PowerPoint PresentationDepartment of Psychiatry
Disclosures Nothing to disclose, currently paid by Banner University Medical Center, and on faculty
at University of Arizona.
breastfeeding Learn about literature available regarding mood,
sleep and breastfeeding Know the resources available to refer to regarding
pharmacology and breast feeding Understand principles of psychopharmacology
involved in breastfeeding, including learning about some specific medications, to be able to counsel a woman and obtain informed consent
Be aware of syndrome described as Dysphoric Milk Ejection Reflex
Lactation Physiology
AAP Material on Breastfeeding
Depression and Infant Care
Depressed mothers are: More likely to misread infant cues 64
Less likely to read to infant Less likely to follow proper safety measures Less likely to follow preventative care advice 65
Depression is Associated with Decreased Chance of Breastfeeding A review of 75 articles found “women with depressive symptomatology in the early
postpartum period may be at increased risk for negative infant-feeding outcomes including decreased breastfeeding duration, increased breastfeeding difficulties, and decreased levels of breastfeeding self-efficacy.” 1
Depressive Symptoms and Risk of Formula Feeding An Italian study with 592 mothers participating by completing the Edinburgh Postnatal
Depression Scale immediately after delivery and then feeding was assessed at 12-14 weeks where asked if breast, formula or combo feeding. Scores were significantly higher in the full bottle fed group than the fully breastfed group (but average of both groups was not in the depressive range). An increase of 1 point on the EPDS correlated to a 6% chance of bottle feeding. 2
Excluded mothers taking antidepressants,
Depression and Post Partum Sleep A Norwegian study aimed to estimate the prevalence of and risk factors for poor
maternal sleep and depression among 2830 post-partum women 3
Pittsburgh Quality Sleep Index (PSQI) was used to self rate sleep complaints and the Edinburgh Postnatal Depression Scale (EPDS) was used to measure depressive symptoms. Demographic info was obtained from records. Moms would have been on maternity leave (44 weeks paid in Norway) and info about breastfeeding and sleeping arrangements were added.
57% above cut off for PQSI, and 16.5% for EPDS Multiple logistic regression showed depression was the variable most strongly
associated with sleep problems. Went on to measure sleep using actigraphy in a subset of mothers and there was no
difference in sleep between depressed and non depressed women despite differences in the PSQI
How Do Babies Sleep? Henderson et al studied natural pattern of infant sleep and found that by 3 months of
age 50 % of infants are sleeping from 24:00 until 05:00 AND sleeping for 8 hours straight 5
Breastfeeding and Sleep Survey of sleep and fatigue administered to 6410 mothers in 59 countries. 4
Breastfeeding mothers reported significantly more sleep than mixed or formula only fed (6.6, 6.4, and 6.3 hours).
Breast feeding mothers reported more energy than mixed or formula feeding
Breastfeeding and Sleep Disturbances Doan et al studied parents of infants and found that parents who breastfed (vs
formula) actually got 40-45 min more sleep per night as measured by actigraphy and also self reported less sleep disturbances 6
Contraindications to Breastfeeding Maternal Abuse of street drugs HIV T-Cell lymphotropic virus infection or Brucellosis Untreated miliary TB Antimetabolite chemotherapy and ongoing radiation therapy Active herpetic breast lesions
Infant Galactosemia
2012 revision of the American Academy of Pediatrics policy statement on breastfeeding and the use of human milk
Considerations When Prescribing Medications in Pregnancy The need for the drug by the mother The potential effects of the drug on milk production The amount of the drug excreted into breast milk The extent of absorption by the breast feeding infant The potential adverse effects on the breast feeding infant
AAP publication: The Transfer of Drugs and Therapeutics into Human Breast Milk: An Update on selected topics. Hari Cheryl Sachs and Committee on Drugs. Pediatrics 2013; 132; e796.
Psychopharmacology and BF Safety The amount of medication to which an infant is exposed depends on several factors: factors
pertaining to the specific medication, the maternal dosage of medication, the frequency of maternal dosing as well as chronicity, frequency of infant feedings, and the rate of maternal drug metabolism
Age of the infant, and health status of the infant: During the first few weeks of a full-term infant’s life, there is a lower capacity for hepatic drug metabolism, which is about one-third to one-fifth of the adult capacity. Over the next few months, the capacity for hepatic metabolism increases significantly and, by about 2 to 3 months of age, it surpasses that of adults.
