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macrolide antibiotics during breastfeeding

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

All macrolide antibiotics can be used during breastfeeding with precautionary infant monitoring (1):

  • 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

Clinical considerations (1,2):

  • epidemiologic evidence indicates that the risk of hypertrophic pyloric stenosis in infants might be increased by use of maternal macrolides, especially in infants exposed in the first 2 weeks after birth
    • evidence suggest that this risk may be greater with erythromycin (1)
  • infant effects
    • 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
          • effects are generally mild and resolve upon treatment discontinuation

  • treatment of infant infections
    • 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
    • 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
    • is conflicting data regarding whether there is an increased risk of infantile hypertrophic pyloric stenosis from exposure to macrolides via breast milk (1)
    • some studies have noted an increased risk during the first 90 days of life, and especially in the first 2 weeks after birth (1)
      • a nationwide cohort study showed macrolide use in infants was associated with a strongly increased risk of infantile hypertrophic pyloric stenosis (IHPS), including a 30-fold increased risk with use during the first two weeks after birth and a lower, but significantly increased threefold risk with use on days 14 to 120 (2)
      • risk might be increased with erythromycin, although this may simply reflect greater use
      • note that other studies fail to confirm this association between breastfeeding and maternal macrolide antibiotic use and risk of hypertrophic pyloric stenosis (1)


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