Psychotropic Drugs in Lactation- Motherisk Update 2008

Main Article Content

Myla E. Moretti


Psychotropic, Drugs, Lactation


Breast   feeding   is   accompanied   by   numerous clinical and psychosocial advantages for both the mother and her child.  Since most drugs will pass into human  milk  in some  amount,  the  lactating mother who requires pharmacotherapy adds complexity   to   the   risk-benefit   assessment   for clinicians making treatment decisions. In the case of psychotropic  medications  this issue is particularly worrisome   since   women   who   are   not   well controlled will have impaired bonding with their child. Moreover, these women may not necessarily recognize adverse events or abnormal outcomes in her     infants.     In     an     ideal situation,  the patient would receive pharmacotherapy to assist in disease management, while at the same time successfully breastfeed her child. This goal of this presentation is to discuss the disposition of drugs in lactating  patients  and to outline  the available literature   concerning   the   use   of   psychotropic drugs in lactating women. Part of the continuum of treating women with psychiatric disease in pregnancy concerns the treatment of women after delivery, and for many, this will include drug treatment during lactation. The goal of today’s discussion  is  to  describe  the  issues  and  outline what is currently known about the use of psychotropic drugs in breastfeeding women

Abstract 248 | PDF Downloads 135


1. Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, et al. Breastfeeding and the use of human milk. Pediatrics 2005 Feb;115(2):496-506.
2. Der G, Batty GD, Deary IJ. Effect of breast feeding on intelligence in children: prospective study, sibling pairs analysis, and meta-analysis. BMJ 2006 Nov 4;333(7575):945.
3. Bennett PN, Jensen AA. Drugs and human lactation-a comprehensive guide to the content and consequences of drugs, micronutrients, radiopharmaceuticals, and environmental and occupational chemicals in human milk. 2nd ed . Amsterdam: Elsevier; 1996.
4. American Academy of Pediatrics Committee on Drugs: The transfer of drugs and other chemicals into human milk. Pediatrics 1994 Jan;93(1):137-50.
5. Anderson PO. Drug use during breast-feeding. Clin Pharm 1991 Aug;10(8):594-624. 6. Atkinson HC, Begg EJ. Prediction of drug distribution into human milk from physicochemical characteristics. Clin Pharmacokinet 1990 Feb;18(2):151-67.
7. Begg EJ, Atkinson HC. Modelling of the passage of drugs into milk. Pharmacol Ther 1993 Sep;59(3):301-10.
8. Begg EJ, Duffull SB, Saunders DA, Buttimore RC, Ilett KF, Hackett LP, et al. Paroxetine in human milk. Br J Clin Pharmacol 1999 Aug;48(2):142-7.
9. Stowe ZN, Cohen LS, Hostetter A, Ritchie JC, Owens MJ, Nemeroff CB. Paroxetine in human breast milk and nursing infants. Am J Psychiatry 2000 Feb;157(2):185-9.
10. Hendrick V, Stowe ZN, Altshuler LL, Hostetter A, Fukuchi A. Paroxetine use during breastfeeding. J Clin Psychopharmacol 2000 Oct ;20(5):587-9.
11. Misri S, Kim J, Riggs KW, Kostaras X. Paroxetine levels in postpartum depressed women, breast milk, and infant serum. J Clin Psychiatry 2000 Nov;61(11):828-32.
12. Stowe ZN, Owens MJ, Landry JC, Kilts CD, Ely T, Llewellyn A, et al. Sertraline and desmethylsertraline in human breast milk and nursing infants. Am J Psychiatry 1997 Sep;154(9):1255-60.
13. Wisner KL, Perel JM, Findling RL. Antidepressant treatment during breast-feeding. Am J Psychiatry 1996 Sep;153(9):1132-7.
14. Altshuler LL, Burt VK, McMullen M, Hendrick V. Breastfeeding and sertraline: a 24-hour analysis. J Clin Psychiatry 1995 Jun;56(6):243-5.
15. Epperson N, Czarkowski KA, Ward-O'Brien D, Weiss E, Gueorguieva R, Jatlow P, et al. Maternal sertraline treatment and serotonin transport in breast-feeding mother-infant pairs. Am J Psychiatry 2001 Oct;158(10):1631-7.
16. Kristensen JH, Ilett KF, Dusci LJ, Hackett LP, Yapp P, Wojnar-Horton RE, et al. Distribution and excretion of sertraline and N-desmethylsertraline in human milk. Br J Clin Pharmacol 1998 May;45(5):453-7.
