Allergy & Asthma Medications
IABLE
Medications Allergy & Asthma Medications

Allergy & Asthma Medications

This section reviews commonly used medications for allergies and asthma.

For more detailed information and references on specific medications, please refer to LactMed, e-lactancia, Infant Risk, or Mother to Baby.

Allergy Medications

There are a few drug classes that can be used to treat allergies during lactation. These are separated by class and summarized below.

Antihistamines

While infants should be monitored for sedation, there is no absolute indication to pump and dump with these medications (1).

  • First generation antihistamines (brompheniramine, chlorpheniramine, cyproheptadine, dimenhydrinate, diphenhydramine, doxylamine, hydroxyzine, meclizine, promethazine, triprolidine): The first-generation antihistamines have more side effects than the second-generation agents. They are more sedating and have a greater likelihood of causing sedation in the lactating parent and infant. They are also more likely to decrease milk production when used in high doses or on a regular basis (1). While dyads should be monitored for sedation and milk production may decrease with higher doses of these medications, there is no absolute indication to pump and dump.
  • Second generation antihistamines (azelastine, cetirizine, desloratadine, fexofenadine, levocetirizine, loratadine, olopatadine): The second-generation antihistamines, whether used orally or topically (e.g. azelastine and olopatadine), are generally less sedating than the first generation antihistamines. They are unlikely to cause infant sedation or a drop in milk production, even with regular use (1). There is no absolute indication to pump and dump.

Corticosteroids

There is no absolute indication to pump and dump though high doses of parenteral (intravenous or injected) steroids may warrant a brief period of pumping and dumping (see below). Corticosteroids can be given intranasally, orally, topically, or by injection for different types of allergies.

  • Oral corticosteroids (prednisone, prednisolone, methylprednisolone, dexamethasone): Although older literature suggests withholding breastfeeding for a time after a dose, this is not necessary. There is no absolute indication to pump and dump.
  • Intranasal corticosteroids (fluticasone, betamethasone): There is no absolute indication to pump and dump.
  • Injectable corticosteroids (methylprednisolone): Extremely high doses (such 1 gram of methylprednisolone) might require withholding breastfeeding for 2-4 hours after a dose (2). Otherwise, there is no absolute indication to pump and dump.

Immunotherapy

Allergy shots are considered safe during lactation. There is no absolute indication to pump and dump.

Leukotriene inhibitors

Montelukast has the most evidence, demonstrating that levels are low. Zafirlukast and zileuton are also expected to have very low levels in breastmilk. Little information is available about possible effect on milk production (3). There is no absolute indication to pump and dump with leukotriene inhibitors (montelukast, zafirlukast, zileuton).

Asthma Medications

There are many classes of medications that can be used to treat asthma and other obstructive airway diseases. While there are special considerations for theophylline (as noted below), there is generally no absolute indication to pump and dump with the majority of medications used to treat asthma. The common options are separated by class and discussed below:

Inhaled bronchodilators

Low to negligible maternal serum levels of these drugs and they have low oral bioavailability, so infant absorption is minimal and no effects on infants have been seen. While we do not have evidence about how these medications affect milk production, these medications are considered safe for use in the breastfeeding dyad. There is no absolute indication to pump and dump with inhaled bronchodilators (inhaled short or long-acting beta-agonists and inhaled anticholinergics).

Inhaled corticosteroids

Low levels in milk and low oral bioavailability lead to undetectable levels in breastfed infants. No effects on infants have been seen. These medications are considered safe in the breastfeeding dyad. There is no absolute indication to pump and dump with inhaled corticosteroids (inhaled budesonide).

Leukotriene inhibitors

See above.

Theophylline

This medication may cause irritability or fretful sleep in infants, especially in newborns and premature infants. The lowest therapeutic dose should be used if this medication is necessary as milk levels mirror blood levels in the lactating parent. Neonates and premature infants appear to clear the medication more slowly, so alternative options should be used for lactating parents of infants this age (4). Alternative medications are preferred, especially with lactating individuals who have premature or newborn infants. If theophylline is used, there is no absolute indication to pump and dump but the lowest therapeutic dose should be used and infants should be monitored for side effects (irritability, poor sleep).

Monoclonal antibodies

Many monoclonal antibodies (such as omalizumab amongst others) are being used in asthma. These are large molecules that would not be well absorbed by the infant even if they do transfer into milk. Check LactMed for further details on specific monoclonal antibodies. There is no absolute indication to pump and dump with monoclonal antibodies.

References

  1. Ngo E, Spigset O, Lupattelli A et al Antihistamine use during breastfeeding with focus on breast milk transfer and safety in humans: A systematic literature review. Basic Clin Pharmacol Toxicol. 2022 Jan;130(1):171-181. doi: 10.1111/bcpt.13663.
  2. E-lactancia.org. Methylprednisolone. https://e-lactancia.org/breastfeeding/methylprednisolone/product/ (Accessed June 13 2022).
  3. Datta P, Rewers-Felkins K, Baker T, Hale TW. Transfer of Montelukast into Human Milk During Lactation. Breastfeed Med. 2017 Jan/Feb;12:54-57. doi: 10.1089/bfm.2016.0162.
  4. Yurchak AM, Jusko WJ. Theophylline secretion into breast milk. Pediatrics. 1976 Apr;57(4):518-20.