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Using macrolide antibiotics during breastfeeding

Published
Topics: AzithromycinClarithromycinErythromycin · Infection and infectious diseasesSafety in Breastfeeding ·

Azithromycin, clarithromycin or erythromycin can be used with precautionary infant monitoring. Recommendations apply to full term, healthy infants.

Contents

  1. General considerations
  2. Recommendations
  3. Infant effects
    1. Oral and gut microflora
    2. Treatment of infant infections
    3. Hypersensitivity
    4. Hypertrophic pyloric stenosis
  5. Specific recommendations
    1. Azithromycin
    2. Clarithromycin
    3. Erythromycin
  7. Patient Information
  8. Contact us
  9. About our recommendations
  10. Bibliography
  11. Update history

General considerations

It is important to complete an individual risk assessment (SPS page) for your patient and to apply the principles of prescribing in breastfeeding (SPS page) when looking at the available information and making treatment decisions.

Recommendations

All macrolide antibiotics can be used during breastfeeding with precautionary infant monitoring.

Treatment choice, duration and dose should be primarily based on clinical indications and in line with national and local antimicrobial policy, with suitability in breastfeeding as a secondary consideration.

Reported side effects are not specific to a particular macrolide and are generally mild in nature.

Infant effects

The effect of the macrolide exposure on the infant needs to be considered.

Oral and gut microflora

Exposure to antimicrobials can affect the infant’s natural balance of microflora.

In rare cases, antibiotic exposure has disturbed this balance and caused gastrointestinal disturbances or candidiasis. These effects are generally mild and resolve upon treatment discontinuation.

Treatment of infant infections

There is no conclusive information on whether the concentrations the infant is exposed to through breast milk are enough to be bactericidal or cause bacterial resistance.

If the infant needs treatment themselves with a macrolide or other antibiotic, they should receive the appropriate infant therapeutic dose, regardless of concomitant exposure through breast milk.

Hypersensitivity

There is a theoretical risk of hypersensitivity in the infant after exposure to macrolides through breast milk. Foetal exposure to antibiotics through the placenta may cause sensitisation. Further exposure may result in allergic reactions, even from the negligible quantities seen in breast milk.

As a precaution, the infant should be monitored for signs of hypersensitivity which includes rashes and breathing problems.

Hypertrophic pyloric stenosis

There is conflicting data regarding whether there is an increased risk of infantile hypertrophic pyloric stenosis from exposure to macrolides via breast milk.

Some studies have noted an increased risk during the first 90 days of life, and especially in the first 2 weeks after birth. However, other studies fail to confirm this association. This risk might be increased with erythromycin, although this may simply reflect greater use. In many studies the macrolide was not specified.

Specific recommendations

Use with caution

All formulations of azithromycin, including intravenous therapy can be used during breastfeeding, with precautionary infant monitoring.

Infant monitoring

As a precaution, monitor for gastro-intestinal disturbances such as diarrhoea and vomiting, oral candida infection, rashes, irritability, sleep disturbances, and loss of appetite.

Monitoring the infant will quickly pick up any potential issues. However, further investigation is usually required before the cause can be attributed to the medicine.

Further information

Limited data show that azithromycin passes into breast milk in small amounts.

Azithromycin has a longer half-life than other macrolides and accumulation in the milk is possible. No serious side effects have been observed by azithromycin in breastfed infants.

Azithromycin is used therapeutically in neonates from one month old. The infant dose received via breast milk will be far less than the paediatric therapeutic dose.

Use with caution

All formulations of clarithromycin, including intravenous therapy can be used during breastfeeding with precautionary infant monitoring.

Infant monitoring

As a precaution, monitor for gastro-intestinal disturbances such as diarrhoea and vomiting, oral candida infection, rashes, sleep disturbances, irritability, sweating, and loss of appetite.

Monitoring the infant will quickly pick up any potential issues. However, further investigation is usually required before the cause can be attributed to the medicine.

Further information

Very limited data show that clarithromycin passes into breast milk invery small amounts.

Its short half-life makes accumulation in the breast milk unlikely and its poor oral bioavailability reduces the amount the infant can absorb from breast milk.

Clarithromycin is used therapeutically in full-term neonates from birth. The infant dose received via breast milk has been estimated as less than 1% of the paediatric therapeutic dose.

Use with caution

All formulations of erythromycin, including intravenous therapy can be used during breastfeeding with precautionary infant monitoring.

Infant monitoring

As a precaution, monitor for gastro-intestinal disturbances such as diarrhoea and vomiting, oral candida infection, rashes, sleep disturbances, irritability, sweating, and loss of appetite.

Monitoring the infant will quickly pick up any potential issues. However, further investigation is usually required before the cause can be attributed to the medicine.

Further information

Very limited data show that erythromycin passes into breast milk in very small amounts.

Its short half-life makes accumulation in the breast milk unlikely and its low oral bioavailability reduces the amount the infant can absorb from breast milk.

Erythromycin is used therapeutically in full-term neonates from birth and is well tolerated. The infant dose received via breast milk will be far less than the paediatric therapeutic dose.

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. Editorial change (removal of duplicated clinical considerations section)
  1. Published