Women with bipolar disorder are vulnerable to postpartum illness, and it is generally recommended that mothers continue treatment with a mood stabilizer throughout the postpartum period to reduce their risk of relapse; however, this recommendation is complicated by the all mood stabilizers are secreted into the breast milk, although their concentrations appear to vary considerably (Chaudron and Jefferson, 2000).
Lamotrigine (Lamictal) is being used with increasing frequency in childbearing women. We last reported on its use in of lamotrigine in breastfeeding women in 2005. At that time, several small studies indicated that lamotrigine was passed to infants through the breast milk in relatively high doses. Infant serum levels ranged from 23 to 50% of levels found in the mothers’ serum.
The largest study comes from Dr. Jeffrey Newport and colleagues and includes a total of 30 women taking lamotrigine and their nursing infants. The authors reported that milk/plasma ratios were highly variable, ranging from 5.7% to 147.1%. The mean milk/plasma ratio was 41.3%. This type of variability has been reported in studies of antidepressants and other medications in nursing infants, indicating that milk/plasma ratios may of limited utility in estimating the extent of exposure in the nursing infant.
Using measurement of maternal and infant plasma concentrations, it was estimated that the relative infant dose (RID) of lamotrigine was 9.2% and that the theoretical infant dose (TID) was o.51 mg/kg per day. This RID of 9.2% is lower than the RID cutoff of 10% frequently used as an empiric cutoff for assuming safety during lactation. The authors caution that clinicians should be advised that this rule of thumb is arbitrary and has not been objectively verified. It is reassuring, however, that this dose is considerably lower than doses of lamotrigine used to treat seizures in infants.
Maternal reports and review of pediatric records revealed no adverse events in the nursing infants.
More research is required to better assess the safety of lamotrigine in nursing infants; however, these findings are reassuring and are consistent with previous reports. Lamotrigine levels were detected in all infants assessed; however, no adverse events were reported. While the majority of professional and nutritional organizations support breast milk as the ideal form of nutrition for the infant in the first year of life, women taking psychotropic medications, such as lamotrigine, must weigh the benefits of breastfeeding against the risks of exposure to medication.
Ruta Nonacs, MD, PhD
Chaudron LH, Jefferson JW. Mood stabilizers during breastfeeding: a review. J Clin Psychiatry. 2000 Feb;61(2):79-90.
Newport DJ, Pennell PB, Calamaras MR, et al. Lamotrigine in Breast Milk and Nursing Infants: Determination of Exposure. Pedistrics. 2008. 122(1):e223-e231.
I took Lamictal while I was pregnant and while I was nursing. My pediatrician was concerned with the level of the medication being secreted into the breastmilk, so he ordered weekly (then bi-weekly, then monthly) blood tests (via heel stick) for my daughter just to be sure that her levels were acceptable for her age and weight. It wasn’t fun for me or my daugter, but it certainly was better than having to take mommy off her meds.
I just found this blog today and find it very informative. I was diagnosed with MDD Recurrent and BPD. I had an extremely difficult time during pregnancy and the postpartum period partially due to my mental illness and partially due to several medication issues.
At my six week check up I was informed by the attending OB GYN that I was being dismissed from their practice because I was “too difficult” to deal with because of my “emotional issues.” I was also warned against having future children, not because of the pre-eclampsia or preterm labor I experienced, but because of my mental illness.
To be fair I was not the easiest patient to treat and they did make an exception for me by assigning me a single resident, rather than putting me through a rotation. However, this was their idea to begin with. Yet, the attending literally criticized me for having needed “special treatment” when I was dismissed.
I knew that I would be at risk for emotional issues, which is why I provided my OB with contact information for my psychiatrist, made sure to keep them abreast of any medication changes, and tried to do everything I could to minimize difficulty. I got support from my community’s maternal-infant home services. I enlisted the county’s Infant Mental Health Dept. for support after the baby came. I quit smoking, quit caffeine, and ate lots of spinach along with prenatal vitamins.
Unfortunately, I had a very traumatic birth experience, a horrible recovery experience in the Mother-Baby Unit, and my child spent a couple of days in the NICU. I could not sleep the entire time in the hospital, except for the post op narcotics the first night.
The nurses brought my medications late every time, sometime by hours. Often the doses were wrong and it was only by my hypervigilance I caught it.
Lactation consultants yelled at me for needing sleep, for causing my son’s jaundice and weight loss, and for being on medications. A nurse told me that I needed to “get my priorities” in order when I asked her how to balance my need for sleep and my desire to breastfeed my son.
I had a very bad bout of postpartum depression. I cried and wished we were dead. Instead of bonding us, breastfeeding terrified me. What if he didn’t get enough and I caused him more health problems? What if he lost weight again?
FYI–Moms don’t “give” their baby jaundice. My son had an inconsistent latch because he was born 4 weeks premature. His prematurity was also a factor in jaundice and his heart murmur. Not to mention a 5 week lag in gross motor skills.
I tried pumping alone, but what I needed was a stronger dose of medications and to put my son on formula. It was the hardest, easiest, and best decision that I ever made.
Once I got back on some good meds and got some sleep, I started to see just how screwed up my OB and the L/D-Mother/Baby Unit at my local hospital were.
They did not regularly consult with my shrink or my therapist during my pregnancy, after the birth, or during my postpartum period. In spite of being aware that I was struggling with my “emotional issues.” They did however leave a message on my therapist’s phone telling her they dismissed me from the practice.
Millions of American women suffer from depression and many of them get pregnant and have children. Women who never had a history of mental illness can end up with PPD. It is a major issue facing women all across our nation. Yet, I was treated like a pariah by the very people who were supposed to be caring for me and my child.
Thank you so much for sharing this research. I have no history of mental illness, but suffered post partum psychosis at 7 weeks post partum. I was hospitalized locally and had to go to a larger city to be placed in inpatient care. I had been mid-medicated and mis-diagnosed.
When I was finally prescribed Lamictal, nobody could tell me if it was safe to breastfeed, so in spite of my intense desire and determination to nurse my son, I started weaning. A week later, I found out that the dosage I was on was considered safe, so I started nursing again, but had lost most of my milk supply by then.
I spent the next six months mourning the loss of breastfeeding and wishing I’d been able to get some better information when I needed it.
I will share this site with others in my work to support new parents with perinatal anxiety and mood disorders.