Steroid injection for RA breastfeeding mother

[Birdling]

I am enquiring about a 33yr-old nursing mother with RA, who has been told she must immediately wean her 4 month old baby, due to the length of time on oral predisolone (concern to specialist is of risk to mother, not infant). She has been on oral prednisolone during the pregnancy (7.5 - 20mg daily, mostly 7.5mg) and since 3 weeks after birth (17.5 - 40 mg daily, most commonly 17.5mg), taking them a minimum of 4 hours before feeds. The mother would like to continue to breastfeed, at least until infant is 5 or 6 months if possible, and is unhappy to suddenly wean the baby who is feeding well and settled. Attempts to reduce pred to 10mg daily have been unsuccessful, due to severe flare ups of the arthritis.
The specialist has recommended an injection of slow release steroid into patient, images of patient taking the oral steroids, and a return to methotrexate as per pre pregnancy. The mother would like to try the injection as a replacement or in conjunction with a lower dose of oral steroids, and hold off taking methotrexate until baby is weaned.
Is a steroid injection, or a combination of injection/5 - 10mg daily oral steroid, compatible with the mother continuing to breastfeed? Are there risks to the child from the injection compared to the oral steroids? If able to continue to breastfeed, when would be safe following the injection to resume feeding?

Thank you very much. We have consulted the Medication and Mothers Milk during the lactation period for the medications, and have found it so helpful, but cannot find the specific infor ation regarding the difference with the injection.

[cpride]

Dear Birdling,

Small amounts of prednisone/prednisolone are transferred to the breast milk, although it is probably safe in breastfeeding. There is concern of growth impairment in breastfed infants with high-dose prolonged steroid therapy. Recommend using low-dose therapy, or high-dose short-term therapy when needed to minimize exposure. In small doses, most steroids are certainly not contraindicated in nursing mothers. Following administration, wait at least 4 hours if possible prior to feeding the infant to reduce exposure. With high doses (>40 mg/day), particularly for long periods, steroids could potentially produce problems in infant growth and development, although we have absolutely no data in this area, or which doses would pose problems. Brief applications of high dose steroids are probably not contraindicated as the overall exposure is low. With prolonged high dose therapy, the infant should be closely monitored for growth and development. After an intramuscular injection of prednisolone, it is recommended to pump and discard for 12 hours to allow the initial peak that occurs over the first 8 to 12 hours to pass before resuming breastfeeding. Methotrexate is compatible with breastfeeding in some instances. It is, however, dose related. Call the InfantRisk Center at 806-352-2519. We are open Monday through Friday, 8 to 5 CDT. Let us know what the mother's dose would be and, we can go over the information or have the mom call us directly.

Sincerely,
Cindy Pride, MSN, CPNP
TTUHSC InfantRisk Center