The take-home message for the clinician is that all psychotropics are excreted into breast milk, even if quantification of the agents in breast milk or infant plasma reveals relatively scant concentration (J. Clin. Psychiatry 2003;64:73-80). If mom takes the medicine coincident with lactation, baby is exposed. At our center, we are usually reluctant to discontinue a medication such as an atypical antipsychotic to treat bipolar disorder in the postpartum period even if the mom chooses to breastfeed considering the extent to which women with bipolar disorder are at a high risk for relapse during the puerperium.
Ironically, we probably have more information regarding the excretion of antidepressants and drugs such as lamotrigine, used as a mood stabilizer, into breast milk than most medicines women take during the postpartum period, with data over the past 15 years suggesting that these medications, like other medications, are excreted into breast milk and are present in infant plasma in extremely sparse concentrations. It is noteworthy that cases of frank newborn toxicity directly associated with mothers who breastfeed on psychiatric medications are extremely few and far between, and are anecdotal at best. For some context, the literature on the effects of SSRI use during pregnancy is vast and prevalence of use of these medications during pregnancy and the postpartum period is substantial; that being said, reports of adverse effects reported in the babies of women who breastfeed while taking an SSRI are scant and thus at least somewhat reassuring.
And yet, consistently, I have witnessed that psychiatric medications are highlighted in the literature as particular agents of concern when it comes to lactation, compared with other medicines, for which only sparse data are available. Whether this reflects a bias about the necessity of treating psychiatric disorders during the postpartum period is unknown. Certainly, the long-term implications for the infant of exposure to low concentrations of psychiatric and nonpsychiatric medications in the context of breastfeeding exposure have yet to be clarified.
Whether a woman treated with a psychiatric medication during the post partum should breastfeed is a prime example of a clinical scenario in which there is no perfect decision, and we need to make the best decision possible, taking into account the available data, and the mother’s psychiatric disorder and her wishes. Some women may be extremely committed to breastfeeding and may choose to breastfeed, acknowledging some of the unknowns regarding these medications during lactation, while other women consider some of the ambiguity associated with the long-term effects of exposure while lactating and may choose not to breastfeed.
It is noteworthy that the AAP committee on drugs concluded the benefits of breastfeeding outweigh the risk of exposure to most therapeutic agents via human milk. And those at our center would certainly suggest that this is the case for psychiatric medications, particularly those used to sustain postpartum maternal psychiatric well-being, which is so critical. As is the case with any clinical decision, and certainly with respect to the use of psychiatric medications during pregnancy and lactation, the decision to treat is contingent on a careful risk-benefit analysis, where the risks of exposure to a medicine is weighed against the risk of untreated psychiatric illness. Even with the well-documented benefits of breastfeeding, nothing should trump the treatment of postpartum psychiatric illness, even if the cost is deferring breastfeeding. Treatment cannot be deferred because of the impact of untreated maternal psychiatric illness on maternal morbidity and on the development of children.
Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information about reproductive mental health at www.womensmentalhealth.org. To comment, e-mail him at obnews@frontlinemedcom.com. Dr. Cohen has been a consultant to manufacturers of antidepressants and antipsychotic medications.