Involve the pediatrician
Pump and Dump?
Lactation Risk Categories L1 Compatible: drug has been taken by a large number of breastfeeding women without any observed
increase in adverse effects in the infant; controlled studies fail to demonstrate a risk to the infant, or the product is not orally bioavailable in an infant
L2 Probably compatible: drug has been studied in a limited number of breastfeeding women without an increase in adverse effects in the infant, and/or the evidence of a demonstrated risk is remote
L3 Probably compatible: there are no controlled studies in breastfeeding women; however, the risk of untoward effects to breastfed infant is possible, or controlled studies show only minimal non-threatening adverse effects; drugs should be given only if potential benefit justifies potential risk to infant; new medications that have no published data are automatically categorized in this category, regardless of how safe they may be
L4 Possibly hazardous: positive evidence of risk to breastfed infant or to breast milk production; benefits of use may be acceptable despite the risk to infant; e.g. if the drug is needed in a life-threatening situation or a serious disease for which safer drugs cannot be used or are ineffective
L5 Hazardous: studies in breastfeeding mothers have demonstrated significant and documented risk to the infant based on human experience, or is a medication that has a high risk of causing significant damage to infant; drug is contraindicated in women breastfeeding an infant
Resourses LactMed: toxnet.nlm.nih.gov/newtoxnet/lactmed.htm Infant Risk Center: infantrisk.com MGH: Womensmentalhealth.org Mothertobaby.org has fact sheets you can give to patient
Antidepressants and Lactation A small study compared milk secretory activation between mothers taking
antidepressants and mothers who were not. Mothers taking antidepressants had a delay of 16 hours, but no difference in success of breastfeeding at 4 days 7
Online survey of 930 mothers who took an antidepressant during pregnancy compared those who nursed while taking an antidepressant to those who did not. Drug discontinuation was noted in 10% of infants, and it was much less likely if mother continued antidepressant while breastfeeding 14
Antidepressants MAOIs: Insufficient evidence, and as such not recommended during nursing TCAs:
Amitriptyline and nortriptyline found in variable concentrations. But no adverse effects reported. Also no adverse effects for the small number of infants exposed to imipramine, desipramine, clomipramine.
Doxepin:
In a case report of 2 infants exposed to doxepin both had high levels in the milk, and one of those infants had respiratory depression that resolved within 24 hours of cessation of breastfeeding. 9 In other cases doxepin has been linked to infant death.
Do not use DOXEPIN, linked with infant death in one case.
Antidepressants Sertraline:
Considered preferred. Concentrations of 0.5% down to 0.04% of maternal dose in milk. Milk concentration did not correlate with maternal dose. Drug concentrations are higher in hind milk. Peak concentrations at 8-9 hours (pump and dump would reduce infant expose by 17%). 10,11
Infant serum levels only detectable in 24% of infants, and correlated with mother’s dose and inversely with infant age. 12
Meta-analysis found serum levels were nondetectable or negligible and no adverse events reported 9
Once case of sleep myoclonus in a 4 month old, and one case of agitation that spontaneously resolved 13,
Antidepressants Paroxetine:
Preferred medication. Undetectable or minimal concentration in breastmilk 12
Meta-analysis of 37 infants exposed. Infant serum levels were nondetectable in all but 3 cases which had low levels. No adverse effects were reported 9
Multiple cases with no ill effect to infant In a study of mothers who took paroxetine in the 3rd trimester and breastfed, about a quarter reported
side effects such as decreased alertness, constipation, sleepiness, and irritability 12
One study found 12% of infants of mothers taking paroxetine had adverse events including insomnia, restlessness, crying and poor feeding, all of which resolved within 3 days of discontinuing paroxetine (or in one case decreasing the dose). 17
36 mothers on an avg dose of 20.4mg daily of paroxetine had infants with normal 6 month weights and no abnormal effects 15
One case report of an infant with detectable serum paroxetine levels who had 3 episodes of vomiting and dehydration. The infant was thriving 6 weeks after breastfeeding was discontinued. 16
Antidepressants Fluoxetine: Meta-analysis compiled data from 238 infants on 15 antidepressants and found
fluoxetine had a relatively high infant serum levels (18% had levels over 10% of maternal levels) 11
In a meta-analysis of 190 infants, serum levels varied from undetectable to very high. The infant with the “very high” level had excessive fussiness, decreased sleep, vomiting and diarrhea that stopped when breastfeeding stopped. Infant serum levels did not seem to correlate with maternal dose. 10 cases of adverse events which were transient or confounded by multiple medications.
