Skip to Main Content
The first stop for professional medicines advice

Managing COVID-19 and breastfeeding

Published Last updated See all updates
Topics: COVID-19 TreatmentsCOVID-19 vaccineDexamethasone · Infection and infectious diseasesSafety in BreastfeedingSotrovimabTocilizumab ·

Continue breastfeeding during COVID-19 infection, even if dexamethasone, Paxlovid, sotrovimab or tocilzumab are required. COVID-19 vaccines can also be given.

Contents

  1. COVID-19 vaccination and breastfeeding
    1. Detection in breast milk
    2. The vaccine may protect the infant
    3. Infant monitoring
    4. Further information
  3. Breastfeeding with COVID-19 infection
    1. Minimising risk of infant infection through close contact
  5. Treating COVID-19 infection
    1. Dexamethasone
    2. Paxlovid (nirmatrelvir + ritonavir)
    3. Sotrovimab
    4. Tocilizumab
  7. Patient Information
  8. Contact us
  9. About our recommendations
  10. Bibliography
  11. Update history

COVID-19 vaccination and breastfeeding

COVID-19 vaccines can be given to anyone who is breastfeeding.

There is no known risk associated with giving non-live vaccines during breastfeeding, including COVID-19 vaccines. Therefore, those who are breastfeeding should be offered the COVID-19 vaccine if they are eligible.

Detection in breast milk

Although small quantities of COVID-19 mRNA have been detected in some breast milk samples after vaccination, there is no evidence that this survives the infant gastro-intestinal tract, or that it causes any infant harm. Limited data show no vaccine components in infant serum after breast milk exposure.

The vaccine may protect the infant

The UK Health Security Agency (UKHSA) Immunisation Against Infectious Disease (the Green Book) confirms that emerging safety data are reassuring and antibodies and T-cells have been detected in breast milk after vaccination, which may help to protect the infant. The milk antibody response appears to be weaker if non-mRNA vaccines are used.

Infant monitoring

Side effects in the breastfed infant from exposure to the vaccine through breast milk are highly unlikely. As a precaution, monitor for fever, drowsiness, irritability and gastro-intestinal disturbances. These should be self-limiting; contact a healthcare professional if there are any concerns.

Further information

Patient information is available from the UK Health Security Agency (UKHSA) .

Breastfeeding with COVID-19 infection

Breastfeeding should continue as normal.

Although the COVID-19 virus has been detected in breast milk samples, its viability has not been confirmed. There is no evidence to show that the presence of the virus in milk causes infection in breastfed infants.

There is evidence that maternal antibodies, generated in response to COVID-19 virus, and other bioactive factors, do pass into breast milk. This can help protect the infant.

Minimising risk of infant infection through close contact

In order for breastfeeding to be facilitated it is important that mother and baby stay close together. However, consider the following to reduce the risk of the infant becoming infected:

  • Wash your hands for at least 20 seconds before touching the infant or any expressing equipment
  • avoid coughing or sneezing on the infant while breastfeeding
  • consider wearing a face mask whilst breastfeeding
  • if used, clean breast pumps as recommended by the manufacturer after each use.

Treating COVID-19 infection

The treatment of COVID-19 remains a dynamic situation. Therefore if a medicine being considered is not listed here, contact the UK Drugs In Lactation Advisory Service (UKDILAS) (SPS page), our specialist medicines in breastfeeding advice service.

Recommendations apply to infants born full term and healthy.

Use with caution

Dexamethasone can be used with caution, although there is no published evidence for use in breastfeeding.

See Using oral or parenteral corticosteroids during breastfeeding for further information

Use with caution

Paxlovid (nirmatrelvir + ritonavir) can be used with caution and infant monitoring during breastfeeding.

Infant monitoring

Monitoring the infant will quickly pick up any potential issues, but usually further investigation is required before the cause can be identified. If a side effect is suspected, contact a healthcare professional for further advice.

As a precaution, monitor the infant for:

  • poor feeding and adequate weight gain
  • irritability
  • gastro-intestinal disturbances including vomiting and diarrhoea
  • poor sleeping and fatigue
  • hypersensitivity reactions, including rash
  • signs of jaundice.

Further information

A moderate amount of published evidence for ritonavir shows negligible levels in breast milk resulting in variable infant serum levels, ranging from undetectable to low. There have been no side effects reported in breastfed infants to date.

There is no published evidence for the excretion of nirmatrelvir into breast milk, but it is likely to pass through in very low amounts due to its favourable pharmacokinetics. Its poor oral bioavailability also means the infant is unlikely to absorb a significant amount from breast milk.

Paxlovid is administered as a short course, and nirmatrelvir and ritonavir both have a short half-life, so the risk of accumulation in the infant is very low.

