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Drugs in breast milk - Quick reference guide.

This guide is based on information compiled by the Trent and West Midlands Medicines Information Services. It contains a summary of the significance of the excretion of the commonly used drugs via breast milk, and their absorption by the infant.

It is intended to be used only to assess risk where the infant is normal, healthy, and born full-term. Infants born prematurely or who have serious illnesses present more complex problems, and such cases should be referred to one of the specialist centres above.

In the interests of clarity and easy reference this guide is limited to those drugs which are more commonly prescribed for breast-feeding mothers. It is not intended that it should include all drugs and non-inclusion does not imply safety.

The drugs have been listed in pharmacological groups and where available evidence suggests that members of generic groups behave similarly, the generic name is listed (e.g. phenothiazines, aminoglycosides).

The drugs have been classified in the light of currently available evidence and where information is scarce the drugs have been classified as requiring monitoring.

Classification of drugs on this chart may not apply to long-term usage.

For more detailed information and further references the following articles are drawn to your attention:

  • Ito S. Drug therapy for breast-feeding women. New Eng J Med 2000; 343: 118-126
  • Auerbach KG. Breastfeeding and maternal medication use. J Obs Gyn Neonatal Nurs 1999; 28(5): 554-563
  • Howard CR, Lawrence RA. Drugs and breastfeeding. Clin Perinatal 1999; 26(2): 447-478
  • Dillon AE, et al. Drug therapy in the nursing mother. Obs Gyn Clin N Am 1997; 24(3) :675-696

For further information or to report suspected reactions contact the relevant manufacturer or your local Medicines Information Centre.

 

These drugs are unsuitable for administration to breast-feeding mothers because;
Serious adverse effects have been described. Serious adverse effects have been described.
Serious adverse effects may be anticipated on theoretical grounds. Serious adverse effects may be anticipated on theoretical grounds.

These drugs can be administered to breast-feeding mothers only where the mother and infant can be monitored.
Minor adverse effects have been described. Minor adverse effects have been described.
Insufficient information relating to breast-feeding available to allow classification as a safe drug. Insufficient information relating to breast-feeding available to allow classification as a safe drug.
Minor adverse effects may be anticipated on theoretical grounds. Minor adverse effects may be anticipated on theoretical grounds.
May suppress lactation. May suppress lactation.

These drugs may be administered to breast-feeding mothers.
They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.
Adverse effect (minor, reversible or of doubtful association) reported in a single case and therefore probably clinically insignificant. Adverse effect (minor, reversible or of doubtful association) reported in a single case and therefore probably clinically insignificant.
Drug       Information
         
Analgesics       normal doses, short-term use.
Codeine       They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Dextropropoxyphene     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. incl co-proxamol
Morphine     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Paracetamol     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Pethidine     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. single-dose only
Salicylates (low dose or
short-course use only)		   Insufficient information relating to breast-feeding available to allow classification as a safe drug.   Risk of Reye's Syndrome unknown
         
Antacids     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
         
Anthelmintics        
Mebendazole     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Piperazine   Insufficient information relating to breast-feeding available to allow classification as a safe drug.   7-day course
Piperazine and senna     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. 2-day course. Delay breast feeding for
8 hours after each dose
       
Anti-arrhythmics   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Amiodarone Serious adverse effects may be anticipated on theoretical grounds.      
       
Antibacterials       see also antituberculars
Aminoglycosides   Minor adverse effects may be anticipated on theoretical grounds.   avoid in neonates
Cephalosporins     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Chloramphenicol IV/oral Serious adverse effects have been described.      
Chloramphenicol Ophthalmic     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Clarithromycin   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Erythromycin     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Metronidazole        
   (high dose)   Insufficient information relating to breast-feeding available to allow classification as a safe drug.   (eg IV or rectal)
   (low dose)     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. (eg oral 200-400mg tds)
        single course only
Penicillins     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Quinolones   Minor adverse effects may be anticipated on theoretical grounds.    
   Ciprofloxacin Serious adverse effects have been described.      
Sulphonamides   Insufficient information relating to breast-feeding available to allow classification as a safe drug.   except avoid with G6PD
deficiency and in neonates
Tetracyclines        
   (short course)   Minor adverse effects may be anticipated on theoretical grounds.   ie up to 1 week
   (long term) Serious adverse effects may be anticipated on theoretical grounds.     eg for acne
Trimethoprim     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
       
Anticoagulants           
Heparin       They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. including low molecular weight heparins
Nicoumalone       They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.   
Phenindione Serious adverse effects have been described.       single report of adverse effect
Warfarin     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
           
Anticonvulsants          caution with multiple therapy
Carbamazepine     Adverse effect (minor, reversible or of doubtful association) reported in a single case and therefore probably clinically insignificant.  
Ethosuximide     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Phenobarbitone   Minor adverse effects have been described.    
Phenytoin   Minor adverse effects have been described.    
Valproate          
   (low dose)     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
   (high dose)   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
             
Antidepressants        
Fluoxetine and other SSRIs   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Lofepramine   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Tricyclics     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. short-term use in normal doses, eg for PND
   Doxepin Serious adverse effects have been described.     single report of adverse effect
         
Antidiarrhoeals           
Aminosalicylates        
   Mesalazine   Minor adverse effects have been described.    
   Olsalazine   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
   Sulphasalazine   Minor adverse effects have been described.    
Kaolin compounds     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. also avoid with G6PD deficiency
Loperamide     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
       
Anti-D(rho) Immunoglobulin     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
         
Anti-emetics     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. excluding high dose and ondansetron group
         
Antifungals        
Oral and topical     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. but avoid ketoconazole
Parenteral   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
         