One study looked at infants neurobehavioral development at 1 year of age and found it to be normal. 9
Despite higher levels in breast milk most experts do not recommend changing to breastfeed if on fluoxetine prenatally.
Antidepressants Citalopram and escitalopram:
Citalopram has relatively high infant serum levels 11
Several small reports of mothers taking citalopram show generally low levels in infant serum, but with occasional higher levels which may relate to mother being a poor metabolizer of CYP2C19. 17
One study looked at infants breastfed by mothers taking citalopram and found normal weight and development at 1 year compared to controls 11
Infant serum levels in infants whose mothers were taking escitalopram where undetectable or very low 11
Several case reports of infants without adverse effects on escitalopram, but also one report of an infant with irritability, vomiting and fever with moderately elevated LFTs that improved 2 weeks after breastfeeding was discontinued and resolved 1 month later. 20 Another report of a 5 day old exposed to escitalopram both pre and postnatally admitted for necrotizing enterocolitis. 21
Antidepressants Venlafaxine, Desvenlafaxine, Duloxetine:
Venlafaxine: Infants had elevated rate of metabolites in all infants studied of up to 37% 11
In 10 cases, 2 infants had decreased weight gain and the others had no adverse effects. 9, 23
Desvenlafaxine: Levels of desvenlafaxine are about half that of mothers who took venlafaxine. Babies exposed to desvenlafaxine (and polypharmacy)were found to have lower growth rate 22
Duloxetine: has limited data looking at 2 infants. Thus far low levels in milk and infant serum. Monitor infant growth rate
Antidepressants Mirtazapine:
Several case reports of infant serum levels that were either undetectable or low. Case study of 8 infants found normal development at around 6 months of age. 27
Antidepressants Bupropion:
8 case reports of which 7 found non detectable levels with both IR and SR dosage. 1 case report where the mother of a 6 month old was taking the XL formulation (along with escitalopram) and the infant had a seizure. The infant had detectable but low levels of bupropion and its metabolite hydroxybupropion 25,26,27,28
Antidepressants No data with vortioxetine, vilazodone, brexpiprazole and levomilnacipran
Neurostimulation for Depression ECT: Acceptable option as anesthetics and neuromuscular blockers such as propofol
and succinylcholine are acceptable with breastfeeding as soon as the effects wear off TMS: No data
Mood Stabilizers Lithium:
No difference between fore and hind milk 31
Levels reported in 13 infants were all high (10-50% of maternal levels), but no adverse effects reported except for one infant exposed in utero with heart murmur, T wave inversion, cyanosis and hypotonia whose mother was also on a diuretic
TSH elevated in 2 infants (one normalized despite continued breastfeeding) who were exposed during pregnancy 32, 33
Need to monitor infant lithium concentration, TSH, renal function and CBC AAP recommends using caution
Mood Stabilizers Valproate:
If not exposed during pregnancy infant serum levels were less than 6% of maternal levels (studies complicated by polypharmacy) 34
19 infants with no adverse effects, one infant with thrombocytopenia and anemia which resolved when nursing stopped (however could be explained by viral infection.) 35
One study compared IQ of children breastfed with valproic acid vs formula fed by mother on valproic acid and found a statistically different ihigher IQ in breastfed infants at age 6. 36
Monitor for bruising and jaundice, VPA level, platelets and liver enzymes
Mood Stabilizers
Carbamazepine: Levels are detectable but low in breastmilk, limited data on levels in infants not exposed during
pregnancy. One study looked at 54 breastfed infants and infant serum levels ranged from undetectable to 70% of maternal levels of carbamazepine, no correlation was found with maternal and infant serum level . 37
Of 25 infants exposed through nursing 2 had transient hepatic dysfunction (resolved when nursing was stopped) and both demonstrated normal development at 6 months.
