Breastfeeding is one of the best ways to provide a healthy start for your baby. The benefits are well researched. Unfortunately, the postpartum period is a dangerous time for bipolar mothers. Bipolar disorder can even be triggered by childbirth. There is a 50% chance of relapse during the postpartum period, primarily into depression, but there is also a significant risk for hypomania or mania. Fortunately, there are safe medications to take while breastfeeding.
Medication should only be taken if the benefits outweigh the risks of exposure to the infant. All psychotropic medications studied enter breastmilk. It’s just a matter of how much will pass to your baby. Medications that have a 10% or less exposure rate–how much of the maternal dose is passed to the infant–are deemed “safe”, or at the very least safer.
Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), are largely considered safe for breastfeeding mothers and their babies. A great deal of the research on medication use during breastfeeding is concentrated on SSRIs. Of the tricyclic antidepressants (TCAs), paroxetine (Paxil), fluoxetine (Prozac), and sertraline (Zoloft) have a limited exposure to newborns. There have only been a few cases where infants showed adverse effects to antidepressants.
Anti-anxiety agents exhibit similar results to antidepressants, with a great deal of the data pointing to few adverse reactions in infants, and low exposure rates. Many mood stabilizers, on the other hand, are secreted in high amounts in breastmilk and show a risk for toxicity in infants. There is very limited data on antipsychotics, especially atypical antipsychotics, but olanzapine, Risperidone (RisperiDAL), and quetiapine (Seroquel) show promising results.
Here are some of the most common choices for breastfeeding mothers:
Lithium is concentrated in breastmilk–secreted between zero and 30% of maternal dosage–and there is a risk of lithium toxicity in in infants, so breastfeeding is discouraged unless the mother doesn’t respond to other medications on the market. A 2000 case review reported lithium toxicity in two cases out of eleven. Symptoms of toxicity include hypothermia, poor muscle tone, and lethargy. The pediatrician will take blood draws to monitor the baby’s thyroid, creatinine, and blood urea nitrogen (BUN) every six to eight weeks.
Breastfeeding while taking Olanzapine has been studied much more than other medications due in part to a database collected by the manufacturer. There was a study which reported that the exposure rate is roughly 1.8%. Adverse reactions showed up in 15.6% of the babies, including tremor, insomnia, and irritability.
Quetiapine does not easily pass through breastmilk, with studies reporting 0.09% of the maternal dosage excreted. Unfortunately, a study found that one third of the babies reviewed showed some neurodevelopmental delay, but the mothers were taking other medications at the time, so no one knows for sure if it was the quetiapine that contributed.
Lamictal is considered one of the safer medications for breastfeeding mothers, despite a study measuring up to 9.2% of the maternal dosage in breastmilk. The only adverse effect reported was thrombocytosis. The downside with Lamictal is that it takes four to six weeks to reach a therapeutic dose, so doctors recommend that medication use starts during the pregnancy.
Valproic acid (Depakote)
Depakote is also considered safe for breastfeeding. Only 1.7% of the maternal dosage passes into breastmilk due to its high plasma protein binding. Some adverse effects, such as liver damage, have been reported. However, because pediatricians prescribe Depakote to children, it has been deemed compatible with breastfeeding.
Approximately 2.3% to 4.7% of the maternal dosage of Risperidone is secreted through the breastmilk, and no adverse effects have been reported in infants.
All medications taken while breastfeeding will be closely monitored by the baby’s pediatrician, especially lithium. Medication should only be considered for a breastfeeding mother after all of the risks have been discussed. In most cases, stability in the postpartum mother outweighs the risks of medication to the infant.
Did you take any medications while breastfeeding? Why or why not?
[Editor’s note: I could not have written this post without the invaluable article, “What to Tell Your Bipolar Patient Who Wants To Breastfeed,” by Wende Wood.]