Dr. Becker is an instructor in the Department of Psychiatry and Human Behavior and associate director of Consultation-Liaison Psychiatry; Dr. Mayor is clinical assistant professor of Psychiatry and Human Behavior; and Dr. Kunkel is professor of Psychiatry and Human Behavior, vice chair for Clinical Affairs, and director of Consultation-Liaison Psychiatry, all at Thomas Jefferson University in Philadelphia, Pennsylvania.
Disclosures: Drs. Becker and Mayor report no affiliation with or financial interest in any organiziation that may pose a conflict of interest. Dr. Kunkel is on the speaker’s bureaus of Intramed/Forest, Pfizer, and Wyeth.
Please direct all correspondence to: Madeleine A. Becker, MD, Thomas Jefferson University, Department of Psychiatry and Human Behavior, 1020 Sansom St, Suite 1652, Philadelphia, PA 19107; Tel: 215-955-1606; Fax: 215-955-8473; E-mail: Madeleine.firstname.lastname@example.org.
• There is clinical evidence for significant benefit of breastfeeding for the infant.
• Psychiatric illness is common in the postpartum period.
• Psychotropic medications are often necessary to treat postpartum psychiatric illness.
• Based on the existing data, some psychotropic medications are more compatible with breastfeeding than others.
World health experts encourage women to breastfeed, but many primary care physicians, obstetricians, and psychiatrists are hesitant to encourage new mothers who are taking psychiatric medications to do so. Unfortunately, there are only a few case-controlled studies on the safety of psychotropics in breastfeeding. This article outlines the benefits of breastfeeding, both for the infant and for the mother; postpartum illness and its effect on the mother and infant; and the existing data on the most commonly used psychotropics. The effect of psychotropics on the nursing infant is examined and summarized.
Many new mothers who need to take medications for psychiatric illness would like to breastfeed but are hesitant, as they are uncertain about the safety of these medications for their infant. There are currently very few, and no large, case-controlled studies on the safety of psychotropics in lactation. Prospective, randomized, double-blind, placebo-controlled trials cannot be conducted for obvious ethical reasons. Consequently, most of the current information available is compiled from case series and case reports and remains limited in quality and quantity. Drugs that have been on the market for some time (selective serotonin reuptake inhibitors [SSRIs], some mood stabilizers, benzodiazepines, typical antipsychotics) have accumulated relatively large or stable data. Newer drugs (dual-action antidepressants, atypical antipsychotics) have only scarce data. As a result of the lack of controlled studies, physicians are often confronted with a dilemma as to whether or not to prescribe medications for women who want to breastfeed.
In cases in which medication is felt to be necessary, consultation between the mother’s physician (primary care physician [PCP], obstetrician, and/or psychiatrist) and the pediatrician is recommended for choosing the safest options. The potential benefits of breastfeeding should always be weighed against the risks to the neonate. This should be fully discussed with the patient. The treating physician should review with the patient the available information about the risks and benefits. Discussion of risks and benefits of breastfeeding for a mother using psychiatric medications should be documented. Mothers should be made aware that the use of psychiatric medication may have other adverse consequences on the infant that are not known, as our knowledge is based on the limited data we have available at this time. If the patient decides to continue breastfeeding while using psychiatric medication, the infant should be monitored by the pediatrician for possible side effects.
This article first reviews the benefits of breastfeeding both for the infant and the mother. It discusses postpartum psychiatric illness that requires psychotropic medication. It then provides an update on the current data published about the most commonly used psychotropic agents and their safety in breastfeeding.