Antihistamines        
Antihistamines   Minor adverse effects may be anticipated on theoretical grounds.   avoid long-acting formulations
   Clemastine   Minor adverse effects have been described.   single report of adverse effect
   Terfenadine     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Cromoglycate     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Loratadine     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Nedocromil     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
       
Antihypertensives       see also diuretics
ACE inhibitors   Insufficient information relating to breast-feeding available to allow classification as a safe drug.   eg captopril, enalapril
Beta blockers     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. incl labetolol
   Atenolol   Minor adverse effects have been described.   Propranolol, metoprolol or labetolol preferred
   Sotolol   Minor adverse effects may be anticipated on theoretical grounds.   Propranolol, metoprolol or labetolol preferred
Calcium blockers   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
   Nifedipine     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
   Verapamil     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Hydralazine     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Methyldopa     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
          
Anti-inflammatories        
NSAID's          
   Diclofenac      They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
   Ibuprofen     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
   Indomethacin     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
   Ketoprofen     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
   Mefenamic Acid      They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
   Naproxen   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Gold Salts Serious adverse effects may be anticipated on theoretical grounds.      
Salicylates (high dose or
long-term only)
   Insufficient information relating to breast-feeding available to allow classification as a safe drug.   risk of Reye's Syndrome unknown
             
Antimalarials        
treatment Serious adverse effects may be anticipated on theoretical grounds.     eg quinine, chloroquine, primaquine
prophylaxis     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. eg proguanil, chloroquine
   Mefloquine   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
   Dapsone preps Serious adverse effects have been described.     eg maloprim
         
Antimigraine drugs        
Clonidine   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Ergotamine Serious adverse effects have been described.      
Pizotifen   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Sumatriptan   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
         
Antineoplastics Serious adverse effects may be anticipated on theoretical grounds.      
Cyclophosphamide Serious adverse effects have been described.      
         
Antituberculars        
Ethambutol   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Isoniazid   Minor adverse effects may be anticipated on theoretical grounds.    
Pyrazinamide   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Rifampicin     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
         
Anti-ulcer drugs        
H2antagonists   Minor adverse effects may be anticipated on theoretical grounds.    
Omeprazole   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Sucralfate     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
         
Antivirals   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Acyclovir        
   standard oral / topical     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. ie oral, 5 day short course
   IV / High dose / long-term   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
         
Benzodiazepines        
   (high dose)   Minor adverse effects have been described.   eg equiv to > 10 mg diazepam daily
   (low dose)     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. eg equiv to < 10 mg diazepam daily or
short-acting hypnotics
       
Bronchodilators        
Aminophylline   Minor adverse effects may be anticipated on theoretical grounds.    
Theophylline   Minor adverse effects have been described.   single report of adverse effect
Beta agonists        
   Inhalers     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. including all inhaled devices (disks, rotacaps etc)
   Salbutamol (oral)   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
   Terbutaline (oral)     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
         
Corticosteriods       eg equiv to prednisolone
   (high-dose)   Insufficient information relating to breast-feeding available to allow classification as a safe drug.   >50mg daily
   (inhaled and low-dose)     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. <50mg daily
       
Cough and Cold Remedies        
Cough medicines     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. except avoid iodide-containing preparations
Pseudoephedrine     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. occasional use
         
Diuretics   May suppress lactation.   smaller effect with thiazides
         
Ergometrine     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. short course (3-5 days) only
         
Herbal Medicines   Minor adverse effects have been described.    
Ginseng Serious adverse effects have been described.     high-dose may cause androgenisation in neonate
         
Homeopathic Medicines     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
         
Hypoglycaemics        
Oral eg glibenclamide   Insufficient information relating to breast-feeding available to allow classification as a safe drug.    
Insulins     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
         
Iron     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
         
Laxatives        
Bisacodyl     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Bulk laxatives     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Senna standardised     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
         
Oestrogens (high-dose) Serious adverse effects have been described.     see also Oral Contraceptives
         
Oral Contraceptives        
Oestrogen + Progestogen   May suppress lactation.Minor adverse effects have been described.    
Progestogen only     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. preferable to combined preps
         
Progestogens     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. incl. medroxyprogesterone
         
Psycholeptics        
Haloperidol   Minor adverse effects may be anticipated on theoretical grounds.    
Lithium Serious adverse effects have been described.      
Phenothiazines   Minor adverse effects have been described.   eg chlorpromazine, fluphenazine
Thioxanthines   Minor adverse effects may be anticipated on theoretical grounds.   eg flupenthixol, zuclopenthixol
Sulpiride   Minor adverse effects may be anticipated on theoretical grounds.    
         
Topical Medications       if applied to breast remove carefully by washing before feeding and reapply afterwards
         
Thyroid Drugs        
Carbimazole   Minor adverse effects may be anticipated on theoretical grounds.    
Propylthiouracil   Minor adverse effects may be anticipated on theoretical grounds.   preferable to carbimazole
Thyroxine     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
         
Vaccines        
Killed eg Typhoid     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Live attenuated (eg Rubella)     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
       
Vitamins        
Folic Acid     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Vitamin A (high-dose)   Insufficient information relating to breast-feeding available to allow classification as a safe drug.   treatment of deficiency
Vitamin A (low-dose)     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. prophylaxis
Vitamin B + C     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Vitamin D (high-dose) Serious adverse effects may be anticipated on theoretical grounds.     treatment of deficiency
Vitamin D (low-dose)     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects. prophylaxis
Vitamin E     They either: Are not excreted in breast milk. Are not absorbed by the infant. Give very low levels in infant with no apparent effects.  
Vitamin K   Insufficient information relating to breast-feeding available to allow classification as a safe drug.