Psychotropics in Lactation

During lactation period, the continuation of psychotropics is really challenging as different aspects are involved.

Risk of infant

As most of the drugs are excreted through breast milk and common belief, exposure to psychotropic is harmful to the baby. But, few studies reported minor adverse effects and the absolute risk remains less than 1% of exposed infants.

Consequence of untreated mental illness

If untreated relapse of symptoms 60-70% of women that causes impairment of  the mother’s emotional state, functional status, inability to provide proper care, and potential to engage in dangerous behavior. Relapse of symptoms impairs infant’s development and well-being.

Factors need to consider

• Past history and severity
• Past treatment history
• Outcome of the previous treatment
• Current symptoms, severity and the degree of interference in function
• Any psychiatric emergency
• The patient’s and partner’s choice

Factors need to discuss

• Benefits of breastfeeding to the infant,
• The severity of the mother’s symptoms
• Potential risks of untreated
• Risk to the infant exposed to psychotropic through breast milk

Variation in effect

• Genetic differences
• Mothers may or may not exclusively breastfeed
• Total exposure to breast milk with a psychotropic

Pharmacodynamics in lactation

Infants in risk

• Psychotropic typically alkaline and lipid soluble
• Different consequences to a baby’s exposure to a specific blood level compare to an adult
• Immature renal and hepatic systems
• Baby’s blood–brain barrier more permeable

General principles of prescribing Psychotropic in breastfeeding

1. Benefits must be weighed against the risk
2. Monitoring adverse effects of the drugs
3. Inappropriate to withhold treatment to allow breastfeeding where risk of relapse
4. Treatment of maternal illness highest priority
5. Continuation with the drug used during pregnancy to minimize withdrawal symptoms
6. If on sedative, should not sleep with the baby
7. Using the lowest effective dose
8. Avoiding polypharmacy
9. Time the feeds to avoid peak drug levels in the milk or express milk to give later

Antidepressants

1. Relatively safe when clinically warranted
2. SSRIs are one of the best-studied classes of medications during breastfeeding. (Weissman 2004).
3. Tricyclics mostly safe
4. No major adverse effects in TCAs through breast milk
5. Advisable to discontinue MAOIs

Reported adverse effects

Jitteriness, irritability, excessive crying, sleep disturbance and feeding problems. It is not possible to establish a causal link in every case.

Antipsychotics

Recent data on haloperidol, Chlorpromazine, olanzapine, and quetiapine -encouraging, with no adverse effects reported. Clozapine -sedation,irritability, decreased suckling agranulocytosis, and seizures in infants.

Hypnotics and anxiolytics during breastfeeding

• Unsafe to expose infants to repeated long-acting benzodiazepines
• Benzodiazepines -breathing problem, lethargy, poor suckling and weight loss
• Buspirone, zaleplon , zopiclone contraindicated during breastfeeding
• Zolpidem is safe during breastfeeding

Mood stabilizer

1. Lithium cross into breast milk at approximately 40% to 50% of the maternal levels.
2. Lithium in lactation is contraindicated immature kidney and the risk of lithium accumulation is high.
3. Lithium toxicity, including cyanosis and hypothermia
4. Low serum level of carbamazepine and valproate. transient hepatic toxicity such as hyperbilirubinemia.  no other  major adverse events
5. Gabapentin cross into breast milk almost 100% of the maternal levels
6. Little information exists on the use of lamotrigine and topiramate, so caution is advised.

What can We do?

1. Collaborative and multidisciplinary treatment approach (that includes the patient’s psychiatrist, obstetrician, and pediatrician is critically important.)
2. Appropriately educate the patient about the potential risks and benefits of treatment versus no treatment and side effects for mother and baby
3. Avoid communicating “mixed messages” to the patient about the risk and benefits of treatment
4. Institute a universal screening protocol for perinatal mental illness

De-stigmatize mental illness

• Antidepressants: Sertraline
• Antipsychotics : Olanzapine
• Mood-stabilisers: Often best to switch to mood-stabilising antipsychotic
• Anxiolytic and Sedatives: Lorazepam, zolpidem