Summary of Use during Lactation

Hydrocortisone (cortisol) is a normal component of breastmilk, but it has not been studied in milk after exogenous administration in pharmacologic amounts. Although it is unlikely that dangerous amounts of hydrocortisone would reach the infant, a better studied corticosteroid might be preferred. Maternal use of hydrocortisone as an enema would not be expected to cause any adverse effects in breastfed infants. Local maternal injections, such as for tendinitis, would not be expected to cause any adverse effects in breastfed infants. Medium to large doses of corticosteroids given systemically or injected into joints or the breast have been reported to cause temporary reduction of lactation. See also Hydrocortisone, Topical.

Cortisol in breastmilk might have a role in intestinal maturation, the intestinal microbiome, growth, body composition or neurodevelopment, but adequate studies are lacking.[1] Concentrations follow a diurnal rhythm, with the highest concentrations in the morning at about 7:00 am and the lowest concentrations in the late afternoon and evening.[2,3] Cortisol concentration in milk also increase with infant age and decrease with complementary feeding and infant illness.[4] Cortisol in milk may protect against later infant obesity, especially in girls;[5] however, in another study, milk glucocorticoid levels were positively associated with percent fat mass, adiposity and head circumference at 1 year of age.[6] Maternal stress can increase breastmilk cortisol levels, especially with preterm births.[7,8] Some information indicates that maternal adverse childhood experiences may decrease cortisol concentration in their breastmilk.[9]

Drug Levels

Numerous methods have been used to measure cortisol in milk. Some have measured only unconjugated cortisol and others have hydrolyzed sulfate and glucuronide conjugates to measure total cortisol. Neonates are unable to deconjugate these moieties, so the age of the infant affects the relevance of findings.[10]

Maternal Levels. Cortisol was measured in the colostrum and milk of 11 women monthly for up to 12 months postpartum. Levels in late pregnancy averaged 24.5 mcg/L and fell over the first 10 days postpartum to an average of 1.8 mcg/L. Milk cortisol levels between months 2 and 12 averaged 7.2 mcg/L, but varied with time and among individuals (range 0.2 to 32 mcg/L).[11]

Free cortisol was measured in 13 women on days 1, 2, and 3 postpartum (7 spontaneous births) or days 3, 4, and 5 postpartum (6 elective cesarean sections). Milk levels were measured before and after nursing, but the values were not statistically different. In the women with spontaneous deliveries, before and after milk levels averaged 17.2 mcg/L on day 1, 16.8 mcg/L on day 2, and 7.4 mcg/L on day 3 postpartum. In the women with cesarean deliveries, before and after milk levels averaged 26.5 mcg/L on day 3, 15.1 mcg/L on day 4, and 14.1 mcg/L on day 6 postpartum.[12]

Thirteen full-term mothers donated milk between 8 and 28 weeks postpartum. Unconjugated cortisol concentrations ranged from 1.45 to 8.34 mcg/L.[10]

A study compared 10 mothers who delivered preterm (<32 week) infants to 10 who delivered at 37 weeks or greater. Breastmilk cortisol concentrations were 50% lower in mothers of preterm infants in the first week postpartum, although the difference was not statistically significant.[3]

A study of 23 mothers found that the average cortisol concentration in breastmilk was 1.6 mcg/L over 24 hours. Concentrations were highest in the morning between 4:00 am and 10:00 am and lowest in the evening between 4:00 pm to 10:00 pm.[2]

Cortisol was measured in the breastmilk of 22 women who delivered preterm infants between 28 and 32 weeks of gestation. The average cortisol concentration in breastmilk was 4.48 mcg/L with considerable variation. Mothers who gave birth before 30 weeks of gestation had an average cortisol concentration of 1.61 mcg/L and those who delivered after 30 weeks had an average concentration of 2.16 mcg/L.[13]