Two case reports in which Paxlovid was given to breastfeeding women did not report any side effects in their infants.

The manufacturer’s advice to avoid breastfeeding during treatment and for 7 days after the last dose is not considered necessary.

Use with caution

Sotrovimab can be used with caution and infant monitoring during breastfeeding.

Infant monitoring

Monitoring the infant will quickly pick up any potential issues, but usually further investigation is required before the cause can be identified. If a side effect is suspected, contact a healthcare professional for further advice.

As a precaution, monitor the infant for:

  • adequate feeding
  • hypersensitivity reactions, including rash.

Further information

There is no published evidence for sotrovimab in breastfeeding. However, it is a large molecule so it is difficult for it to pass into breast milk.

As sotrovimab has limited oral bioavailability, and is a protein molecule that is likely to be partially destroyed in the infant’s gastrointestinal tract, infant absorption via breast milk would be limited. Therefore side effects are unlikely.

Absorption may be increased slightly in the neonatal period due to increased gastrointestinal permeability, although this has not been proven.

Use with caution

Tocilizumab can be used with caution and infant monitoring during breastfeeding.

Infant monitoring

Monitoring the infant will quickly pick up any potential issues, but usually further investigation is required before the cause can be identified. If a side effect is suspected, contact a healthcare professional for further advice.

As a precaution monitor the infant for:

  • changes in feeding
  • fever or frequent infections
  • gastro-intestinal disturbances including diarrhoea, nausea, and constipation
  • hypersensitivity reactions, including rash.
  • unusual behaviour or irritability
  • poor sleeping

Further information

Evidence for tocilizumab during breastfeeding comes from other licensed indications which may use different dosing schedules and may have involved prior exposure in pregnancy.

Tocilizumab is a large molecule, so it will be difficult for it to pass into breast milk. Limited published evidence confirms levels in milk are often negligible. The infant is estimated to be exposed to 0.007–3.9% of the weight-adjusted maternal dose.

Tocilizumab has negligible oral bioavailability, and since it is a protein molecule that will be mostly destroyed in the infant’s gastrointestinal tract, infant absorption via breast milk is likely to be insignificant. Absorption may be increased slightly in the neonatal period due to increased gastrointestinal permeability, although this has not been proven.

There is only one case report in which infant serum levels have been sampled. Levels were initially influenced by pregnancy exposure, but at about 4 weeks infant levels were undetectable. After a further tocilizumab dose, levels were also undetectable after about 4 weeks.

Effects in infants

Since tocilizumab is given as a single infusion for COVID-19 treatment, the potential for it to accumulate and cause any effect in the infant is minimised.

Side effects such as immunological reactions or severe infections have not been reported in any infants exposed to date. Most were followed for up to 12 months.

Live (attenuated) vaccination

Tocilizumab is an immunosuppressive therapy. However, routine infant vaccinations, including live (attenuated) vaccinations, do not need to be withheld due to exposure to tocilizumab via breast milk. The risk of immunosuppression in the infant is negligible, and therefore:

  • rotavirus vaccine can be given according to normal routine immunisation schedules
  • BCG (Bacillus Calmette-Guérin) vaccine can be given if there is clinical need.

Some infants exposed to tocilizumab via breast milk were given live vaccination (rotavirus and BCG vaccines) with no adverse effects experienced.

If the infant was exposed to tocilizumab during pregnancy, it is likely that infant serum levels will be affected for a period of time after birth. Contact the UK Drugs In Lactation Advisory Service (UKDILAS) (SPS page), or the UK Teratology Information Service (UKTIS) for further advice regarding live vaccination in this scenario.

Patient Information

The NHS website provides advice for patients on the use of specific medicines in breastfeeding.

Contact us

Get in touch with the UK Drugs In Lactation Advisory Service (UKDILAS) (SPS page), our specialist breastfeeding medicines advice service if you need support in the following situations:

  • you need further advice
  • the medicine in question is not included here
  • the infant is unwell or premature
  • multiple medicines are being taken

About our recommendations

Recommendations are based on published evidence where available. However, evidence is generally very poor and limited, and can require professional interpretation. Assessments are often based on reviewing case reports which can be conflicting and lack detail.

If there is no published clinical evidence, assessments are based on: pharmacodynamic and pharmacokinetic principles, extrapolation from similar drugs, risk assessment of normal clinical use, expert advice, and unpublished data. Simulated data is now increasingly being used due to the ethical difficulties around gathering good quality evidence in this area.

Bibliography

Full referencing is available on request.

Update history

  1. Link to Covid-19 vaccination page removed as page has been removed
  1. COVID-19 vaccination is available, including other safety issues to consider link updated
  1. Published