Monitor for jaundice, drowsiness, weight gain, and developmental milestones. Check liver, bilirubin, CBC, and Carbamazepine levels
Mood Stabilizers
Lamotrigine: Milk/Plasma ratio of 0.61 with infant serum concentration of 30% of maternal concentrations38
No reports of infant SJS Multiple case reports without adverse events Of 8 infants who had platelets monitored 7 were elevated with no adverse event 40
A mother on 850mg daily had an infant have a severe apneic spell requiring chest compressions. 41
Monitor for rash, respiratory depression, CBC, consider lamotrigine levels
Antipsychotics Clozapine: Concentrated in breast milk 9
Infant serum levels 279% that of mother’s serum levels. Case reports of infant with sedations, agranulocytosis, and cardiovascular instability. Monitor for somnolence, CBC with diff (weekly), NMS. Infant would go on clozapine
registry Probably best to avoid
Antipsychotics Olanzapine: Several reports of infant’s levels being undetectable for mothers with doses up to 20 mg
daily, 1 case report with infant with detectable level. The manufacture compiled 102 breastfed infants whose mother was taking olanzapine
and 15% reported adverse events (somnolence, irritability, tremor and insomnia) though many exposed prenatally also. 46-47
A case control study compared mothers who took olanzapine and breastfed vs those who took the drug and did not breastfeed, vs those taking Tylenol. Mothers completed a survey 1-2 years later showing no statistical difference in the groups with regards to development. 66
Probably preferred antipsychotic in breastfeeding
Antipsychotics Aripiprazole: Very limited data, Can lower prolactin levels and several case reports of difficulty with establishing supply. Only a handful of cases with doses around 15mg daily. One case where serum levels
were detected the infant was exposed in utero. One case of a 3 month old infant who was growing normally, and one case a baby was partially breastfed and at 4 months was reaching normal developmental milestones. 42-44
One case of a 12 day old on lamotrigine, aripiprazole, sertraline and synthroid presented with severe weight loss and dehydration who developed DIC and required 5 toe amputation. 45
Probably pick another agent
Antipsychotics Risperidone: 4 case reports of infants breastfed (mother’s dose up to 4mg daily) and infant levels
where undetectable. 48
No reports of adverse events (except sedation in a infant with mother and significant polypharmacy). Several reports of normal development. 49-52
Can cause galactorrhea
Antipsychotics Quetiapine: Probably a good choice during breastfeeding, at least at low doses. Max milk levels 1 hour after dose and correlated with maternal dose. 62 No difference in
fore vs hind milk. 63
A lot of the cases were moms on very low doses The few cases of infant levels were below 10% All case reports did not note adverse events, and development was within normal limits
for the cases in which it was reported.
Antipsychotics Haloperidol: Levels in infants of mothers on 5-20mg collected. They had low levels present, not
related to dose. Several cases showed normal development and no adverse effects, but one study with
haloperidol plus chlorpromazine showed 2 infants (out of 4) had a decline in developmental scores at 12-18 months 53
Antipsychotics Ziprasidone has 1 case report of no adverse events 54
Asenapine, paliperidone, Iloperidone, and lurasidone have no data
Lactation on an Inpatient Psychiatric Unit Is it safe? Is it wise? Who gets to decide?
Insomnia Sleep hygiene Risk of mother falling asleep Diphenhydramine: has surprisingly little data, but occasional use is acceptable Trazadone: 0.6% maternal dose, and no reported adverse events Zolpidem: variable levels in milk, one case of infant sedation Eszopiclone: no data Melatonin: Limited data on safety and infant plasma levels, but short term course is
unlikely to have negative effect.
