Breastfeeding and
Psychiatric Medications By Ruta
Nonacs, MD, PhD
Massachusetts General Hospital
Bupropion
and Breastfeeding (December 2002)
Q. I'm
looking for further information regarding postpartum depression
and the use of
Wellbutrin (bupropion). Prior to my pregnancy
I was taking Wellbutrin for depression and had relief of my symptoms.
(I had also tried
Celexa and
Paxil with no success). When I became
pregnant, I discontinued all medications but still felt really
good and had a healthy pregnancy. I delivered my son about 6
weeks ago; I'm breastfeeding but I'm really starting to feel
pretty down and overwhelmed. I'm wondering if I can go back on
Wellbutrin and still continue breastfeeding?
A. Data
have accumulated over the last few years on the use of antidepressants
in nursing mothers. It appears that all antidepressants are
secreted into the breast milk; however, the amount of medication
to which the nursing child is exposed appears to be relatively
small. We have the most information is available for
fluoxetine
(Prozac),
sertraline (Zoloft), paroxetine (Paxil), and the
tricyclic antidepressants. In general, one should try to choose
an
antidepressant for which there are data to support its safety
during breastfeeding. However, there are often situations where
one may choose another antidepressant that has not been as
well characterized. For instance, if a woman has not responded
well to any of the above medications.
To date,
there has been only one report on the use of
bupropion in two
breastfeeding mothers. Serum levels of bupropion and its metabolite
were undetectable in the infants, and there were no observed
adverse events in the nursing infants. While this information
is reassuring, further study is needed to fully determine the
effects of bupropion in nursing infants.
In general,
the risk of adverse events in the nursing infant appears to
be low. The child should be monitored for any changes in behavior,
level of alertness, or sleep and feeding patterns. In this
setting, collaboration with the child's pediatrician is essential.
Baab SW,
Peindl KS, Piontek CM, Wisner KL. 2002. Serum bupropion levels
in two breastfeeding mother-infant pairs. J Clin Psychiatry
63: 910-1.
Paxil
and Breastfeeding (August 2002)
Q. I
am trying to get more information about the effects of
Paxil
(paroxetine) and breastfeeding. How safe is it? Any side effects
for the baby? My daughter is 7 months old and is down to 2-3
feedings a day. I plan to start Paxil and would like to continue
with two feedings a day if it is safe to do so. If I take the
Paxil at bedtime, is there a time of day when the level is lower
in my body and less of the drug would be passed on to the baby,
or is the level constant so the time of feeding and time of taking
the Paxil do not matter? I would appreciate any information.
My daughter had a very hard first five months and I don't want
to pass along the Paxil to her if it is not safe or if it may
cause her any side effects. Thanks.
A. All
medications are secreted into the breast milk, although concentrations
appear to vary. There is a fair amount of information on the
use of Paxil in nursing women. While Paxil may be detected
in the breast milk, there have been no reports of adverse events
in the nursing infant. The only situation where one may want
to avoid breastfeeding is when the baby is premature or has
signs of hepatic immaturity, which may make it more difficult
for the infant to metabolize the medication to which he or
she is exposed. Premature babies are also probably more vulnerable
to the toxic effects of these medications.
There may
be some ways to minimize the amount of medication to which
the nursing infant is exposed. First, the lowest dose of medication
that is effective should be used. Second, in older infants,
it may be possible to time the feedings so as to minimize exposure.
The levels of Paxil in the breast milk peak about 8 hours after
ingestion of medication and decline thereafter, reaching the
lowest levels immediately before the next dose of medication
is to be taken. Theoretically, the amount of medication to
which the infant is exposed could be reduced by avoiding nursing
during times at which the medication concentration in the breast
milk would be the highest (i.e., 8 hours after taking the medication).
Studies with sertraline (Zoloft) indicate that this approach
leads to a 20% reduction in the amount of medication to which
the infant is exposed.
Burt VK,
Suri R, Altshuler L, Stowe Z, Hendrick VC, Muntean E. The use
of psychotropic medications during breast-feeding. Am J Psychiatry
2001; 158(7): 1001-9.
Newport
DJ, Hostetter A, Arnold A, Stowe ZN. The treatment of postpartum
depression: minimizing infant exposures. J Clin Psychiatry 2002;
63(7): 31-44.
