Psychiatrist Linda Chaudron, M.D., M.S., runs a perinatal clinic at the
University of Rochester Medical Center, where some of the new mothers she sees
are taking psychotropic drugs.
Deciding whether a breastfeeding mother should remain on a particular
medication, stop using it, or switch to another, presumably safer, drug is no
simple matter. For a start, while some of Chaudron's clinic patients have
planned for pregnancy and breastfeeding, others have become pregnant with
little knowledge of how the drugs they are taking might affect their fetus or
infant, Chaudron told Psychiatric News.
Chaudron, who has been studying the effects of psychiatric medications used
while a mother is breastfeeding, is an associate professor of psychiatry and
obstetrics and gynecology and associate chair for clinical services at the
University of Rochester School of Medicine. She is a coauthor of the recent
joint report from APA and the American College of Obstetricians and
Gynecologists (ACOG) on treatment recommendations for depression in pregnant
women (Psychiatric News, September 4).
The psychiatrists, pediatricians, and ob/gyns who care for mothers and
their infants all need guidance on the risks of maternal medications during
breastfeeding, but data can be hard to find, she said.
Use of psychotropic drugs during breastfeeding is supported by
evidence-based research for less than one-third of such medications for which
information was available, according to a review of four decades of medical
literature in the October
Despite efforts worldwide to promote breastfeeding of infants, little is
known about the excretion of psychotropic drugs in breast milk or adverse
effects on nursing babies, wrote Filomena Fortinguerra, Pharm.D., Antonio
Clavenna, M.D., and Maurizio Bonati, M.D., of the Laboratory for Mother and
Child Health in the Public Health Department of the Mario Negri Institute for
Pharmacological Research in Milan, Italy.
Nursing women are often confused or anxious about using these medications,
and often will stop using them or stop breastfeeding. Balancing drug risk to
an infant against the potential harms of untreated mental illness is
Product-information data sheets offer little help in solving that dilemma.
They frequently say that the drug should not be used during lactation or that
breastfeeding should be discontinued, wrote the authors.
"The warnings are not necessarily related to observed or reported
adverse effects," they said. "They are often used as a defensive
measure on the part of the manufacturer when the drug's safety information is
The Italian researchers searched Medline, Embase, and PsychINFO for studies
published from 1967 through July 2008 on 96 selected psychotropic drugs. They
found no documentation for 34 of those drugs. Of the remaining 62 medications
(found in 183 original articles), there was evidence to back the use of only
19 (31 percent) among lactating women. SSRI antidepressants and antiepileptics
appear to be the best-studied classes of drugs. Some of the drugs they include
are used in Europe, but not in the United States.
The study considered factors such as maternal drug dosage, the ratio of the
concentration of the drug in the mother's milk to that in her plasma, the
fraction of the mother's dose that the baby ingested, and the incidence of
adverse effects to the infants.
Each drug has to be considered individually, said the authors, because"
there are documented differences between drugs within the same class,
and there is no class action in relation to breastfeeding."
Drugs within each therapeutic category that result in minimal exposure to
the infant should be considered as first choices for breastfeeding
For instance, among the 20 antidepressants reviewed, sertraline,
paroxetine, and fluvoxamine are the first choices to prescribe, in the
authors' opinion. Citalopram, escitalopram, and fluoxetine, in contrast, are
contraindicated during lactation because of the relatively high amounts
ingested by infants, the reported adverse effects in infants, and their long
half-life. Too few extended studies of SSRIs are available to judge any
long-term neurobehavioral effects.
Chlorpromazine and olanzapine could be considered first-choice drugs among
antipsychotics, while clozapine, lithium, and sulpiride are contraindicated,
wrote Fortinguerra, Clavenna, and Bonati.
"Because psychosis requires long-term treatment and because the data
on safety of antipsychotics during lactation are limited, the benefits of
breastfeeding may be weighed against the potential risks of medication,"
There are few data available on the effects of hypnotics and anxiolytics on
neonates, but long-acting benzodiazepines should be ruled out and infants
monitored for sedation, nausea, or poor feeding.
The authors noted several points based on their analysis. Valproic acid and
carbamazepine are the preferred medications for epilepsy during breastfeeding.
Ethosuximide, phenobarbital, lamotrigine, primidone, topiramate, and
zonisamide are contraindicated, because of reported adverse effects in infants
and the relatively high dosage delivered to them in breast milk.
Only three mother-baby pairs have been included in studies of
methylphenidate, the only psychostimulant studied, so it is not possible to
evaluate its safety in nursing infants.
"This is a nice overview for psychiatrists, pediatricians, and
ob/gyns to refer to about safety issues, but it shows how little information
is out there," said Chaudron.
Even with the help of the data in the Pediatrics article, care for
breast-fed infants requires close cooperation among the patient and all of the
medical providers working with her and her child, said Chaudron.
The APA and ACOG joint report in August recommended that women with
depression discuss their diagnosis and treatment with their ob/gyn and their
psychiatrist and that these physicians later consult closely with each
They should be aware that the mother is both breastfeeding and taking
psychotropic drugs and explore the risks and benefits of all options.
"But if the mother is stable on a given medication, my advice is to
go with what is known," she said. "It's hard to recommend a change
if something is working."
An abstract of "Psychotropic Drug Use During Breastfeeding: A
Review of the Evidence" is posted at<http://pediatrics.aappublications.org/cgi/content/abstract/peds.2009-0326v1>.▪