Anxiolytics Buspirone: has insufficient data. One case report with undetectable milk and infant serum levels.55
Hydroxyzine: Chronic use may effect milk supply, but occasional use probably will not. No data on milk or serum concentrations. Of 174 mothers taking hydroxyzine there were 8 adverse events noted, primarily sedation. 68
Motherisk Study included 124 infants exposed to benzodiazepines via breastmilk, only 1.6% experienced sedation
Clonazepam: Not a preferred choice, associated with multiple adverse events including serious adverse events.
Diazepam: Infant serum levels are unpredictable and can range from unpredictable to very high. Associated with sedation and weight loss making diazepam a poor choice. 56
Lorazepam: Low breast milk levels, safe to administer to infants, no adverse effects noted in breastfed infants (toxnet.nlm.nih.gov)
Oxazepam: has a short half life and low levels in breast milk. It is also acceptable to give to infants. There are reports of sedation.
Alprazolam: One case reported of withdrawal from alprazolam when medication was tapered.
ADHD Treatments Guanfacine has no data on serum levels or safety, but may lower prolactin Strattera has no published data Clonidine: infant levels ranged from undetectable to 66% of maternal levels. There
have been several reports of infants without adverse effects, but one report of an infant with hypotonia, seizures and apnea that resolved 24 hours after breastfeeding was stopped. Possible galactorrhea. 57
Dextroamphetamine/amphetamine: found up to 15% serum levels in infants. 4 cases published of mothers on 18-35mg daily where infant developed normally without adverse events. Some data to show a non statistical decrease in prolactin with IV amphetamines. Monitor for agitation and poor weight gain. 58-59
Methylphenidate: 4 infants studied all (3 tested) had undetectable methylphenidate levels and no adverse effects were reported. Possible decrease prolactin levels. Monitor for agitation and poor weight gain. 60
Cannabis Neurodevelopmental effects, delayed motor development at 1y, lethargy, less
frequent and shorter feeds, high milk-plasma ratio in heavy users New study 61 on transfer of inhaled cannabis into human breast milk. Looked at women who smoke cannabis regularly and are 2-5 months postpartum and
breast feeding. 8 moms where told not to smoke for 24 hours and baseline levels where drawn. Then
they were told to smoke 3-4 hits of cannabis and breastmilk samples were collected at 20 min, 1, 2 and 4 hours intervals afterwards and THC was quantified by high performance liquid chromatography tandem mass spectroscopy.
THC detected at low concentrations at all time points beyond baseline. THC was transferred into mother’s milk such that exclusively breastfeeding infants ingested estimated 2.5% of maternal dose (range 0.4-8.7%)
Dysphoric milk ejection reflex (D- MER) Only recently described in the literature, with 3 publications found on pubmed Websites, books and blogs Negative feelings with each breastfeeding (milk let down) episode. Described as
lasting 90-120 seconds with feeling worthless, poor concentration (effecting math skills and reading skills), feeling homesick, and feeling hollow.
Resolves after weaning. Speculation that it may involve oxytocin or dopamine (dopamine could drop to
increase prolactin). In one case a woman reported that pseudoephedrine was very helpful 67
Conclusion Breastfeeding has many health benefits to mother and baby Traditional beliefs about breastfeeding and sleep are probably incorrect Psychopharmacology during breastfeeding is challenging due to limit data in most
agents, but with only rare exception it is not a reason to prevent a mother from breastfeeding, albeit with close monitoring to the infant in some cases Be sure about the diagnosis and severity of symptoms Find out about what has worked in the past Avoid polypharmacy whenever possible Coordinate with the Pediatrician
Mother should be able to provide informed consent without a sense of judgment from her physicians
Use your resources!
References 1. Dennis CL & McQueen K (2009). The relationship between infant-feeding outcomes and postpartum depression: A
qualitative systematic review. Pediatrics, 123, e736-e751. 2. Gagliardi L, Petrozzi A Rusconi F. Symptoms of maternal depression immediately after delivery predict unsuccessful
breast feeding. Archives of Disease in Childhood 2012; 97:355-357 3. Dorheim SK, Bondevik GT, Eberhard-Gran M, & Bjorvatn B (2009). Sleep and depression in postpartum women:A
population-based study. Sleep, 32 (7), 847-855. 4. Kendall-Tackett K, Cong Z, Hale T. The Effect of Feeding Method on Sleep Duration, Maternal Wellbeing, and
Postpartum Depression. Clinical Lactation, 2011, vol 2-2, 22-26. 5. Henderson JMT, France KG, Owens JL and Neville MB. Sleeping Through the Night: The consolidation of Self-regulated
Sleep Across the First Year of Life. Pediatrics. Volume 126, Number 5, Nov 2010. 6. Doan T, GardinerA, Gay CL, Lee KA. Breastfeeding increases sleep duration of new parents. J Perinat Neonatal Nurs.
