Clinically significant anxiety symptoms are common during the postpartum period and frequently complicate the treatment of postpartum depression. While SSRIs are indicted for the treatment anxiety symptoms, especially when they co-occur with depression, many women may need to use a benzodiazepine for managing more severe symptoms of anxiety or insomnia.
An early study from Birnbaum and colleaguses at the CWMH included 11 infants exposed to clonazepam (Klonopin) and an antidepressant. No adverse events were reported in this sample. In a subsequent meta-analysis including 21 nursing infants exposed to benzodiazepines adverse events were reported in four (or 19.0%) of the exposed infants. Reported adverse events included lethargy, irritability, poor weight gain, and respiratory distress.
A recent study from the Motherisk program helps to clarify the risks associated with benzodiazepines in breastfeeding mothers, including a total of 124 exposed infants. Women who contacted the Motherisk program with questions regarding the use of benzodiazepines during lactation were recruited into the study. In a subsequent telephone interview, information regarding medication use, frequency of breastfeeding, the health of their infants, and demographic characteristics was collected.
The most commonly used benzodiazepines were lorazepam (52%), clonazepman (18%), and midazolam (15%). About half of the women (n=60) were also taking other medications, most commonly antidepressants and opioids, in addition to the benzodiazepines. The mean age of the children at the time of follow-up was 11 months (range 2-24 months). Adverse events, specifically sedation, were observed in only 1.6% (2 of 124) infants exposed.
One of the women with a sedated infant reported using alprazolam 0.25 mg on two occasions. She was also taking sertraline 50 mg and zopiclone 2.5 mg daily. The other woman was on clonazepam 0.25 mg twice daily, flunazepam 1 mg, risperidone 0.75 mg, and bupropion. The authors observed that the women reporting sedation in their infants were taking more psychotropic medications than the women who did not report adverse events in their children.
This report indicates that the risk of adverse events in nursing infants exposed to benzodiazepines is very low. Given that the two sedated infants were exposed to other sedating drugs, the risk of adverse events in benzodiazepine-exposed infants may even be lower than reported here. Based on these findings, benzodiazepines would be a reasonable treatment option for breastfeeding women with anxiety. Exposed infants should be monitored for sedation, especially if the mother is taking other medications.
Ruta Nonacs, MD PhD
Kelly L, Poon S, Madadi P, Koren G. Neonatal Benzodiazepines Exposure during Breastfeeding. J Pediatr. 2012([Epub ahead of print]).