17. Stowe ZN, Hostetter AL, Owens MJ, Ritchie JC, Sternberg K, Cohen LS, et al. The pharmacokinetics of sertraline excretion into human breast milk: determinants of infant serum concentrations. J Clin Psychiatry 2003 Jan;64(1):73-80.
18. Dodd S, Stocky A, Buist A, Burrows GD, Maguire K, Norman TR. Sertraline in paired blood plasma and breast-milk samples from nursing mothers. Hum Psychopharmacol 2000 Jun;15(4):161-264.
19. Dodd S, Stocky A, Buist A, Burrows GD, Norman TR. Sertraline analysis in the plasma of breast-fed infants. Aust N Z J Psychiatry 2001 Aug;35(4):545-6.
20. Isenberg KE. Excretion of fluoxetine in human breast milk. J Clin Psychiatry 1990 Apr;51(4):169.
21. Burch KJ, Wells BG. Fluoxetine/norfluoxetine concentrations in human milk. Pediatrics 1992 Apr;89(4 Pt 1):676-7.
22. Lester BM, Cucca J, Andreozzi L, Flanagan P, Oh W. Possible association between fluoxetine hydrochloride and colic in an infant. J Am Acad Child Adolesc Psychiatry 1993 Nov;32(6):1253- 5.
23. Taddio A, Ito S, Koren G. Excretion of fluoxetine and its metabolite, norfluoxetine, in human breast milk. J Clin Pharmacol 1996 Jan;36(1):42-7.
24. Brent NB, Wisner KL. Fluoxetine and carbamazepine concentrations in a nursing mother/infant pair. Clin Pediatr (Phila) 1998 Jan;37(1):41-4.
25. Yoshida K, Smith B, Craggs M, Kumar RC. Fluoxetine in breast-milk and developmental outcome of breast-fed infants. Br J Psychiatry 1998 Feb;172:175-8.
26. Hale TW, Shum S, Grossberg M. Fluoxetine toxicity in a breastfed infant. Clin Pediatr (Phila) 2001 Dec;40(12):681-4.
27. Suri R, Stowe ZN, Hendrick V, Hostetter A, Widawski M, Altshuler LL. Estimates of nursing infant daily dose of fluoxetine through breast milk. Biol Psychiatry 2002 Sep 1;52(5):446-51.
28. Heikkinen T, Ekblad U, Palo P, Laine K. Pharmacokinetics of fluoxetine and norfluoxetine in pregnancy and lactation. Clin Pharmacol Ther 2003 Apr;73(4):330-7.
29. Bader TF, Newman K. Amitriptyline in human breast milk and the nursing infant's serum. Am J Psychiatry 1980 Jul;137(7):855-6.
30. Breyer-Pfaff U, Nill K, Entenmann KN, Gaertner HJ. Secretion of amitriptyline and metabolites into breast milk. Am J Psychiatry 1995 May;152(5):812-3.
31. Brixen-Rasmussen L, Halgrener J, Jorgensen A. Amitriptyline and nortriptyline excretion in human breast milk. Psychopharmacology (Berl) 1982;76(1):94-5.
32. Pittard WB, III, O'Neal W, Jr. Amitriptyline excretion in human milk. J Clin Psychopharmacol 1986 Dec;6(6):383-4.
33. Matheson I, Skjaeraasen J. Milk concentrations of flupenthixol, nortriptyline and zuclopenthixol and between-breast differences in two patients. Eur J Clin Pharmacol 1988;35(2):217-20.
34. Wisner KL, Perel JM. Nortriptyline treatment of breast-feeding women. Am J Psychiatry 1996 Feb;153(2):295.
35. Wisner KL, Perel JM, Foglia JP. Serum clomipramine and metabolite levels in four nursing mother-infant pairs. J Clin Psychiatry 1995 Jan;56(1):17-20.
36. Wisner KL, Perel JM. Serum nortriptyline levels in nursing mothers and their infants. Am J Psychiatry 1991 Sep;148(9):1234-6.
37. Birnbaum CS, Cohen LS, Bailey JW, Grush LR, Robertson LM, Stowe ZN. Serum concentrations of antidepressants and benzodiazepines in nursing infants: A case series. Pediatrics 1999 Jul;104(1):
38. Yoshida K, Smith B, Craggs M, Kumar RC. Investigation of pharmacokinetics and of possible adverse effects in infants exposed to tricyclic antidepressants in breast-milk. J Affect Disord 1997 May;43(3):225-37.
39. Kemp J, Ilett KF, Booth J, Hackett LP. Excretion of doxepin and N-desmethyldoxepin in human milk. Br J Clin Pharmacol 1985 Nov;20(5):497-9.
40. Matheson I, Pande H, Alertsen AR. Respiratory depression caused by N-desmethyldoxepin in breast milk. Lancet 1985 Nov 16;2(8464):1124.
41. Frey OR, Scheidt P, von Brenndorff AI. Adverse effects in a newborn infant breast-fed by a mother treated with doxepin. Ann Pharmacother 1999 Jun;33(6):690-3.