2007 Jul-Sep;21 (3):200-6 7. Sertcelik S, Bakim B, Karamustafalioglu O. [High dose paroxetine-induced galactorrhea with normal serum prolactin
level: A case report]. Klin Psikofarmakol Bul. 2012;22:355-6. 8. Trenque T, Herlem E, Auriche P, Drame M. Serotonin reuptake inhibitors and hyperprolactinaemia: a case/non-case
study in the French pharmacovigilance database. Drug Saf. 2011;34:1161-6. 9. Burt V, Suri R Altshuler L, Stowe Z, Hendrick V, Muntean E. The use of psychotropic medications during breastfeeding.
Am J Psychiatry 2001; 158:1001-1009.
10. Salazar FR, D'Avila FB, de Oliveira MH et al. Development and validation of a bioanalytical method for five antidepressants in human milk by LC-MS. J Pharm Biomed Anal. 2016;129:502-8.
11. Weissman AM, Levy BT, Hartz AJ et al. Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. Am J Psychiatry. 2004;161:1066-78.
12. Hendrick V, Fukuchi A, Altshuler L et al. Use of sertraline, paroxetine and fluvoxamine by nursing women. Br J Psychiatry. 2001;179:163-6.
- 13. Sunder KR, Wisner KL, Hanusa BH et al. Postpartum depression recurrence versus discontinuation syndrome: observations from a randomized controlled trial. J Clin Psychiatry. 2004;65:1266-8.
14. Epperson N, Czarkowski KA, Ward-O'Brien D et al. Maternal sertraline treatment and serotonin transport in breast-feeding mother-infant pairs. Am J Psychiatry. 2001;158:1631-7.
15. Casper RC, Fleisher BE, Lee-Ancajas JC et al. Follow-up of children of depressed mothers exposed or not exposed to antidepressant drugs during pregnancy. J Pediatr. 2003;142:402-8
16. Hendrick V, Smith LM, Hwang S et al. Weight gain in breastfed infants of mothers taking antidepressant medications. J Clin Psychiatry. 2003;64:410-2.
17. Hendrick V, Smith LM, Hwang S et al. Weight gain in breastfed infants of mothers taking antidepressant medications. J Clin Psychiatry. 2003;64:410-2.
18. Heikkinen T, Ekblad U, Kero P et al. Citalopram in pregnancy and lactation. Clin Pharmacol Ther. 2002;72:184- 91.
19. Weisskopf E, Panchaud A, Nguyen KA et al. Simultaneous determination of selective serotonin reuptake inhibitors and their main metabolites in human breast milk by liquid chromatography-electrospray mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci. 2017;1057:101-9.
20. Berle JO, Steen VM, Aamo TO et al. Breastfeeding during maternal antidepressant treatment with serotonin reuptake inhibitors: infant exposure, clinical symptoms, and cytochrome P450 genotypes. J Clin Psychiatry. 2004;65:1228-34.
21. Gentile S. Escitalopram late in pregnancy and while breast-feeding. Ann Pharmacother. 2006;40:1696-7. 22. Rampono J, Teoh S, Hackett LP et al. Estimation of desvenlafaxine transfer into milk and infant exposure during its use
in lactating women with postnatal depression. Arch Womens Ment Health. 2011;14:49-53. 23. Ilett KF, Kristensen JH, Hackett LP et al. Distribution of venlafaxine and its O-desmethyl metabolite in human milk and
their effects in breastfed infants. Br J Clin Pharmacol. 2002;53:17-22. 24. Kristensen JH, Ilett KF, Rampono J et al. Transfer of the antidepressant mirtazapine into breast milk. Br J Clin Pharmacol.
