Short term use (a single course of less than 3 week’s duration) is acceptable for most tetracyclines, with precautionary infant monitoring. Long term use is generally not recommended.
Tetracycline is the preferred choice in breastfeeding due to more published evidence of use in breastfeeding and negligible amounts in breast milk.
However, 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.
Infant Effects
The potential effects of the tetracycline antibiotic exposure on the infant need to be considered.
Bone deposition and dental staining
There is a theoretical concern regarding bone deposition of tetracyclines and possible staining of infant’s dental enamel. However, these effects have not been confirmed, and are unlikely during short term use.
As a precaution, prolonged or repeated courses should be avoided where possible during breastfeeding.
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 an 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 antibiotics 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.
Specific recommendations
Preferred choice
Tetracycline is the preferred choice tetracycline antibiotic during breastfeeding, although infant monitoring is still required.
Infant monitoring
As a precaution, monitor for skin rashes, gastrointestinal disturbances (vomiting, diarrhoea) and candidiasis (oral thrush, nappy rash).
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
Published evidence of use in breastfeeding shows negligible amounts pass into breast milk. Side effects have not been reported in breastfed infants.
It is bound by calcium to a higher extent than other tetracycline antibiotics, further inhibiting the amount the infant can absorb from breast milk.
Use with caution
Demeclocycline can be used with caution during breastfeeding, with infant monitoring.
Infant monitoring
As a precaution, monitor for skin rashes, gastrointestinal disturbances (vomiting, diarrhoea) and candidiasis (oral thrush, nappy rash).
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
There is limited published evidence of use in breastfeeding which shows very small amounts pass into breast milk.
Absorption by the infant is also inhibited by calcium in the breast milk.
Use with caution
Doxycycline can be used with caution during breastfeeding, with infant monitoring.
Infant monitoring
As a precaution, monitor for skin rashes, gastrointestinal disturbances (vomiting, diarrhoea) and candidiasis (oral thrush, nappy rash).
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
There is limited published evidence of use in breastfeeding which shows small to moderate amounts pass into breast milk.
There is less binding of calcium in breast milk to doxycycline compared to other tetracycline antibiotics. This may result in increased infant absorption.
Use with caution
Minocycline can be used with caution during breastfeeding with infant monitoring.
Infant monitoring
As a precaution, monitor for skin rashes, gastrointestinal disturbances (vomiting, diarrhoea) and candidiasis (oral thrush, nappy rash).
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
There is limited published evidence of use in breastfeeding which shows very small amounts pass into breast milk.
Black discolouration of breast milk has been reported due to iron chelation, although this is not thought to be harmful.
There is less binding of calcium in breast milk to minocycline compared to other tetracycline antibiotics. This may result in increased infant absorption.
Use with caution
Oxytetracycline can be used with caution during breastfeeding with infant monitoring.
Infant monitoring
As a precaution, monitor for skin rashes, gastrointestinal disturbances (vomiting, diarrhoea) and candidiasis (oral thrush, nappy rash).
Monitoring the infant will quickly pick up any potential issues but usually further investigation is required before the cause can be attributed to the medicine.
Further information
There is limited published evidence of use in breastfeeding which shows negligible amounts pass into breast milk. Side effects have not been reported in breastfed infants.
Absorption by the infant is also inhibited by calcium in the breast milk.
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.