What are your practice recommendations regarding live vaccinations in infants/children of women who are currently on DMARDs and are breastfeeding?

This question needs some clarification to provide an exact answer. However, in regards to DMARDs in lactation, per the ACR 2020 Reproductive Health Guidelines and resources like LactMed and Mother to Baby (both free!), Methotrexate, Leflunomide, and Mycophenolate are not recommended in lactation. This is more so based on theory vs. data, but that is the stance of multiple medical organizations at this juncture.

That leaves us with Azathioprine, Sulfasalazine, and Hydroxychloroquine as DMARDs for use in breastfeeding. Out of the 3, only Azathioprine is immunosuppressive, Hydroxychloroquine and Sulfasalazine are immunomodulatory, and therefore no issues with causing immunosuppression in the baby. Azathioprine has been shown to pass minimally,...