Recommended oral or parenteral (injected) corticosteroids of choice during breastfeeding include beclometasone, budesonide, hydrocortisone, methylprednisolone and prednisolone. This is regardless of whether they are given orally or parenterally (although not all medicines are available as both forms).
Try to minimise infant exposure by using the lowest effective dose for the shortest effective duration.
There is very limited information on the use of corticosteroids during breastfeeding, although they are likely to be present in milk.
Avoid prolonged high dose therapy where possible since adrenal suppression and other side-effects may occur in the infant. Where such use is unavoidable, monitor the infant’s adrenal function.
Consideration also needs to be given to monitoring the infant at lower doses if the clinical situation is more complex, for example, if the infant is premature or unwell, or there is exposure to additional medicines via breast milk with similar side-effects.
Short-term use of high dose steroids is normally considered compatible with breastfeeding as the overall exposure will still be low.
Choice considerations
Corticosteroids are used for a wide range of indications. Therefore, choice should primarily be directed at adequately treating the condition first, with safety in breastfeeding a secondary consideration.
Where possible, choose topical or inhaled routes of administration. This will give lower systemic concentrations, which should lead to lower concentrations in breast milk.
There have been limited reports of corticosteroids reducing milk production, when used orally, injected into joints or intramuscularly. For this reason if poor milk production is suspected, infants should be monitored for adequate weight gain.
Specific recommendations
Preferred choice
Oral beclometasone is a preferred choice in breastfeeding due to low systemic absorption and low oral bioavailability.
Monitoring
High doses, or exposure over a long period of time, may require infant monitoring for adrenal suppression. As a precaution, all infants should be monitored for adequate feeding, growth and weight gain.
Further information
There is no published evidence for the use of beclomethasone during breastfeeding . However, low levels are anticipated in milk due to the medicine’s properties.
Use with caution
Betamethasone can be used with caution during breastfeeding, although shorter-acting alternatives are preferred.
Monitoring
High doses or exposure over a long period of time, may require infant monitoring for adrenal suppression. As a precaution, all infants should be monitored for adequate feeding, growth and weight gain.
Further information
There is no published evidence for use in breastfeeding. However, it is used therapeutically in infants over 1 month. Oral doses of up to 8mg daily are unlikely to cause adverse effects in the infant.
Preferred choice
Budesonide is a preferred choice in breastfeeding as levels in breast milk are expected to be negligible.
Monitoring
High doses or exposure over a long period of time, may require infant monitoring for adrenal suppression. As a precaution, all infants should be monitored for adequate feeding, growth and weight gain.
Further information
There is no published evidence of safety for use in breastfeeding. However, negligible levels are anticipated in milk due to the medicine’s properties.
Use with caution
Deflazacort can be used during breastfeeding but alternatives are preferred.
Monitoring
High doses, or exposure over a long period of time, may require infant monitoring for adrenal suppression. As a precaution, all infants should be monitored for adequate feeding, growth and weight gain.
Further information
There is no published evidence for use in breastfeeding. However, it is used in infants over 1 month. Oral doses of up to 60mg daily are unlikely to cause adverse effects in the infant.
Use with caution
Dexamethasone (including local injection) can be used with caution, although there is no published evidence for use in breastfeeding. Alternatives are preferred.
Monitoring
High doses, or exposure over a long period of time, may require infant monitoring for adrenal suppression. As a precaution, all infants should be monitored for adequate feeding, growth and weight gain.
Further information
There is no published evidence of use during breastfeeding. However, it is used therapeutically in infants over 1 month. Oral doses up to 8mg daily are unlikely to cause adverse effects in the infant.
There have been reports of a possible decrease in prolactin release after administration which may reduce milk production.
Use with caution
Fludrocortisone can be used during breastfeeding with caution.
Monitoring
High doses, or exposure over a long period of time, may require infant monitoring for adrenal suppression. As a precaution, all infants should be monitored for adequate feeding, growth and weight gain.
Further information
There is no published evidence of use during breastfeeding. However, the amount in milk is unlikely to be clinically relevant.
Fludrocortisone is used as replacement therapy in adrenal insufficiency, hence the aim is to maintain ‘normal’ plasma hormone ranges in the mother. It is therefore unlikely to be harmful in breastfeeding.
Fludrocortisone can also be used in full-term neonates from birth for adrenal insufficiency.
Preferred choice
Hydrocortisone (including local injection and buccal administration) are a preferred choice during breastfeeding. Hydrocortisone is a normal component of breast milk.
Monitoring
High doses, or exposure over a long period of time, may require infant monitoring for adrenal suppression. As a precaution, all infants should be monitored for adequate feeding, growth and weight gain.
Further information
There is no published evidence for using hydrocortisone therapeutically in breastfeeding. However, hydrocortisone is a natural steroid produced in the adrenal cortex and is therefore a normal component of breast milk. Oral doses up to 160mg daily are unlikely to cause adverse effects in the infant.
It is used in full-term neonates from birth.
Preferred choice
Methylprednisolone is a preferred choice during breastfeeding, due to negligible to very small amounts present in breast milk.
Monitoring
High doses, or exposure over a long period of time, may require infant monitoring for adrenal suppression. As a precaution, monitor for adequate feeding, growth and weight gain.
Further information
Oral or intravenous use
There is limited published evidence for using methylprednisolone during breastfeeding that shows very small amounts pass into breast milk when given orally or intravenously. Oral doses up to 40mg daily and intravenous doses of up to 1g daily are unlikely to cause side-effects in the infant. To date, no side effects have been reported.
Other injectable routes
Although there is no evidence for using other administration routes of methylprednisolone during breastfeeding, their pharmacokinetics would not suggest any difference and they would not be expected to pass into milk in significant amounts.
Intra-articular injections of methylprednisolone may temporarily decrease milk production.
Depot injections are unlikely to cause side-effects in the infant due to their slow release profile.
Preferred choice
Prednisolone is a preferred choice during breastfeeding due to experience of use and small amounts being present in breast milk.
Monitoring
High doses, or exposure over a long period of time, may require infant monitoring for adrenal suppression. As a precaution, all infants should be monitored for adequate feeding, growth and weight gain.
Further information
There is limited published evidence of use in breastfeeding, although there is extensive experience. Small amounts are present in breast milk after oral administration. Oral doses up to 40mg daily are unlikely to cause adverse effects in the infant.
Patient Information
The NHS website provides advice for patients on the use of specific medicines in breastfeeding.
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.