2007; 63:322-7. 25. Briggs GG, Samson JH, Ambrose PJ et al. Excretion of bupropion in breast milk. Ann Pharmacother. 1993;27:431-3. 26. Baab SW, Peindl KS, Piontek VM et al. Serum bupropion levels in 2 breastfeeding mother-infant pairs. J Clin Psychiatry.
2002;63:910-1. 27. Davis MF, Miller HS, Nolan PE. Bupropion levels in breast milk for 4 mother-infant pairs: more answers to lingering
questions. J Clin Psychiatry. 2009;70:297-8. 28. Chaudron LH, Schoenecker CJ. Buproprion and breastfeeding: a case of a possible infant seizure. J Clin Psychiatry.
2004; 65(6): 881-882. 29. Schou M, Amdisen A: Lithium and pregnancy. 3: Lithium ingestion by children breastfed by women on lithium
treatment. Br Med J 1973; 2:138 30. Moretti ME, Koren G, Verjee Z et al. Monitoring lithium in breast milk: an individualized approach for breast-feeding
mothers. Ther Drug Monit. 2003;25:364-6. 31. Tanaka T, Moretti ME, Verjee ZH et al. A pitfall of measuring lithium levels in neonates. Ther Drug Monit. 2008;30:752-4. 32. Viguera AC, Newport DJ, Ritchie J et al. Lithium in breast milk and nursing infants: clinical implications. Am J
Psychiatry. 33. Marin Gabriel MA, Olza Fernandez I, Donoso E, Gutierrez Cruz N. [Lithium and artificial breastmilk; or is maternal
breastfeeding better?]. An Pediatr (Barc). 2011;75:67-8. 34. Wisner K, Perel J: Serum levels of valproate and carbamazepine in breastfeeding mother-infant pairs.
Psychopharmaology (Berl) 1998; 18:167-169
35. Piontek CM, Baab S, Peindl KS et al. Serum valproate levels in 6 breastfeeding mother-infant pairs. J Clin Psychiatry. 2000;61:170-2.
36. Meador KJ, Baker GA, Browning N et al. Breastfeeding in children of women taking antiepileptic drugs: Cognitive outcomes at age 6 years. JAMA Pediatr. 2014;168:729-36.
37. Kacirova I, Grundmann M, Brozmanova H. Therapeutic monitoring of carbamazepine concentrations in breastfeeding mothers, maternal milk and nursed infants. Ther Drug Monit. 2011;33:503.
38. Ohman I, Tomson T, Vitols S:Lamotrigine levels in plasma and breast milk in nursing women and their infants (abstract). Epilepsia 1998; 21 (suppl 2):39
39. Popescu L, Marceanu M, Moleavin I. Withdrawal of lamotrigine caused by sudden weaning of a newborn: a case report. Epilepsia. 2005;46 (Suppl 6):407. Abstract p1351.
40. Newport DJ, Pennell PB, Calamaras MR et al. Lamotrigine in breast milk and nursing infants: determination of exposure.
41. Nordmo E, Aronsen L, Wasland K et al. Severe apnea in an infant exposed to lamotrigine in breast milk. Ann Pharmacother. 2009;43:1893-7.
42. Lutz UC, Hiemke C, Wiatr G et al. Aripiprazole in pregnancy and lactation a case report. J Clin Psychopharmacol. 2010;30:204-5.
43. Watanabe N, Kasahara M, Sugibayashi R et al. Perinatal use of aripiprazole: a case report. J Clin Psychopharmacol. 2011;31:377-9
44. Nordeng H, Gjerdalen G, Brede WR et al. Transfer of aripiprazole to breast milk: A case report. J Clin Psychopharmacol. 2014;34:272-5.
45. Morin C, Chevalier I. Severe hypernatremic dehydration and lower limb gangrene in an infant exposed to lamotrigine, aripiprazole, and sertraline in breast milk. Breastfeed Med. 2017;12:377-80.
46.Lutz UC, Wiatr G, Orlikowsky T et al. Olanzapine treatment during breast feeding: a case report. Ther Drug Monit. 2008;30:399-401.
47. Friedman SH, Rosenthal MB. Treatment of perinatal delusional disorder: a case report. Int J Psychiatry Med. 2003;33(4):391-4.
