Breastfeeding has been associated with multiple medical and psychological benefits. Women with a strong desire to breastfeed, but with a limited milk supply, are often interested in potential ways to augment their milk production.
There are strong parallels between the clinical management of bipolar disorder and epilepsy, and women with these disorders face significant challenges while pregnant or planning to conceive. In this setting, treatment decisions must balance the risks of recurrence of severe illness with the risks of potential harm to the fetus when certain medicines are taken during pregnancy.
A clinician asks: “I am a psychiatrist treating a patient with Bipolar Disorder on Seroquel and Topamax. I would like to know what information is available regarding the safety of these medications to the infant if used during breastfeeding.”
The U.S. Food and Drug Administration (FDA) has proposed major revisions to prescription drug labeling in order to provide more accurate and helpful information on the effects of medications used during pregnancy and breastfeeding. As it stands, the current system used by the FDA classifies the reproductive safety of medications using five risk categories (A, B, C, D and X) based on data derived from human and animal studies. While widely used to make decisions regarding the use of medications during pregnancy, many have criticized this system of classification, indicating that this type of drug labeling is often not helpful and, even worse, may be misleading.
Approximately 25% of American women of reproductive age smoke tobacco, and many continue to smoke during and after pregnancy despite the known potential harm to their own health and to their child’s health. These health threats remain after the child’s birth as the baby is exposed to nicotine and other toxins in both ambient air and breast milk.
All medications are secreted into the breast milk, although concentrations appear to vary. There is a fair amount of information on the use of Paxil (paroxetine) in nursing women. While Paxil may be detected in the breast milk, there have been no reports of adverse events in the nursing infant. The only situation where one may want to avoid breastfeeding is when the baby is premature or has signs of hepatic immaturity, which may make it more difficult for the infant to metabolize the medication to which he or she is exposed. Premature babies are also probably more vulnerable to the toxic effects of these medications.
Because rates of postpartum illness are very high in women with bipolar disorder, it is generally recommended that mothers continue treatment with a mood stabilizer throughout the postpartum period to reduce their risk of relapse; however, the use of medications during the postpartum period is complicated by the issue of breastfeeding. All medications are secreted into the breast milk, although their concentrations appear to vary (Chaudron and Jefferson, 2000).
It is clear that women with bipolar disorder are at high risk for relapse during the immediate postpartum period (Viguera 2000). There is evidence that the resumption of lithium prior to or within 24-48 hours of delivery can significantly reduce the risk of postpartum illness (Cohen 1995). While this intervention is the current standard of care for this high risk population, women have historically been instructed to avoid breastfeeding while taking lithium based on early reports suggesting high levels of lithium in the breast milk and several cases of lithium toxicity in nursing infants (Schou 1973). While the American Academy of Pediatrics guidelines are less restrictive in their current recommendation, they do urge caution. However, systematic studies regarding the levels of exposure to lithium in nursing infants and the potential risks of this exposure have been lacking.
Postpartum depression is a relatively common event, affecting 10 to 15% of women after the birth of a child. Many women, however, do not receive treatment, and one of the most common reasons for avoiding or deferring treatment is concern regarding the use of medications while breastfeeding. A preliminary study from Lee and colleagues at the Motherisk Program in Toronto, Canada has investigated the use of St. John’s wort in breastfeeding women.
Data have accumulated over the last few years on the use of antidepressants in nursing mothers. It appears that all antidepressants are secreted into the breast milk; however, the amount of medication to which the nursing child is exposed appears to be relatively small. We have the most information is available for fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and the tricyclic antidepressants. In general, one should try to choose an antidepressant for which there are data to support its safety during breastfeeding. However, there are often situations where one may choose another antidepressant that has not been as well characterized. For instance, if a woman has not responded well to any of the above medications.
