Managing Psychiatric Medications in the Breast-Feeding Woman

, , , ; UCLA Neuropsychiatric Institute and Hospital, Los Angeles, Calif.

Disclosures

Medscape General Medicine. 1998;1(3) 

In This Article

Benzodiazepines

The literature regarding benzodiazepine use in nursing mothers includes a total of 36 infants, with 5 reports of diazepam, 2 reports of clonazepam, 2 reports of alprazolam, and individual reports of temazepam, oxazepam, and lorazepam

Five reports document the effects of diazepam use on 10 nursing infants.[46,47,48,49,50] The M/P ratios of parent compound and metabolites ranged from 0.08 to 1.0. Infant serum concentrations were measured in 5 of the cases and found to be detectable for either diazepam or its metabolites. Two of the 10 infants were sedated, with 1 baby also showing weight loss. Four infants had no adverse effects; clinical status was not reported for the remaining 4 infants.

The reports of clonazepam use during nursing include 2 infants exposed to medication during pregnancy and postpartum.[51,52] The M/P ratios ranged from 0.33 to 0.37. In the first case, infant serum concentrations were detectable but declined over time. The infant was cyanotic, apneic, lethargic, and hypotonic at delivery with resolution of symptoms between postnatal days 5 and 10. No adverse effects were noted at 5 months of age. The second infant had a clonazepam concentration of 4.7ng/mL, and clinical status was not reported.

The effects of alprazolam during nursing have been addressed in 2 reports. In 1 study[53] of 8 nursing mothers, M/P ratios averaged 0.36 for the parent compound, but metabolites were nondetectable in breast milk. Infant serum concentrations and clinical status were not reported. One case report documents withdrawal in a 1-week-old infant exposed to alprazolam in utero and during nursing.[54] Within 2 days of nursing termination, the infant exhibited irritability, crying, and poor sleep for an unspecified period of time.

Single reports examine nursing and the use of lorazepam, temazepam, and oxazepam.[55,56,57] In a study of 4 mothers given a single dose of lorazepam, M/P ratios ranged from 0.15 to 0.26. Infant serum concentrations and clinical status were not reported.[55] A report of 10 infants exposed to temazepam through nursing found that temazepam and its metabolite oxazepam (via a minor N-dimethylation pathway) were nondetectable in 2 infants; concentrations were not reported in the other infants.[56] No adverse effects were noted in any of the infants. A third report examining oxazepam use found M/P ratios of 0.10 to 0.33. Infant plasma concentrations and clinical status were not reported.[57]

Of the 36 infants described, infant serum concentrations of parent or metabolite compounds were measured in 9 cases. Concentrations were nondetectable for 2 infants (temazepam),[56] detectable for 5 infants (diazepam),[46,47,50] and detectable with pregnancy exposure but dropped during lactation for 2 infants (clonazepam).[51,52] Infant clinical status was reported in 18 cases, with no adverse effects in 14 babies (10 exposed to temazepam, 4 exposed to diazepam). Two infants had sedation/weight loss (diazepam), 1 infant had apnea and hypotonia that resolved during lactation (clonazepam), and 1 infant had symptoms of withdrawal (alprazolam).

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