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Selected Drug Information
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Medication Use During Pregnancy
| Drug/Class | Pregnancy Considerations (Risks, Effects, Notes) |
|---|---|
| First-Generation Antipsychotics (FGAs) |
Overall: Unlikely to be major teratogens, though some specific malformations reported with individual agents. Early studies potentially confounded (hyperemesis, low-dose phenothiazines). Large studies show no meaningful increase in major/cardiac malformations. 2023 study noted potential signal (cardiac) with chlorprothixene. Haloperidol: Possible low risk of limb defects (few cases, not replicated). Other Associations: Increased risk of gestational diabetes, possibly preterm birth (higher risk than SGAs suggested in one study), increased postpartum bleeding, higher placenta-to-birth-weight ratio. Neonatal Effects: Reports of dyskinesia, jaundice (phenothiazines), withdrawal (somnolence, jitteriness), neurological issues, persistent pulmonary hypertension (PPHN - absolute risk low, usually mild/transient). Prolonged hospital stays reported. |
| Second-Generation Antipsychotics (SGAs) - General |
Overall: Unlikely to be major teratogens, though specific malformations reported with some agents. Large studies show no meaningful increase in major/cardiac malformations. One large study noted small absolute risk increase with risperidone (possible signal, needs caution/study). 2023 study noted potential signals: olanzapine/oral clefts, gastroschisis/brain anomalies with SGAs as a class. Conflicting Data: One study linked SGAs to specific defects (conotruncal heart, tetralogy of Fallot, anorectal atresia, gastroschisis), but confounded (obesity, substance use, etc.). Prospective Study: Found SGA exposure associated with increased birth weight, modest increase in cardiac septal defects (possible screening bias/co-exposure), neonatal withdrawal (15%). Other Associations: Increased risk of gestational diabetes (potentially highest with clozapine, olanzapine, quetiapine), possibly preterm birth, low birth weight, postpartum bleeding. Increased C-section risk, large-for-gestational-age babies (vs no antipsychotic; higher than FGAs in one study). Maternal illness/lifestyle are confounders. Neonatal Effects: Reports of withdrawal symptoms, neurological disorders, PPHN (absolute risk low, effects usually mild/transient). Neurodevelopment: Unclear overall effect. Small study: transient delays at 2/6 months (gone by 12m). Large cohorts link ADHD/ASD to maternal illness, not specifically antipsychotic exposure. One study: no increased psychiatric disorders in exposed children. 2022 study: not causally associated with neurodevelopmental disorders, but signal for aripiprazole needs investigation. |
| Lurasidone | Available data do not suggest it's a major teratogen. |
| Olanzapine | Associated with lower birth weight (conflicting data exists), large head circumference, macrosomia, and increased risk of gestational diabetes. Potential signal for oral clefts (2023 study). |
| Clozapine | May have higher likelihood of neonatal seizures vs other SGAs. Theoretical risk of fetal/neonatal agranulocytosis (overall pharmacovigilance suggests not less safe than others). NICE includes as option. One study: lower adaptive behaviour, more sleep/lability issues vs risperidone/quetiapine/olanzapine. Should be continued if effective. Plasma level monitoring beneficial, esp. if smoking habits change. Increased gestational diabetes risk. |
| Quetiapine | Relatively low placental passage. One study linked antipsychotic use (quetiapine most used) to increased postpartum bleeding, prolonged neonatal stay, higher placenta-to-birth-weight ratio. Increased gestational diabetes risk. |
| Cariprazine | Manufacturer advises against use due to malformations in animal studies; probably avoid. |
| Aripiprazole | May *not* be associated with increased gestational diabetes risk. Potential safety signal regarding neurodevelopmental disorders requires further study (2022 study). |
| Drug/Class | Pregnancy Considerations (Risks, Effects, Notes) |
|---|---|
| Tricyclic Antidepressants (TCAs) |