A closer look into this topic has become timely with the recent (May 2008) public announcement of the Food and Drug Administration’s proposed final rule on pregnancy and lactation labeling. The letter system, which categorizes drugs into risk categories A, B, C, D, and X, will be eliminated. This system is outdated and does not account for new information about drug safety and risk profiles in pregnancy and lactation. Additionally, it is over-simplified, leading to imbalanced counseling of clients by healthcare providers. The new labeling system will have separate sections for pregnancy and for lactation, and each section will have three main components: risk summary, clinical considerations, and analysis of data (animal vs. human). Some of the information proposed for inclusion in the new labeling for lactation are discussed in this article, namely, compatibility of a specific drug with breast-feeding; amount of drug passed on to the infant from breast milk; possible effects of the drug on the breastfeeding infant; recommendations for monitoring these effects; and a review of the available data addressing these issues.1
The Benefits of Breastfeeding
The World Health Organization, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists recommend breast milk exclusively for at least the first 6 months of life,2-6 and continued breast milk with food through 6–12 months of age.7 There is evidence for significant health-related, nutritional, immunologic, developmental, psychologic, social, economic, and environmental advantages for breastfeeding.6-8
Breastfeeding is associated with a reduction in infant mortality rates.3,7,9-11 Other associated benefits include a reduction in the risk of infectious diseases (meningitis),12,13 gastrointestinal infection,14,15 deaths due to diarrhea,16 necrotizing enterocolitis,17 otitis media,18,19 respiratory infections,15,16,20,21 urinary tract infections,22,23 and sepsis.13 Breast-fed infants have reduced rates of sudden infant death syndrome.7,10 Other positive outcomes include a lower incidence of pediatric cancers,24,25 including lymphoma, leukemia, and Hodgkins disease. Reports also include a lower incidence of diabetes,26 obesity,27-31 and asthma32-35 in children and adults who were breastfed as infants. Increased analgesia during painful procedures for infants has also been reported in breastfed infants.36,37
Some research has also suggested a possible increase in cognitive development in infants who were breastfed.7,38 However, other more recent studies have found that this association with increased cognitive function is weaker than previously thought39 and possibly most significant for babies of small gestational size40,41 or attributable to factors other than breast milk.42 This area is still controversial and requires further study.
Maternal benefits of breastfeeding include decreased postpartum bleeding, more rapid uterine involution,43 and faster weight loss to pre-pregnancy weight.44,45 Studies have also shown a reduced risk of breast cancer46-51 and ovarian cancer,52-54 and possibly a lower prevalence of the metabolic syndrome.55
Other benefits of breastfeeding include lower overall healthcare costs for less infant illness.56 Breastfeeding is much more economical than buying formula. Environmental benefits include less waste generated by disposal of formula packaging.7 However, for women who are unable or disinclined to breastfeed, formula is a reasonable alternative to breastfeeding.
When Breastfeeding is Contraindicated
Some women should not breastfeed because of certain health risks it may pose to the baby. Breastfeeding is not recommended for mothers receiving certain chemotherapeutic agents or radioactive isotopes and selected other medications rated to be unsafe by the American Academy of Pediatrics. Mothers with herpes simplex lesions on the breast, HIV, or active tuberculosis, or those abusing drugs should also not breastfeed.7 Infants with galactosemia, premature children, and children with inherited disturbances in metabolism may be particularly vulnerable to the effects of psychotropics during breastfeeding.57
Another reason a women may choose not to breastfeed includes mental illness where the risk of sleep disruption could worsen the condition, such as bipolar disorder. In some instances, women may opt to bottle feed, as the burden of frequent night feedings and prolonged sleep deprivation may be shared with another caregiver.
Postpartum Psychiatric Illness
There is a high rate of psychiatric illness after childbirth. This may be attributable to hormonal factors, but also can be associated with psychological stress and previous psychiatric illness in the mother.58,59 Given the high rate of psychiatric illness during and after pregnancy, the healthcare practitioner should carefully and thoroughly evaluate the postpartum patient who is at risk for psychiatric illness to determine whether medication is necessary. They should understand the risks associated with psychiatric medications, and carefully assess the need for medication in the nursing mother.
Postpartum blues is a temporary and common condition affecting up to 85% of new mothers. This condition is characterized by tearfulness, mood lability, irritability, and anxiety. Symptoms usually begin around postpartum days 2–4 and resolve spontaneously, usually in ~2 weeks. Symptoms are generally transient and require no medication treatment. However, women with postpartum blues may be at increased risk for the subsequent development of postpartum depression.60
The highest rates of major depressive disorder (MDD) occur in women during the childbearing years, between 25–44 years of age.2,61 Postpartum depression is common, and occurs in up to 5% to 20% of women.57 Symptoms of postpartum depression are the same as for depression at other times and include depressed mood, insomnia, anhedonia, and suicidal ideation. The criteria of “postpartum onset” specifier in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition–Text Revision,62 is applied to the first 4 weeks after childbirth. The International Statistical Classification of Diseases and Health Related Problems, Tenth Revision,63 coding permits classifications of postpartum mental disorders 6 weeks after childbirth. In reality, many clinicians would consider depressive symptoms to be “postpartum depression” for a much longer period than this. Proposals for revisions of classifications include a specifier for onset within 3 months postpartum.64 The Edinburgh Postnatal Depression Scale is recommended for screening in women at risk for postpartum depression.
