Breastfeeding & Psychiatric Medications - MGH Center

for Women's Mental Health

womensmentalhealth.org/specialty-clinics-2/breastfeeding-and-psychiatric-medication-2/

Breastfeeding & Psychiatric MedicationsMGH Center for Women's Mental Health2022-

08-22T13:23:01-04:00

Given the prevalence of psychiatric illness during the postpartum period, a significant
number of women may require pharmacological treatment while nursing. Appropriate
concern is raised, however, regarding the safety of psychotropic drug use in women who
choose to breastfeed while taking these medications. While many women with
postpartum illness delay treatment because they are worried that the medications they
take may harm the nursing infant, the accumulated data indicates that the risk of adverse
events in the nursing infant is low.

General Principles

Given the many benefits of breastfeeding, some women taking psychiatric medications
may wish to nurse their infants. When making this decision, several variables must be
considered. These include the known and unknown risks of medication exposure for the
baby via breast milk, the effects of untreated illness in the mother, and the benefits of and
maternal preferences for breastfeeding. There are established health benefits of
breastfeeding for babies and mothers.

Efforts have been made to quantify the amount of psychotropic medications and their
metabolites in the breast milk of nursing mothers. In order to more accurately measure
the infant’s exposure to medication, serum drug levels in the infant have also been
assessed. From the available data, it appears that all medications, including
antidepressants, antipsychotic agents, mood stabilizers, and benzodiazepines, are
secreted into the breast milk. However, concentrations of these agents in breast milk vary
considerably. The amount of medication to which an infant is exposed depends on
several factors: factors pertaining to the specific medication, the maternal dosage of
medication, the frequency of dosing and infant feedings, and the rate of maternal drug
metabolism.

The decision to breastfeed while taking medications is more complicated when a baby is
premature or has medical complications. The nursing infant’s chances of experiencing
toxicity are dependent not only on the amount of medication ingested but also on how
well any ingested medication is metabolized. Most psychotropic medications are
metabolized by the liver. During the first few weeks of a full-term infant’s life, there is a
lower capacity for hepatic drug metabolism, which is about one-third to one-fifth of the
adult capacity. Over the next few months, the capacity for hepatic metabolism increases
significantly and, by about 2 to 3 months of age, it surpasses that of adults. In premature

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infants or in infants with signs of compromised hepatic metabolism (e.g.,
hyperbilirubinemia), breastfeeding typically is deferred because these infants are less
able to metabolize drugs and may be more likely to experience adverse events.

Antidepressants

Antidepressants in general are considered to be relatively safe for use during

breastfeeding when clinically warranted, and SSRIs in particular are one of the best
studied classes of medications during breastfeeding. Excellent and thorough reviews on
the topic of antidepressants and breastfeeding have been published (Burt
2001; Weissman 2004). In the most rigorous studies, nursing women have repeatedly
provided breast milk samples and infant blood samples in order for investigators to
quantify medication exposure to the infant.

Data have accumulated regarding the use of various antidepressant medications during
breastfeeding. Available data on the use of tricyclic antidepressants (TCAs),
fluoxetine, paroxetine, and sertraline during breastfeeding have been encouraging and
suggest that the amounts of drug to which the nursing infant is exposed is low and that
significant complications related to neonatal exposure to antidepressants in breast milk
appear to be rare. Typically very low or non-detectable levels of drug have been detected
in the infant serum, and one recent report indicates that exposure to medication in breast
milk does not result in clinically significant blockade of serotonin (5-HT) reuptake in
infants.

Although less information is available on other antidepressants, serious adverse events

related to exposure to these medications have not been reported. There have been a
small number of case reports of adverse events in infants exposed to antidepressants in
breast milk, including jitteriness, irritability, excessive crying, sleep disturbance, and
feeding problems. In many cases it has not been possible to establish a causal link
between these events and exposure to drug.

Many clinicians and their patients ask which antidepressant is the “safest” for
breastfeeding. It is somewhat misleading to say that certain medications are “safer” than
others. All medications taken by the mother are secreted into the breast milk, and there is
no evidence to suggest that certain antidepressants pose significant risks to the nursing
infant.