Three hundred fifty-four milk samples were collected by 170 mothers of preterm infants in the morning at about 5 and 10 days and at 4 months corrected age. The median concentration of cortisol in preterm milk was 0.5 mcg/L (range 0.03 to 3.7 mcg/L) and of cortisone was 4.3 mcg/L (range 0.3 to 15.5 mcg/L). Cortisone concentrations were greater than cortisol at all time points. The cortisol concentration was higher in mature milk than in samples collected on days 5 and 10: day 5: 0.6 mcg/L; day 10: 0.5 mcg/L; 4 months 1.2 mcg/L. In contrast, cortisone concentrations did not change significantly over time: day 5, 5.2 mcg/L; day 10, 5.0 mcg/L; 4 months, 4.5 mcg/L. Mothers who received a complete course of antenatal corticosteroids had lower concentrations of cortisol (mean difference –0.3 mcg/L) and cortisone (mean difference –1.8 mcg/L) than mothers who did not.[14]

Thirty-eight healthy nursing mothers provided 24-hours milk samples during the first, third and sixth month of lactation. Cortisol concentrations averaged 11.2, 11.2, and 12 mcg/L, respectively. No associations were detected related to maternal or infant characteristics that were measured such as maternal psychological status and infant psychomotor development.[15]

Forty-eight women from upstate New York donated milk samples for cortisol analysis. Milk cortisol levels ranged from 0.98 to 10.07 mcg/L. Milk cortisol increased by 7.1% with each month of child age. Introduction of complementary foods was associated with a 41% lower milk cortisol and current symptoms of child illness were associated with 33% lower milk cortisol.[4]

Infant Levels. Relevant published information was not found as of the revision date.

Effects in Breastfed Infants

None reported with any systemic corticosteroid.

Effects on Lactation and Breastmilk

Published information on the effects of hydrocortisone on serum prolactin or on lactation in nursing mothers was not found as of the revision date. Medium to large doses of corticosteroids given systemically or injected into joints or the breast have been reported to cause temporary reduction of lactation.[16-20]

A study of 46 women who delivered an infant before 34 weeks of gestation found that a course of another corticosteroid (betamethasone, 2 intramuscular injections of 11.4 mg of betamethasone 24 hours apart) given between 3 and 9 days before delivery resulted in delayed lactogenesis II and lower average milk volumes during the 10 days after delivery. Milk volume was not affected if the infant was delivered less than 3 days or more than 10 days after the mother received the corticosteroid.[21] An equivalent dosage regimen of hydrocortisone might have the same effect.

A study of 87 pregnant women found that betamethasone given as above during pregnancy caused a premature stimulation of lactose secretion during pregnancy. Although the increase was statistically significant, the clinical importance appears to be minimal.[22] An equivalent dosage regimen of hydrocortisone might have the same effect.

Alternate Drugs to Consider

(Systemic) Methylprednisolone, Prednisolone, Prednisone

References

1.

Hollanders JJ, Heijboer AC, van der Voorn B, et al. Nutritional programming by glucocorticoids in breast milk: Targets, mechanisms and possible implications. Best Pract Res Clin Endocrinol Metab 2017;31:397-408. [PubMed: 29221568]

2.

Pundir S, Wall CR, Mitchell CJ, et al. Variation of human milk glucocorticoids over 24 hour period. J Mammary Gland Biol Neoplasia 2017;22:85-92. [PubMed: 28144768]

3.

van der Voorn B, de Waard M, van Goudoever JB, et al. Breast-milk cortisol and cortisone concentrations follow the diurnal rhythm of maternal hypothalamus-pituitary-adrenal axis activity. J Nutr 2016;146:2174-2179. [PubMed: 27629575]

4.

Anyim R, Li S, Armstrong D, et al. Predictors of milk cortisol in North American women. Am J Hum Biol 2024;36:e23985. [PubMed: 37712627]

5.

Hahn-Holbrook J, Le TB, Chung A, et al. Cortisol in human milk predicts child BMI. Obesity (Silver Spring) 2016;24:2471-2474. [PMC free article: PMC5400496] [PubMed: 27891832]

6.

Pundir S, Gridneva Z, Pillai A, et al. Human milk glucocorticoid levels are associated with infant adiposity and head circumference over the first year of life. Front Nutr 2020;7:166. [PMC free article: PMC7516011] [PubMed: 33015131]

7.

