Principles of psychotropic use while breastfeeding

All psychotropics are excreted into breastmilk (albeit to varying degrees)—if a psychotropic is taken while breastfeeding, the infant will be exposed to it. This being said, the placental transfer of most drugs exceeds breastmilk excretion, and, generally, the concentration of the drug in breastmilk is significantly lower than the therapeutic concentration for infants.

Note: Do not stop or discourage breastfeeding unless there is substantial evidence that the drug will harm the infant and no alternative is available.

The benefits of breastfeeding are sufficiently important to encourage breastfeeding unless there is substantial evidence that the drug will harm the infant and no alternative is available.

Discuss the approach to psychotropic use in breastfeeding with the patient and, if the patient consents, their significant other(s) so they can make an informed choice (see also Shared decision making). There are 4 options to consider:

  • continue the drug and breastfeed
  • continue the drug and formula feed
  • stop the drug and breastfeed
  • switch to a drug with a superior breastfeeding safety profile and breastfeed.
Potential benefits and harms to the patient and infant associated with psychotropic use while breastfeeding provides a framework to help decide whether to use a psychotropic while breastfeeding. Exercise particular caution if the infant is premature, has a low birth weight, is physically ill, or has an impaired ability to metabolise or excrete drugs.
Table 1. Potential benefits and harms to the patient and infant associated with psychotropic use while breastfeeding

[NB1] [NB2]

Infant

Patient

Potential harms of psychotropic use

  • short-term toxicity [NB3]
  • long-term neurodevelopmental effects [NB4]
  • stress and worry about potential for harms from drug exposure

Potential benefits of psychotropic use

  • reduced:
    • abuse and neglect
    • adverse impact of poor parental mental state on the parent–infant relationship
  • reduced:
    • relapse of psychiatric disorder
    • suicide
    • self-harm
    • infanticide
    • relationship deterioration
    • use of harmful substitutes (eg alcohol)
Note:

NB1: See the relevant drug monograph for additional information on potential harms.

NB2: Data on potential harms caused by psychotropics are often confounded by the underlying disorder—see Overview of psychotropic breastfeeding data.

NB3: The risk of short-term toxicity in the infant depends on a variety of complex factors, in addition to the drug itself. These include timing of dose in relation to breastfeeding; differing concentration in foremilk versus hindmilk; weight of the patient and infant; and ability to metabolise and/or excrete the drug and its active metabolites.

NB4: Long-term neurodevelopmental effects of psychotropic breastmilk exposure are largely unexplored.

There is no risk-neutral or universally applicable treatment for a patient with a psychiatric disorder who is breastfeeding; individualise treatment based on the considerations listed above.

Avoid polypharmacy and drugs with long half-life (eg diazepam) and use the lowest possible dose in patients who are breastfeeding to reduce the risk of accumulation in the breastfed infant.

Monitor the infant for excessive sedation, irritability, agitation and gastrointestinal dysfunction (eg colic, poor feeding). However, before attributing these symptoms to a drug, consider alternative causes—there is a high incidence of these problems in all infants. If the infant’s symptoms are severe or clearly caused by the drug, discuss the preferred approach with the parent.

Patients taking a sedating drug (eg some psychotropics) should avoid bed-sharing with an infant because of the increased risk of sudden infant death syndrome (SIDS)Australian Breastfeeding Association 2022Jullien 2021Moon 2022.

For the latest updates, newsletters and patient handouts on the use of drugs while breastfeeding, see:

The Principles of psychotropic use in females of childbearing potential also apply to patients who are breastfeeding.