In terms of selecting an appropriate antidepressant, one should try to choose an

antidepressant for which there are data to support its safety during breastfeeding (i.e.,
sertraline, paroxetine, fluoxetine, tricyclic antidepressants). However, some situations
may warrant the use of antidepressants with less available safety data. For example, if a
woman has responded to a particular antidepressant in the past, it would be reasonable
to consider using that antidepressant again. If she has been taking an antidepressant
during the course of her pregnancy and has been doing well, it would be prudent to
continue with that same antidepressant after delivery, as switching to another
antidepressant may put her at increased risk for relapse.

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We do not regularly measure drug levels in the breastfeeding mother or baby; however,
there may be certain situations where information on exposure to drug in the child may
help make decisions regarding treatment. If there is a significant change in the child’s
behavior (e.g., irritability, sedation, feeding problems, or sleep disturbance), an infant
serum drug level may be obtained. If levels are high, breastfeeding may be suspended.
Similarly if the mother is taking a particularly high dosage of medication, it may be helpful
to measure drug levels in the infant to determine the degree of exposure.

Anti-Anxiety Agents

Given the prevalence of anxiety symptoms during the postpartum period, anxiolytic
agents are often used in this setting. Data regarding the use of benzodiazepines have
been limited; however, the available data suggest that amounts of medication to which
the nursing infant is exposed are low. Case reports of sedation, poor feeding, and
respiratory distress in nursing infants have been published; however, the data, when
pooled, suggest a relatively low incidence of adverse events in infants exposed to
benzodiazepines in the breast milk.

Mood Stabilizers

For women with bipolar disorder, breastfeeding may pose more significant challenges.
First, on-demand breastfeeding may significantly disrupt the mother’s sleep and thus may
increase her vulnerability to relapse during the acute postpartum period. Second, there
have been reports of toxicity in nursing infants related to exposure to various mood
stabilizers, including lithium and carbamazepine, in breast milk.

Lithium is excreted at relatively high levels in the mother’s milk, and infant serum levels
are about one-third to one-half of the mother’s serum levels. Reported signs of toxicity in
nursing infants have included cyanosis, hypotonia, and hypothermia. Although
breastfeeding typically is avoided in women taking lithium, some women may choose to
use lithium while nursing. In this setting, the lowest possible effective dosage should be
used and both maternal and infant serum lithium levels should be followed. In
collaboration with the pediatrician, the child should be monitored closely for signs of
lithium toxicity, and lithium levels, thyroid stimulating hormone (TSH), blood urea nitrogen
(BUN), and creatinine should be monitored every 6-8 weeks while the child is nursing.

Several recent studies have suggested that lamotrigine reaches infants through breast
milk in variable doses, with infant serum levels ranging from 20%-50% of the mother’s
serum concentrations. In addition, maternal serum levels of lamotrigine increase
significantly after delivery, which may contribute to the high levels found in nursing infants.
None of these studies have reported any adverse events in breastfeeding newborns. To
read more on the safety of lamotrigine versus lithium, please reference this past blog.

One worry shared by clinicians and new mothers is the risk for Stevens-Johnson
syndrome (SJS). This is a severe, potentially life-threatening rash, most commonly
resulting from a hypersensitivity reaction to a medication, which occurs in about 0.1% of
bipolar patients treated with lamotrigine. Thus far, there have been no reports of SJS in

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infants associated with exposure to lamotrigine. In fact, it appears that cases of drug-
induced SJS are extremely rare in newborns. Despite the variable levels of medication
found in infants in studies to date, none of these studies have reported any adverse
events in the breastfeeding newborns. More research is required to assess the safety of
lamotrigine in nursing infants, and decisions regarding the use of this drug in
breastfeeding women involves a careful consideration of the risks and benefits of using
this medication.