Breastfeeding
and Bipolar Disorder (June 2002)
Q.
I was diagnosed with bipolar disorder (manic depression) in July
of 2001. In January, I became pregnant and immediately stopped
my Lithium. I am now 18 weeks along and my psychiatrist would
like me to start on Lithium again. I do not want to, as I would
like to breastfeed. It seems that the biggest concern is that
I will experience postpartum depression. One suggestion was to
start an antidepressant at 8 months and to continue it through
breastfeeding. What is a safe antidepressant to use while breastfeeding?
Also are there any safe mood stabilizers to use while breastfeeding?
A. Women with bipolar disorder are particularly vulnerable
during the postpartum period. Studies indicate at least 50% of
women with bipolar disorder relapse during the first few months
after childbirth. While most women present with depressive symptoms,
there is also a significant risk of hypomania or mania. Prophylactic
treatment with a mood stabilizer, initiated either towards the
end of pregnancy or at the time of delivery, significantly reduces
the risk of postpartum illness. Thus far we have no data on the
use of antidepressants in this setting. Although antidepressants
may help reduce the risk of recurrent illness in women with unipolar
depression, there is evidence that using antidepressants without
a mood stabilizer in patients with bipolar disorder may increase
the likelihood of having a hypomanic or manic episode.
We often recommend that women with bipolar disorder remain on
a mood stabilizer during the postpartum period; however, the use
of medications during the postpartum period is complicated by
the issue of breastfeeding. All medications are secreted into
the breast milk, although their concentrations appear to vary.
Lithium is found in the breast milk at relatively high concentrations,
and there have been reports of toxicity in nursing infants exposed
to lithium in the breast milk. Symptoms of toxicity in these infants
include lethargy, poor muscle tone, and changes on the electrocardiogram.
While there are risks associated with breastfeeding on lithium,
it is probably the safest mood stabilizer to use in this setting.
Other mood stabilizers, like valproic acid and carbamazepine,
may cause liver damage in the nursing infant, which is a serious
and potentially life-threatening complication.
For women with bipolar disorder, breastfeeding raises concerns
for another reason. For a young infant, breastfeeding entails
multiple feedings during the night. Sleep deprivation is destabilizing
for those with bipolar disorder and may help to precipitate a
relapse during this vulnerable time. For women with bipolar disorder,
we recommend that somebody else take over the nighttime feedings
in order to protect the mother’s sleep and to increase her
chances of staying well.
Cohen LS,
Sichel DA, Roberston LM, et al: Postpartum prophylaxis for
women with bipolar disoder. Am J Psychiatry 1995; 152: 1641-1645.
Viguera AC, Nonacs R, Cohen LS, Tondo L, Murray A, Baldessarni RJ: Risk of
Recurrence of Bipolar Disorder in Pregnant and Nonpregnant Women After Discontinuing
Lithium Maintenance. Am J Psychiatry 2000; 157: 179-184.
Breastfeeding
and Antidepressants (January 2002)
Q. For
women who are breastfeeding, it appears that certain antidepressants
are safer than others. Researching the American Journal of
Psychiatry and the New England Journal of Medicine, data point
to sertraline (Zoloft) as the drug of choice. What is your
recommendation for breastfeeding women? Should any blood tests
be conducted on mother and nursing infant?
A. When
discussing the use of antidepressant medications by breastfeeding
women, 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. The amount of
drug to which the infant is exposed depends on many factors,
including the medication dosage, as well as the infant’s
age and feeding schedule. To date, we have not found that certain
medications are found at lower levels in the breast milk and
may therefore pose less of a risk to the nursing infant. Nor
have we found that any antidepressant medication has been associated
with serious adverse events in the baby.
In general,
one should try to choose an antidepressant for which there
are data to support its safety during breastfeeding. The most
information is available on fluoxetine (Prozac), followed by
sertraline (Zoloft), paroxetine (Paxil), and the tricyclic
antidepressants. Other antidepressant medications have not
been studied as well.
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.
Burt VK,
Suri R, Altshuler L, Stowe Z, Hendrick VC, Muntean E. The use
of psychotropic medications during breast-feeding. Am J Psychiatry
2001; 158: 1001-9.
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