Aparicio M, Browne PD, Hechler C, et al. Human milk cortisol and immune factors over the first three postnatal months: Relations to maternal psychosocial distress. PLoS One 2020;15:e0233554. [PMC free article: PMC7241837] [PubMed: 32437424]

8.

Tekgündüz SE, Lazoğlu M, Nailoğlu M, et al. The relationship of preterm, term, and post-term births to maternal stress and human milk cortisol levels. Breastfeed Med 2023;18:462-8. [PubMed: 37335326]

9.

Vacaru SV, Brett BE, Eckermann H, de Weerth C. Determinants of maternal breast milk cortisol increase: Examining dispositional and situational factors. Psychoneuroendocrinology 2023;158:106385. [PubMed: 37757597]

10.

van der Voorn B, Martens F, Peppelman NS, et al. Determination of cortisol and cortisone in human mother's milk. Clin Chim Acta 2015;444:154-5. [PubMed: 25687161]

11.

Kulski JK, Hartmann PE. Changes in the concentration of cortisol in milk during different stages of human lactation. Aust J Exp Biol Med Sci 1981;59 (Pt 6):769-78. [PubMed: 7340774]

12.

Patacchioli FR, Cigliana G, Cilumbriello A, et al. Maternal plasma and milk free cortisol during the first 3 days of breast-feeding following spontaneous delivery or elective cesarean section. Gynecol Obstet Invest 1992;34:159-63. [PubMed: 1427417]

13.

Pundir S, Mitchell CJ, Thorstensen EB, et al. Impact of preterm birth on glucocorticoid variability in human milk. J Hum Lact 2018;34:130–6. [PubMed: 28903014]

14.

Muelbert M, Alexander T, Vickers MH, et al. Glucocorticoids in preterm human milk. Front Nutr 2022;9:965654. [PMC free article: PMC9552215] [PubMed: 36238462]

15.

Zielinska-Pukos MA, Bryś J, Kucharz N, et al. Factors influencing cortisol concentrations in breastmilk and its associations with breastmilk composition and infant development in the first six months of lactation. Int J Environ Res Public Health 2022;19:14809. [PMC free article: PMC9690377] [PubMed: 36429527]

16.

McGuire E. Sudden loss of milk supply following high-dose triamcinolone (Kenacort) injection. Breastfeed Rev 2012;20:32-4. [PubMed: 22724311]

17.

Babwah TJ, Nunes P, Maharaj RG. An unexpected temporary suppression of lactation after a local corticosteroid injection for tenosynovitis. Eur J Gen Pract 2013;19:248-50. [PubMed: 24261425]

18.

Smuin DM, Seidenberg PH, Sirlin EA, et al. Rare adverse events associated with corticosteroid injections: A case series and literature review. Curr Sports Med Rep 2016;15:171-6. [PubMed: 27172081]

19.

Das N, Dave S, Dangaich R, et al. Lactation failure following therapeutic steroid treatment in a mother with postpartum depression and spinal-dural arteriovenous fistula: Case report and literature review. Int J Gynaecol Obstet 2023. [PubMed: 38093554]

20.

Rosen-Carole C, Datta P, Palmiter K, et al. Transfer of injected triamcinolone into human milk of a lactating patient suffering from idiopathic granulomatous mastitis. Breastfeed Med 2023;18:74-7. [PubMed: 36638194]

21.

Henderson JJ, Hartmann PE, Newnham JP, Simmer K. Effect of preterm birth and antenatal corticosteroid treatment on lactogenesis II in women. Pediatrics 2008;121:e92-100. [PubMed: 18166549]

22.

Henderson JJ, Newnham JP, Simmer K, Hartmann PE. Effects of antenatal corticosteroids on urinary markers of the initiation of lactation in pregnant women. Breastfeed Med 2009;4:201-6. [PubMed: 19772378]

Substance Name

Hydrocortisone

CAS Registry Number

50-23-7

Drug Class

Breast Feeding

Lactation

Milk, Human

Corticosteroids, Systemic

Glucocorticoids

Anti-Inflammatory Agents