Funcionamiento Familiar:

It can be agonizing for a patient to agree to take med-ication while breastfeeding. A new mother must weigh the uncertainty of exposing her baby to drugs against the risks of withholding the benefits of breast milk. This ambiguity can be unnerving to a woman deeply committed to breastfeeding her child; she may feel that continuing her medication creates a conflict of interest, placing her own welfare above that of the baby. As a result, she may decide to stop medication

“temporarily” against medical advice until the new-born has benefited from breast milk, at least for a few months. The clinician’s role is crucial in highlighting the risks of relapse even when medication is with-drawn even temporarily.

The following questions may help the patient give informed consent:

• Does the new mother believe that the psychiatric medication is crucial to her health, with complica-tions resulting from nonadherence? Is there wishful thinking that her medication is “something

op-tional,” a lifestyle choice that can be made elec-tively, according to convenience or desire?

• Does the woman recognize that avoiding medica-tions, whether or not she is breastfeeding, puts her at risk for relapse, decompensation, and hospital-ization (with the attendant separation from her baby and other children)? Such a complication risks disruption of mother-infant bonding during the time of greatest vulnerability for recurrence, the postpartum period.

• Has the mother considered the unambiguous, clearly documented impact of untreated psychiat-ric illness on the cognitive, behavioral, and social development of infants (Jacobsen 1999)?

Until the new mother has factored these risks against the potential impact of medication in breast milk and considered the option of substituting formula for breast milk, she has not made a fully informed decision. In the spirit of comprehensive management and a team approach to postpartum dis-orders, the treating clinician should discuss the diag-nosis and treatment recommendations with the pedia-trician, especially when the mother is breastfeeding.

This will also help to avoid conflicting recommen-dations.

• Recommendations: The following is a summary of the data available at the time of this writing on the use of psychotropic medications during breastfeeding. De-tails for specific medications can be found in Appen-dix 7–A, “Psychotropics in Pregnancy and Lactation,”

in this chapter. It is best to perform a search of the current literature before finalizing a treatment plan for the woman who plans to breastfeed.

Antidepressants

The American Academy of Pediatrics classifies the antidepressants as “drugs whose effect on the nursing infant is unknown but may be of concern” (American Academy of Pediatrics Committee on Drugs 2001).

The contrast between the growing database on SSRI exposure through breastfeeding and the rare adverse report is encouraging. Long-term data are still pend-ing on the developmental effects of SSRI exposure through breast milk, but the little evidence that we have is reassuring (see Appendix 7–A in this chapter).

Mood Stabilizers

Lithium is generally considered incompatible with breastfeeding because it accumulates in both maternal

breast milk and infant serum, leading to potential tox-icity in the nursing infant (American Academy of Pe-diatrics Committee on Drugs 2001; Llewellyn et al.

1998). Note also that newborns generally are vulnera-ble to dehydration, which would heighten their risk for lithium toxicity.

Despite these potential hazards, a recent literature review (Misri and Lusskin 2004e) confirmed that case reports of adverse effects of lithium on breastfeeding infants have been rare. Very careful monitoring of the mother and the infant is advised during breastfeeding (see Appendix 7–B in this chapter, “A Primer on Using Lithium in Pregnancy and Lactation”).

The anticonvulsants valproic acid (Depakote, De-pakene) and carbamazepine (Tegretol) have won their place among mood stabilizers. The American Acad-emy of Pediatrics Committee on Drugs and the Amer-ican Academy of Neurology consider both valproic acid and carbamazepine to be compatible with breast-feeding because of consistent, although limited, re-ports of low to unquantifiable concentrations of these medications in breast milk; levels have been reported to be higher in infants who were also exposed during pregnancy (American Academy of Pediatrics Com-mittee on Drugs 2001; Yonkers et al. 2004). The relative safety of these agents in breastfeeding stands in con-trast to their teratogenic potential in pregnancy.

Infants exposed to either of these anticonvulsants during breastfeeding should be monitored for possi-ble hepatic complications, with maternal and infant serum drug levels and liver function tests every 2–4 weeks or as indicated by the clinical situation (Misri and Lusskin 2004e).

Gabapentin (Neurontin), topiramate (Topamax), and lamotrigine (Lamictal) have also been used for the treatment of bipolar disorder, but data on breastfeed-ing are quite limited (see Appendix 7–A).

Antipsychotics

Breastfeeding on antipsychotics is not recommended due to a lack of information (Misri and Lusskin 2004e), particularly because medication-free alternatives, such as formula, are available to the baby. However, some women will still breastfeed while taking these medications. It is hoped that women with chronic psy-chotic illnesses like schizophrenia will receive assis-tance and be monitored closely, because their ability to parent may be compromised by their disorder.

When antipsychotic medications are continued, it is best to avoid polypharmacy, use the lowest doses pos-sible, and monitor the infant carefully, using

standard-ized developmental screening tools if available. See Appendix 7–A for specific studies and medications.

Anxiolytics

Benzodiazepines are not contraindicated during breast-feeding but should be used cautiously (and are not a substitute for antidepressants or antipsychotics). The main concern is sedation in the newborn. For this rea-son, low doses of medications with no active metabo-lites, such as clonazepam or lorazepam, are preferred (Misri and Lusskin 2004e).

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