48. Ilett KF, Hackett LP, Kristensen JH, Vaddadi KS et al. Transfer of risperidone and 9-hydroxyrisperidone into human milk. Ann Pharmacother. 2004;38:273-6.
49. Aichhorn W, Stuppaeck C, Whitworth AB. Risperidone and breast-feeding. J Psychopharmacol. 2005;19:211-3.
50. Weggelaar NM, Keijer WJ, Janssen PK. A case report of risperidone distribution and excretion into human milk: How to give good advice if you have not enough data available. J Clin Psychopharmacol. 2011;31:129-31.
51. Ratnayake T, Libretto SE. No complications with risperidone treatment before and throughout pregnancy and during the nursing period. J Clin Psychiatry. 2002;63(1):76-7.
52. Kelly LE, Poon S, Madadi P, Koren G. Neonatal benzodiazepines exposure during breastfeeding. J Pediatr.
53. Yoshida K, Smith B, Craggs M et al. Neuroleptic drugs in breast-milk: a study of pharmacokinetics and of possible adverse effects in breast-fed infants. Psychol Med. 1998;28:81-91.
54. Werremeyer A. Ziprasidone and citalopram use in pregnancy and lactation in a woman with psychotic depression. Am J Psychiatry. 2009;166:1298
55. Brent NB, Wisner KL. Fluoxetine and carbamazepine concentrations in a nursing mother/infant pair. Clin Pediatr (Phila). 1998;37:41-4.
56. Patrick M, Tilstone W, Reavey P. Diazepam and breastfeeding. Lancet 1972; 542-543
57. Hartikainen-Sorri AL, Heikkinen JE, Koivisto M. Pharmacokinetics of clonidine during pregnancy and nursing. Obstet Gynecol. 1987;69:598-600.
58. Steiner E, Villen T, Hallberg M et al. Amphetamine secretion in breast milk. Eur J Clin Pharmacol. 1984;27(1):123-4.
59. Ilett KF, Hackett LP, Kristensen JH, Kohan R. Transfer of dexamphetamine into breast milk during treatment for attention deficit hyperactivity disorder. Br J Clin Pharmacol. 2007;63:371-5.
60. Bolea-Alamanac BM, Green A, Verma G et al. Methylphenidate use in pregnancy and lactation: a systematic review of evidence. Br J Clin Pharmacol. 2014;77:96-101.
61. Baker T, Datta P, Rewers-Felkins K, Thompson H, Kallen R, and Hale T. Transfer of Inhaled Cannabis Into Human Breast Milk. Obstetrics and Gynocology, 0:0 2018
62. Misri S, Corral M, Wardrop AA, Kendrick K. Quetiapine augmentation in lactation: a series of case reports. J Clin Psychopharmacol. 2006;26:508-11.
63. Rampono J, Kristensen JH, Ilett KF et al. Quetiapine and breast feeding. Ann Pharmacother. 2007;41:711-4. 64. Center on the Developing Child at Harvard University. 2009. Maternal Depression Can Undermine the
Development of Young Children: Working Paper No. 8. Cambridge, MA: Harvard University. http://developingchild.harvard.edu/
65. Wulczyn, Fred. 2009. Epidemiological Perspectives on Maltreatment Prevention. In !e Future ofChildren. Vol. 19 No. 2 Brookings Institute: Princeton.
66. Friedman SH, Rosenthal MB. Treatment of perinatal delusional disorder: a case report. Int J Psychiatry Med. 2003;33(4):391-4.
67. Heise A and Wiessinger D. Dysphoric milk ejection reflex: A case report.Internation Breastfeeding Journal 2011, 6:6
68.Soussan C, Gouraud A, Portolan G et al. Drug-induced adverse reactions via breastfeeding: a descriptive study in the French Pharmacovigilance Database. Eur J Clin Pharmacol. 2014;70:1361-6.
Disclosures
Depressive Symptoms and Risk of Formula Feeding
Depression and Post Partum Sleep
How Do Babies Sleep?
Psychopharmacology and BF Safety
Insomnia
Anxiolytics
Conclusion
Questions?
References