Exposure: Significant fetal exposure via umbilical cord/amniotic fluid. Historical Use: Widely used previously without obvious major harm. Risks: Clomipramine: Weak link to cardiovascular defects cannot be ruled out. Neonatal withdrawal warning (breathing difficulty, lethargy, colic, irritability, BP changes, tremor/spasms) if taken until delivery. Not recommended during pregnancy/without contraception. Rare neonatal QT prolongation/torsades, Timothy syndrome (with amitriptyline) reported. General TCAs: Associated with increased preterm delivery risk. Third trimester use can cause neonatal withdrawal (agitation, irritability, seizures, respiratory distress, metabolic issues), usually mild/temporary. Long-Term Development: Limited data; no clear adverse effects in small studies. Observed associations with later affective disorders likely due to parental mental health, not drug. No convincing link to neurodevelopmental disorders/ASD. Recommendation: Sertraline/Escitalopram preferred first-line if no prior history. |
| Selective Serotonin Reuptake Inhibitors (SSRIs) |
Teratogenicity: Generally not considered major teratogens. Congenital Heart Defects: Conflicting data. Some studies suggested link (esp. fluoxetine, paroxetine), others found no association. Any risk might link to mood disorder itself or confounders (e.g., alcohol). Placental Exposure: Sertraline appears lowest. Pregnancy/Birth Outcomes: May be small increased risk of preterm birth, low birth weight, lower Apgar, NICU admission (note: maternal depression itself increases these). Neonatal Issues: Poor Neonatal Adaptation/Withdrawal (jitteriness, irritability, feeding difficulties; risk may be higher with prematurity, higher doses, possibly SSRIs other than sertraline). PPHN (may be increased risk, esp. late exposure; absolute risk small, may be lower with sertraline). Maternal Risks: Small increased risks of gestational hypertension, pre-eclampsia, placental issues, postpartum haemorrhage reported (maternal depression also increases these). MHRA advises awareness of PPH risk with SSRI/SNRI use in month before delivery. Neurodevelopment: Inconclusive data, often confounded by maternal illness. Some studies suggested small ASD risk, but larger/better studies often don't confirm or attribute to confounders. No reliable link to ADHD. Reports of cognitive/motor/speech/behaviour issues - causality unclear. Associations with later emotional/affective disorders likely due to parental factors. Recent study noted brain morphology changes, clinical meaning unknown. Overall evidence suggests antidepressant use *itself* doesn't increase neurodevelopmental disorder risk when confounders managed. Recommendation: Sertraline or escitalopram reasonable first-line if no prior history (ACOG/COPE). |
| Venlafaxine (SNRI) | Early reports linked to specific birth defects, but 2022 meta-analysis concluded SNRIs aren't major teratogens. Associated with neonatal withdrawal/poor adaptation, small for gestational age, postpartum haemorrhage (MHRA warning applies). Potential PPHN risk (low absolute risk). |
| Duloxetine (SNRI) | May be linked to small increase in postpartum haemorrhage risk (MHRA warning applies). One case of neonatal withdrawal reported. Studies haven't identified specific major risks (malformations, stillbirth). |
| Trazodone | Limited safety data. One recent study found no higher risk of major anomalies compared to SSRIs. |
| Bupropion | Limited safety data. Not clearly linked to malformations, possibly to increased spontaneous abortion (may be due to underlying illness). Might have slightly higher risk of ventricular septal defects. Linked to increased ADHD risk in exposed children. 2022 study found no association with major malformations, abortion, stillbirth, or neonatal death. |
| Mirtazapine | Limited safety data. Not clearly linked to malformations, possibly to increased spontaneous abortion (may be due to underlying illness). 2022 study found no association with major malformations, abortion, stillbirth, or neonatal death. |
| Moclobemide / Reboxetine | Very limited data suggest no teratogenic potential. |
| Monoamine Oxidase Inhibitors (MAOIs) | Should be avoided due to suspected increased risk of congenital malformations and risk of hypertensive crisis. |
| Electroconvulsive Therapy (ECT) | Considered safe for mother and fetus (general anaesthesia carries inherent risks). NICE recommends for severe depression, severe mixed/manic states, or catatonia if physical health seriously threatened. |
| Brexanolone | ACOG suggests considering for third trimester onset depression. |
| Drug/Class | Pregnancy Considerations (Risks, Effects, Notes) |
|---|---|
| Lithium |
