Wherever possible, travelling into endemic countries should be delayed until after the lactation period. If travelling is unavoidable, the appropriate malaria prophylaxis must be chosen, first and foremost, based on efficacy rather than safety during breastfeeding.
Chloroquine, proguanil, and mefloquine are considered compatible with breastfeeding.
The Center for Disease Control and Prevention indicates that atovaquone may be used during breastfeeding where the infant weighs at least 5kg.
Short term use of doxycycline is unlikely to be harmful to a breastfed infant. However, for malaria prophylaxis doxycycline therapy is likely to be in excess of five weeks, and therefore doxycycline should be avoided during lactation for this indication if other suitable prophylactic options are available. If no other options are available, breastfeeding can continue with caution.
Hydroxychloroquine is not licensed or routinely recommended for malaria prophylaxis, except when a patient already taking it as treatment for a medical condition also requires chloroquine for malaria prophylaxis, in which case hydroxychloroquine can be substituted; dose changes may be required. In this situation, hydroxychloroquine would be considered compatible during breastfeeding.
Although many of the drugs pass into breast milk in small amounts, prophylactic treatment, at the full recommended dose, must also be given to the infant.
Regional Principal Medicines Information Pharmacist, Trent Medicines Information Service & UK Drugs in Lactation Advisory Service