Although the American Academy of Pediatrics has deemed both carbamazepine

(Tegretol) and valproic acid (Depakote) to be appropriate for use in breastfeeding
mothers, few studies have assessed the impact of these agents on infant well-being. Both
of these mood stabilizers have been associated in adults with abnormalities in liver
function and fatal hepatotoxicity. Hepatic dysfunction secondary to carbamazepine
exposure in breast milk has been reported several times. Most concerning is that the risk
for hepatotoxicity appears to be greatest in children younger than 2 years of age; thus,
nursing infants exposed to these agents may be particularly vulnerable to serious adverse
events. In those women who choose to use valproic acid or carbamazepine while nursing,
routine monitoring of drug levels and liver function tests in the infant is recommended. In
this setting, ongoing collaboration with the child’s pediatrician is crucial.

Antipsychotic Agents

Information regarding the use of antipsychotic drugs is limited and is particularly lacking
for the newer atypical agents. While the use of chlorpromazine has been associated with
adverse events including sedation and developmental delay, adverse events appear to be
rare when medium- or high-potency agents are used.

Less data, however, is available on the atypical antipsychotic agents. Data on clozapine
suggest that it may be concentrated in the breast milk; however, there are no data on
infant serum levels, making it difficult to interpret the relevance of this finding. Given the
severity of adverse events associated with clozapine exposure in adults (i.e., decreased
white blood cell count), the use of this medication should be reserved for those with
treatment-refractory illness, and monitoring of white blood cell counts in the nursing infant
is mandatory.

There is very limited data on the use of other atypical antipsychotic agents during
lactation; however, limited data available on olanzapine, risperidone, and quetiapine
suggest that the excretion of these medications in breast milk is low and that adverse
effects appear to be rare. Monitoring of the infant is encouraged, as there has been one
report of an infant who had sedation on a higher dose of olanzapine, which resolved after
the mother’s dose was halved to 5mg/day. To date, there have been no reports on the
use of the antipsychotic medications, ziprasidone (Geodon) and aripiprazole (Abilify)
while breastfeeding.

Treatment Guidelines

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Consultations regarding the safety of psychiatric medications in breastfeeding women
should include a discussion of the known benefits of breastfeeding to mother and infant
and the possibility that exposure to medications in the breast milk may occur. Although
routine assay of infant serum drug levels was recommended in earlier treatment
guidelines, this procedure is probably not warranted; in most instances low or non-
detectable infant serum drug levels will be evident and serious adverse side effects are
rarely reported. This testing is indicated, however, if neonatal toxicity related to drug
exposure is suspected. Infant serum monitoring is also indicated when the mother is
nursing while taking lithium, valproic acid, carbamazepine, or clozapine.

We have varying amounts of study pertaining to individual medications, with SSRIs being
among the best studied medications in breastfeeding. Also, data that is available informs
most specifically on the short-term safety of these medications, and long term systematic
data are unavailable. Therefore, in each individual case, the known and unknown risks of
exposure must be balanced with the risks of untreated maternal illness in the mother and
her desire to breastfeed.

For the latest information on breastfeeding and psychiatric medication, please visit our
blog.

How do I get an appointment?

Despite the high rate of postpartum depression seen in women after childbirth, the illness
is frequently not treated because of women’s wish to breastfeed. Clinical consultation is
offered to women who may benefit from use of medication while breastfeeding, taking into
account all available information regarding the safety of this practice during lactation.
Consultations regarding treatment options can be scheduled by calling our intake
coordinator at 617-724-7792.

At this time the Center does not have any active studies investigating breastfeeding and
psychiatric medications. New studies may become active in the near future. In order to
remain informed about any studies for which you may be eligible, click here

PARTICIPATE IN RELATED RESEARCH

The National Pregnancy Registry for Psychiatric Medications:

All pregnant women between the ages of 18-45 with a history of psychiatric illness are
eligible to enroll in the registry.

LEARN MORE

MGHPDS Mobile App

Are you pregnant? Do you own a smart phone? Get the MGH Perinatal Depression Scale
app.

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LEARN MORE

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