Exposure: Crosses placenta freely. Risks: Associated with increased congenital anomalies (esp. 1st trimester, possibly higher doses). Ebstein's anomaly link well-known, but recent data suggest much lower risk than thought, possibly linked to maternal mental health generally. Risk period weeks 2-6 post-conception. Possible increased risk of septal defects. Associated with potential preterm birth, large babies (conflicting data), neonatal issues (goitre, hypotonia, lethargy, arrhythmia, respiratory symptoms, low Apgar). May increase neonatal readmission risk (conflicting data). Neurodevelopment: Probably doesn't affect neonatal brain development. Management: Avoid if possible. If essential, inform patient of risks, continue. Slow discontinuation pre-conception preferred if stopping. If continuing: high-res ultrasound/echo. Dose needs increase during pregnancy (increased body water), drops abruptly postpartum - requires careful monitoring (levels q4wks, weekly from 36wks). Deliver in hospital (fluid balance). Stop lithium during labour. NICE: Preferred over traditional mood stabilisers (except valproate) in specific circumstances if antipsychotics unsuitable/ineffective. |
| Valproate |
Risks: Clear causal link to fetal abnormalities (esp. neural tube defects like spina bifida; also atrial septal defects, cleft palate, hypospadias, polydactyly, craniosynostosis). High risk major malformations (~10%). Linked to reduced head circumference. Clear causal link to motor/neurodevelopmental problems (delay up to 40%, language/memory/speech difficulties, lower IQ, increased ASD, learning deficits - potentially dose-related). Decreased school performance. May increase pre-eclampsia risk. Management: Strongly contraindicated in women of child-bearing potential unless all other treatments failed + effective long-term contraception (UK: requires 2 specialist agreement). Stop *before* pregnancy (gradual taper 2-4wks, COPE rec + high-dose folic acid). Folate during pregnancy doesn't prevent valproate NTDs (forms early), but pre-conception/pregnancy folate still recommended for potential neurodevelopmental benefits. Hard to justify use given risks. Strongly avoid (NICE). |
| Carbamazepine |
Risks: Clear link to fetal abnormalities (e.g., neural tube defects), lower risk than valproate. Teratogenic effect likely dose-related. May require maternal vitamin K (3rd trimester). Lower Apgar scores reported (low absolute risk). Management: Avoid if possible. If essential: low-dose monotherapy. NICE advises against for mental health problems if planning pregnancy/pregnant/breastfeeding; suggests stopping if possible. |
| Lamotrigine |
Risks: Growing evidence suggests safer than valproate/carbamazepine. Major malformation risk similar to general population. Some reports of parental-reported behaviour problems, possible autism risk association, but overall effect on neurodevelopment appears *not* significant. Management: Clearance increases significantly during pregnancy, drops postpartum - requires frequent level monitoring. Can be an option for bipolar depression. |
| Topiramate |
Risks: Associated with major malformations, specifically orofacial clefts (risk may be higher at epilepsy doses). Large study reported increased risk neurodevelopmental disorders, small for gestational age, congenital malformations. Management: Should not be used in pregnant women. Women of child-bearing age need effective contraception. |
| Oxcarbazepine | Data unclear. Meta-analysis: non-significant increased malformation risk, possible association fetal/perinatal deaths (study limitations). |
| Pregabalin | Data unclear. Nordic study: small increased risk major malformations. UK MHRA/manufacturers advise awareness of risk, use effective contraception. |
| General Anticonvulsants | Large study found anticonvulsant mood stabilisers were *not* associated with placenta-mediated complications or preterm birth. |
| Drug/Class | Pregnancy Considerations (Risks, Effects, Notes) |
|---|---|
| Benzodiazepines |
Risks: Early studies linked 1st trimester use to oral clefts (later studies often haven't confirmed). Use might be marker for other risks. Associated with C-section, miscarriage, NICU admission, neonatal ventilation, low birth weight, preterm delivery, small head circumference/gestational age. 3rd trimester use linked to "floppy baby syndrome" (hypotonia, lethargy). Late pregnancy use linked to substantially higher risk stillbirth/preterm birth (early use mainly linked to SGA). Neurodevelopment: Available data do not show association with neurodevelopmental disorders. Recommendations: NICE advises against routine use (except short-term severe anxiety/agitation). Recommends gradual stopping if planning pregnancy/pregnant/breastfeeding. ACOG advises avoiding/using sparingly. |