42. Pons G, Schoerlin MP, Tam YK, Moran C, Pfefen JP, Francoual C, et al. Moclobemide excretion in human breast milk. Br J Clin Pharmacol 1990 Jan;29(1):27-31.
43. Chaudron LH, Schoenecker CJ. Bupropion and breastfeeding: a case of a possible infant seizure. J Clin Psychiatry 2004 Jun;65(6):881-2.
44. Wisner KL, Perel JM, Findling RL. Antidepressant treatment during breast-feeding. Am J Psychiatry 1996 Sep;153(9):1132-7.
45. Briggs GG, Samson JH, Ambrose PJ, Schroeder DH. Excretion of bupropion in breast milk. Ann Pharmacother 1993 Apr;27(4):431-3.
46. Dusci LJ, Good SM, Hall RW, Ilett KF. Excretion of diazepam and its metabolites in human milk during withdrawal from combination high dose diazepam and oxazepam. Br J Clin Pharmacol 1990 Jan;29(1):123-6.
47. Stebler T, Guentert TW. Determination of diazepam and nordazepam in milk and plasma in the presence of oxazepam and temazepam. J Chromatogr 1991 Mar 8;564(1):330-7. 48. Wretlind M. Excretion of oxazepam in breast milk. Eur J Clin Pharmacol 1987;33(2):209-10. 49. Oo CY, Kuhn RJ, Desai N, Wright CE, McNamara PJ. Pharmacokinetics in lactating women: prediction of alprazolam transfer into milk. Br J Clin Pharmacol 1995 Sep;40(3):231-6.
50. Froescher W, Eichelbaum M, Niesen M, Dietrich K, Rausch P. Carbamazepine levels in breast milk. Ther Drug Monit 1984;6(3):266-71.
51. Bar-Oz B, Nulman I, Koren G, Ito S. Anticonvulsants and breast feeding: a critical review. Paediatr Drugs 2000 Mar;2(2):113-26.
52. Hagg S, Spigset O. Anticonvulsant use during lactation. Drug Saf 2000 Jun;22(6):425-40.
53. Nau H, Kuhnz W, Egger HJ, Rating D, Helge H. Anticonvulsants during pregnancy and lactation. Transplacental, maternal and neonatal pharmacokinetics. Clin Pharmacokinet 1982 Nov;7(6):508-43.
54. von Unruh GE, Froescher W, Hoffmann F, Niesen M. Valproic acid in breast milk: how much is really there? Ther Drug Monit 1984;6(3):272-6.
55. Moretti ME, Koren G, Verjee Z, Ito S. Monitoring lithium in breast milk: an individualized approach for breast-feeding mothers. Ther Drug Monit 2003 Jun;25(3):364-6.
56. Stewart RB, Karas B, Springer PK. Haloperidol excretion in human milk. Am J Psychiatry 1980 Jul;137(7):849-50.
57. Whalley LJ, Blain PG, Prime JK. Haloperidol secreted in breast milk. Br Med J (Clin Res Ed) 1981 May 30;282(6278):1746-7.
58. Wiles DH, Orr MW, Kolakowska T. Chlorpromazine levels in plasma and milk of nursing mothers. Br J Clin Pharmacol 1978 Mar;5(3):272-3.
59. Uhlir F, Ryznar J. Appearance of chlorpromazine in the mother's milk. Act Nerv Super (Praha) 1973 May;15(2):106.
60. Olesen OV, Bartels U, Poulsen JH. Perphenazine in breast milk and serum. Am J Psychiatry 1990 Oct;147(10):1378-9.
61. Ambresin G, Berney P, Schulz P, Bryois C. Olanzapine excretion into breast milk: a case report. J Clin Psychopharmacol 2004 Feb;24(1):93-5.
62. Goodwin G, Young AH. Using guidelines in real clinical situations: clozapine and breast feeding in bipolar disorder. J Psychopharmacol 2005 May;19(3):317-8.
63. Barnas C, Bergant A, Hummer M, Saria A, Fleischhacker WW. Clozapine concentrations in maternal and fetal plasma, amniotic fluid, and breast milk. Am J Psychiatry 1994 Jun;151(6):945.
64. Lutz UC, Wiatr G, Orlikowsky T, Gaertner HJ, Bartels M. Olanzapine treatment during breast feeding: a case report. Ther Drug Monit 2008 Jun;30(3):399-401.
65. Gardiner SJ, Kristensen JH, Begg EJ, Hackett LP, Wilson DA, Ilett KF, et al. Transfer of olanzapine into breast milk, calculation of infant drug dose, and effect on breast-fed infants. Am J Psychiatry 2003 Aug;160(8):1428-31.
66. Croke S, Buist A, Hackett LP, Ilett KF, Norman TR, Burrows GD. Olanzapine excretion in human breast milk: estimation of infant exposure. Int J Neuropsychopharmacol 2002 Sep;5(3):243-7.
67. Rampono J, Kristensen JH, Ilett KF, Hackett LP, Kohan R. Quetiapine and breast feeding. Ann Pharmacother 2007 Apr;41(4):711-4.
68. Lee A, Giesbrecht E, Dunn E, Ito S. Excretion of quetiapine in breast milk. Am J Psychiatry 2004 Sep;161(9):1715-6