Women with a history of depression, postpartum depression, or previous psychiatric disorder are at an increased risk for postpartum depression.57,65-67 Social isolation, high parity, and psychological distress in late pregnancy are associated with postpartum depression.65 During pregnancy there is a high rate of relapse in patients with a history of MDD. A recent study68 of pregnant women with moderate-to-severe recurrent depression, who were taking antidepressants before conception and who then chose to discontinue medication, showed a 68% relapse rate of depression during their pregnancies. This was compared with a 25% relapse rate for those women who chose to continue antidepressants throughout their pregnancies.68
Postpartum psychosis is much less common, affecting ~0.1% to 0.2% of all women.69 It is characterized by mood lability, agitation, confusion, thought disorganization, hallucinations, and disturbed sleep. Postpartum psychosis has been associated with an increased risk of suicide, infant neglect, and infanticide,67,70 and is considered an emergency. Although relatively rare in the general population, the risk of postpartum psychosis in mothers with a history of previous inpatient psychiatric hospitalization is increased significantly compared to those without.71,72 There is also a very high risk of postpartum psychosis in mothers with bipolar depression, reported as high as 46%.2,58,59 Women who have had an episode of postpartum psychosis are at risk for developing bipolar affective disorder, suggesting that this could be a subcategory of bipolar disorder.67 Rates of relapse of bipolar disorder after pregnancy are high, ranging from 20% to 35%.67
Anxiety disorders are also very common, especially in the postpartum period. Postpartum panic disorder has been the most frequently reported anxiety condition.2,67 Rates of obsessive-compulsive disorder (OCD) have been reported to be higher postpartum than during pregnancy. Both OCD and generalized anxiety disorder (GAD) have been found to have higher rates in the postpartum population than in the general population.73
Although the DSM-IV-TR does not specifically identify childbirth as an example of a traumatic event, childbirth can be recognized as a stressful medical/surgical procedure that involves intense pain and invasive procedures, suggesting that it is relevant to consider it as a stressor. Posttraumatic stress disorder (PTSD) is also now being recognized in postpartum period.73 Stressful life events as well as depression during pregnancy and GAD have been identified as being related to PTSD symptoms.73-75 Anxiety late in pregnancy also was found to be predictive of PTSD.76
Schizophrenia in pregnancy has been associated with an increased risk of stillbirths, infant death, preterm delivery, and low birth weight.77,78 Postpartum schizophrenia and psychosis, particularly if left untreated, can lead to increased rates of refusal of care, maternal self-mutilation, postnatal death, and poor perinatal outcomes.2,70,78
Untreated Maternal Psychiatric Illness
Psychiatric illness has been known to negatively influence mother-child interactions. Maternal depression is associated with an increase in premature births, low birthweight infants, fetal growth restriction, and postnatal complications.2 Infants of mothers with untreated depression have been shown to cry more and are more difficult to console.79 There is evidence that having a maternal psychiatric disorder also increases the risk of childhood behavioral problems.80
Maternal depression may also result in poor compliance with care and increased exposure to additional medications, illicit drugs, herbal remedies, alcohol, and tobacco. Untreated psychiatric illness has also been associated with difficulties with maternal-infant bonding.2 Studies81 also show that mothers with depression have a poor pattern of infant healthcare utilization, including an increased use of acute care and emergency room visits as well as decreased utilization of preventative services such as well-care visits and up-to-date vaccinations. Depressed mothers are also less likely to continue to breastfeed82 and less likely to promote childhood development by playing and talking to their baby and following predictable routines.83,84 Maternal depression has been shown to increase the risk of subsequent childhood psychopathology, including disruptive behaviors, anxiety disorders, and depression.85-88 On the other hand, remissions in maternal depression positively affect both mother and child, resulting in a significantly lower rate of children’s psychiatric symptoms and diagnoses.89
There is a high risk of relapse of psychiatric illness during and after pregnancy, and there is much evidence that untreated maternal illness may be harmful to both mother and baby. Psychotherapy should always be considered as part of the treatment choices. However, there are often instances when medications are helpful and in many cases necessary. With this in mind, the risks of fetal exposure to medication must be carefully weighed against the risk of the untreated psychiatric illness.
