infants.¹

Avoid oral doxepin due to active metabolite, presence in infant serum, and several reports side effects.¹