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.”

With regard to topiramate (Topamax), there is relatively little information on breastfeeding.  One case series included five women with epilepsy treated with topiramate during pregnancy and lactation.  Breastfed infants had very low topiramate concentrations, and no adverse effects were observed in the infants.

The literature includes a handful of case reports assessing the use of quetiapine (Seroquel) in breastfeeding women.  The largest series included six women treated with multiple medications, including quetiapine.  Levels of quetiapine were typically low in the breast milk and infant serum.  Four of the six infants showed normal development; two of the children had mild developmental delays.  It is not clear if these delays were a result of exposure; however, it is reassuring to note that in the two children showing mild delays, estimated levels of quetiapine exposure through breast milk were not higher than in the children with no delays.  Based on the limited number of case reported in the literature (a total of 8 mother-infant pairs), there appears to be low levels of infant exposure to quetiapine through the breast milk, and no clear association between adverse outcome and exposure has been observed.

Clearly more research is required to assess the safety of these drugs in nursing infants, and decisions regarding the use of these drugs in breastfeeding women involve a careful consideration of the risks and benefits. For women with bipolar disorder, breastfeeding raises concerns for another reason.  The sleep deprivation associated with exclusively breastfeeding a new infant may be destabilizing for those with bipolar disorder and may precipitate a relapse during this vulnerable time.

Ruta Nonacs, MD PhD

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