Psychotropic Medications and Breastfeeding
All psychiatric drugs pass into breast milk. Most psychiatric drugs are lipid soluble and pass easily into breast milk through passive diffusion across cell membranes. The most reliable method for measuring infant drug exposure is by measuring the drug level in the infant’s serum.60 The relative infant dose is one way of quantifying infant drug exposure, and is defined as the percentage of the maternal plasma level, in mg/kg, received by the infant in a 24-hour period. This is the infant plasma drug level divided by the average maternal plasma drug level. Most medications are considered safe when the infant dose is <10%. Breast milk levels also are measured and used to gauge potential for infant drug exposure. The American Academy of Pediatrics (AAP) has rated the compatibility of drugs during lactation. This rating is based on the reports found in the literature and is intended to assist the physician in counseling the mother regarding breastfeeding while taking medication (Table 1).90
The AAP Committee on Drug Safety rates all antidepressants as effects “unknown” and may be “of concern” in breastfeeding.90 However, a pooled analysis of antidepressant levels in lactating mothers suggests that it is probably safe to use antidepressants during lactation.91
The growing evidence is generally reassuring concerning safety of using SSRIs in breastfeeding mothers. There are few reports of adverse effects on exposed infants to these medications.57 The excretion of SSRIs into breast milk ranges from relatively low to undetectable.57,92,93 Long-term effects of infant exposure to SSRIs have been less well studied.
Fluoxetine 20–40 mg results in relatively low infant plasma levels.93-96 A PubMed search identified a total of 67 cases of exposure. Norfluoxetine, the active metabolite of fluoxetine, has a very long half-life; it may likely be responsible for higher levels than the other SSRIs and accumulation in infants.91,98 There have been several reports93,97-99 of tremulousness, excessive crying, colic, poor feeding, and in one case lethargy in infants exposed to fluoxetine through breast milk. However, in most studies, no adverse effects were seen in infants up to 1 year of age.57,93-96
Sertraline has been relatively well studied. Ninety-five cases were identified looking at breastfeeding level and effects on infants. Levels in nursing infants have been reported as low to undetectable in infant serum and low in breast milk. No adverse effects have been reported in the exposed infants.91,100-105 No significant change in serotonin transport in the infants were found in exposed infants.106
Citalopram exposure through breast milk produced relatively higher infant levels than the other SSRIs.91,107,108 Nevertheless, infant levels are still found to be very low to undetectable in most studies.109,110 One study108 reported poor sleep in an exposed infant, but symptoms resolved after the dose was reduced. Fifty-three cases were identified in the literature. Most studies did not report adverse events in infants who were breastfed while their mothers were taking citalopram, including a small case-controlled study of 31 women-infant pairs.110,111
Few cases have been published to date on the safety of the use of escitalopram in nursing. In a total of nine mother-infant pairs, infant levels were found to be low to undetectable and no adverse effects were seen in infants who had normal developmental milestones.112,113 Another study114 with two mother-infant pairs showed breast milk levels as similar to levels found with citalopram, and infants showed no adverse effects.
In the 10 case reports found on PubMed on fluvoxamine, the drug has shown to produce variable but relatively low levels in exposed infants with no adverse effects reported100,115-118 and no adverse effects after 2–3 years.119
Infants exposed to paroxetine through breastfeeding have been found to have low to undetectable serum levels. A total of 88 mother-infant pairs were examined. All of these cases reported no significant adverse side effects in the exposed infants observed100,120-122 and did not appear to affect weight gain or developmental milestones.123
Summary of SSRI Data
Low infant plasma levels have been found with all the SSRIs, but higher concentrations have been reported for fluoxetine98,99 and citalopram.91 Sertraline and paroxetine usually produced undetectable infant levels.91,92 The reviewed literature suggests that sertraline and paroxetine should be considered first-line choices in breast-feeding mothers who need to take SSRIs.61 However, the risk of relapse should always be considered; if a woman has been stable on another antidepressant throughout her pregnancy, one should not necessarily change medication, as the evidence suggests that most SSRI levels have been found to be quite low in the infant. However, fluoxetine and citalopram should not be first choices, and if needed for their effectiveness in individual women, they should be used with caution. An alternative is the decision not to breastfeed. This should be considered and discussed with the patient.
The AAP rates the effects of tricyclic antidepressants (TCAs) as “unknown but may be of concern.” The levels of TCAs ingested by nursing infants was found to be low (<1% of maternal dose).124 Most reports show no adverse effects in the nursing infant.57,125 In most cases, there have been no adverse effects found with exposure to nortriptyline, imipramine, desipramine, or clomipramine.2,57,124
Doxepin has a long half-life and can accumulate in exposed infants. Despite low transfer into breast milk and infant plasma, two cases126,127 of infants exposed to doxepin through breast milk were associated with sedation and respiratory depression, likely due to accumulation in the infant. Because of this limited data it has been suggested that doxepin should be avoided during breastfeeding.57 However, with such a small number of cases it is difficult to draw any conclusions regarding the safety of doxepin in lactation.
Nortriptyline levels have been shown to be low to undetectable in infant serum, and no adverse effects were noted in the exposed infants.91,128,129
Monoamine Oxidase Inhibitors
No current data was found regarding monoamine oxidase inhibitors.
Serotonin-Norepinephrine Reuptake Inhibitors
There are very few case reports published on the safety of venlafaxine in nursing. These show low to variable infant plasma levels in breast-fed infants. The mean infant dose ranged from 4.7% to 9.2%, which is relatively high compared with data published for other antidepressants.130 None of the cases of exposure to venlafaxine showed any adverse effects to the exposed infants.57,130-132
No data is currently available for duloxetine.
Dopamine Reuptake Inhibitors
There are no studies and only a few case reports on the safety of bupropion in breastfed infants. Low infant serum levels were found.133,134 No adverse effects in two exposed infants were found.133 One study135 reported a seizure in a 6-month-old infant, which was possibly attributable to the use of bupropion during breastfeeding.
There is very little data on trazadone. In the few cases examined, levels in breast milk have been found to be low.136
There are few studies looking at mirtazapine—a total of six cases of infant exposure in the literature. In these cases, infant levels were low to undetectable. No adverse effects were seen in the exposed infants, including no sedation or weight gain.137-139
The AAP Committee on Drug Safety considers effects of benzodiazepines as “unknown, but may be of concern” in breastfeeding. Generally, the evidence shows that benzodiazepines have lower infant milk/plasma ratios than other psychotropic medications. Benzodiazepines with shorter half-lives (ie, lorazepam, alprazolam, and oxazepam) have been found to be very low in breast milk. No adverse effects were found in most exposed infants.2,57,140-144
Diazepam levels are very low in breast milk.143,145,146 Generally, infants have not shown any adverse effects, although there have been two cases147,148 reported where exposed infants became lethargic. These effects resolved after cessation of breastfeeding. Because of the longer half-life of diazepam, however, woman taking high doses or having long-term treatment should probably not breastfeed.57
There is very limited data on zolpidem at this time, but in cases of five nursing women the drug was excreted in very low levels in breast milk.149
The AAP Committee on Drug Safety considers lithium to be associated “with significant effects on some nursing infants and should be given to nursing mothers with caution.”90 Breast milk levels have been found to be high, at ~50% of maternal serum levels.150-152 Infant levels have been reported as variable, but higher than many other medications; from 33% to 55% of maternal levels.151 In the few case reports,153,154 adverse infant effects reported have included cyanosis, hypotonia, heart murmur, electrocardiogram changes, lethargy, and hypothermia. A more recent case study152 of 10 mother-infant pairs found that infant serum levels are probably only 25% of mother’s serum level, which is somewhat lower than previously thought. Occasional and transient lab abnormalities of elevated blood urea nitrogen (BUN), creatine, and thyroid stimulating hormone were observed in the sample of infants studied. Another recent study155 found considerable variability (0% to 30% of maternal dose) in infant serum levels of lithium, but again, lower than previously thought.
Infants may be more susceptible to both dehydration and lithium toxicity due to their immature kidney function and the potential for rapid dehydration. Therefore, the hydration status, BUN and creatine, lithium level, and thyroid levels should be carefully monitored in both mother and baby if it is necessary to use lithium in nursing.
The AAP Committee on Drug Safety considers valproic acid to be “compatible” with breastfeeding. Levels have been found to be very low in breast milk156 and very low in infant serum (0.9% to 7.6%).157-159 Only one adverse event of thrombocytopenia and anemia in an exposed infant was reported.160
The AAP Commitee on Drug Safety considers carbamazepine to be “compatible” with breastfeeding. Levels reported in infant serum were highly variable, from 15% to 65% of maternal levels.158,161 However, in case reports,162-164 carbamazepine was associated with infant hepatotoxicity. Exposed infants should be monitored by serum levels and liver function tests.
The effects of lamotrigine are classified by the AAP as “unknown, but may be of concern.” Lamotrigine is excreted in relatively high levels in breast milk. Infant serum levels were ~30% of maternal levels, likely due to a slow immature elimination in infants. However, none of the case reports found adverse effects in the infants.165-169 There have been no reported cases of Stevens-Johnson syndrome in nursing infants to date. Because of this concern, however, infants should be closely monitored.167
Summary of Mood Stabilizers
Carbamazepine and valproic acid are more compatible with breast feeding than lithium. Lamotrigine is not recommended while breastfeeding.57
The physician, however, always needs to give careful consideration to the need of keeping the mother on the medication that has kept her stable in the past (or during the pregnancy), rather than to risk relapse.
The AAP Committee on Drug Safety rates the effects of haloperidol, chlorpromazine, thiothixene, mesoridazine, and trifluoperazine as “unknown and may be of concern” to nursing infants. Haloperidol is excreted in relatively high amounts in breast milk, but also has been shown to have no adverse effects on the infant.170,171 Chlorpromazine exposure has been associated with drowsiness and lethargy in one infant.172 In one study of seven infants with exposure to chlorpromazine through breast milk, there were no adverse effects reported at 16-month and 5-year follow-up evaluations.173 One study171 showed that infants exposed to haloperidol and chlorpromazine through breast milk exhibited developmental delays at 12–18 months of age. It is unclear if these delays were due to medication exposure or other factors.
Risperidone has not been rated by the AAP Committee on Drug Safety. There are only three case reports174-176 published to date on the safety of risperidone in lactation. Infant serum levels have been found to be low to undetectable in samples of nursing infants of women taking risperidone. No adverse effects in any of the exposed infants were reported.
Olanzapine has not yet been rated for safety in breastfeeding, and there are few case reports at this time. Serum levels were low to undetectable in the small number studied.177,178 Most infants showed no adverse effects.177-179 In one infant exposed, there was a report179 of cardiomegaly, jaundice, and sedation. However, it is unclear whether this is accounted for by breastfeeding or in utero exposure.
Quetiapine has not yet been rated on safety in breastfeeding. There are only two case reports180,181 to date on this medication. Breast milk levels were found to be low and there were no reported adverse effects in the exposed infants.
There are very few studies published on the safety of clozapine. The AAP rates effects as “unknown and of concern” in breastfeeding. It has been found in one case182 to have a relatively high accumulation in breast milk. There has been a case published,183 possibly attributing delayed speech acquisition to clozapine, in an infant after the mother was treated with clozapine both prenatally and during breastfeeding. Although no cases have been reported of agranulocytosis in nursing infants, it is a theoretical risk.184
Ziprasidone has not yet been rated. There are no studies published on its safety in breastfeeding.
There are no cases or studies published on safety of aripiprazole during lactation.
Summary of Antipsychotics
With limited data, if women breastfeed while taking antipsychotics, infants should be monitored closely for possible adverse effects. It is recommended that clozapine should not be used, as there is a theoretical risk of agranulocytosis in the infant.57
Table 21,56,60,85-87,92,93,118-120,122-152,155-176 summarizes the safety data of the major psychotropic medications when used during lactation.
The following clinical pearls summarize the guiding principles for using medications during breastfeeding.64,91,185 There is much evidence to suggest that untreated maternal psychiatric illness is harmful to both mother and baby. All psychotropic medications are transferred to human milk. One must ask if it is necessary to prescribe medications. If so, consultation between the mother’s physician (PCP, obstetrician, and/or psychiatrist) and the pediatrician is recommended for choosing the safest options. If the patient decides to continue breastfeeding while using psychiatric medication, the treating physician should review the available information with the patient. An alternative to consider in all cases is the decision not to breastfeed. When medication is necessary, the safest effective drug should be used. Exposure should be minimized by prescribing the lowest effective dosage of medication that achieves remission of symptoms. Short-acting medications are preferred over longer-acting medications. The decision to breastfeed should always be weighed against the risk to the neonate. This should always be fully discussed with the patient. Some medications may require blood monitoring in the nursing infant. Nursing should be stopped immediately if the nursing infant develops any abnormal symptoms. Discussion of benefits and risks of breastfeeding of a mother using psychiatric medications should be documented. Mothers should be made aware that the use of psychiatric medication may have other adverse consequences on the infant that are not always known, as current knowledge is based on the limited data available at this time. If the patient decides to continue breastfeeding while using psychiatric medication, the infant should be monitored by the pediatrician for possible side effects. The FDA’s proposed rule on pregnancy labeling will remove the letter-based category system. The proposed labeling will include more information about risks involved, clinical considerations, and quality of data used to determine them. PP
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