| Z-drugs (Zolpidem, Zopiclone, etc.) |
Risks: Probably not linked to increased congenital malformations. Increased risk premature birth, low birth weight, SGA reported. Zolpidem may increase C-section likelihood. Late pregnancy use linked to substantially higher risk stillbirth/preterm birth (early use mainly linked to SGA). Neurodevelopment: Available data do not show association with neurodevelopmental disorders. |
| Promethazine | Used for severe morning sickness (hyperemesis gravidarum). Appears non-teratogenic, but data limited. |
| Drug/Class | Pregnancy Considerations (Risks, Effects, Notes) |
|---|---|
| Methylphenidate & Amfetamines |
Risks: Probably not major teratogens. Small increased risk cardiac malformations reported with methylphenidate (not amfetamines). Small increased risk miscarriage (methylphenidate) or premature birth/low birth weight (amfetamines) possible. Neurodevelopment: Available data do not show increased risk of neurodevelopmental disorders in exposed children. |
| Modafinil |
Risks: May be associated with increased risk congenital malformations (cardiac defects, hypospadias, orofacial clefts). Recommendations: MHRA advises against use during pregnancy. Women of child-bearing potential must use effective contraception during treatment and for 2 months after stopping. |
Medication Use During Breastfeeding
| Drug | Infant plasma concentrations | Relative infant dose (RID) | Reported acute adverse effects in infant | Reported developmental effects in infant |
|---|---|---|---|---|
| Agomelatine4,5 | Not assessed | Not available | None reported but not studied | None reported but not studied |
| Brexanolone6 | Not assessed | 1-2% | None reported but not studied | None reported but not studied |
| Bupropion5,7–14 | Undetectable or low | 0.2-2% | Two reports of seizure-like activity in 6-month-olds. In one case the infant experienced sleep disturbance, severe emesis and somnolence. The infant plasma levels were below the level required for quantification. The mother was also taking escitalopram. | None reported but not studied |
| Citalopram2,5,12,15–24 | Undetectable to up to 10% of maternal plasma levels. Higher than for fluvoxamine, sertraline, paroxetine and escitalopram, but lower than for fluoxetine | 3.56-5.37%5 | Sleep disturbance (which resolved on halving maternal dose), colic, decreased feeding, irritability and restlessness. One case of irregular breathing, sleep disorder and hypo- and hypertonia; the infant was exposed to citalopram in utero. Symptoms were attributed to withdrawal syndrome despite the mother continuing citalopram postpartum. | None reported. In a study of 78 infants of mothers taking an SSRI or venlafaxine, no difference in weight was noted at 6 months compared with the 'normative' weight. In a study of 11 infants, normal neurodevelopment was observed up to 1 year. One of the children was unable to walk at 1 year; however, neurological status of the child was deemed normal 6 months later. |
| Duloxetine5,12,25–28 | <1% of maternal plasma levels | <1% | Dizziness, nausea and fatigue | None reported but not assessed |
| Escitalopram5,12,14,29-34 | Undetectable or low | 3-8.3% | Necrotising enterocolitis in a 5-day-old infant (necessitating intensive care admission and intravenous antibiotic treatment). Infant was exposed to escitalopram in utero. Seizure-like activity, sleep disturbance, severe emesis and somnolence in a 6-month-old. Mother was also taking bupropion. | None reported but not studied |
| Fluoxetine2,5,12,15,24,35-46 | Variable: can be >10% of maternal plasma levels. Highest reported levels of SSRIs | 1.6-14.6% | Colic, excessive crying, decreased sleep, diarrhoea, vomiting, somnolence, decreased feeding, hypotonia, moaning, grunting and hyperactivity. One case of seizure activity at 3 weeks, 4 months and then 5 months. Mother was also taking carbamazepine. One case of tachypnoea, jitteriness, irritability, fever and compensated metabolic acidosis. Infant plasma levels were in the adult therapeutic range. The authors diagnosed serotonin syndrome. Mother was taking fluoxetine 60mg. | Normal weight gain and neurological development have been reported for many infants. One retrospective study found lower growth curves compared with nonexposed infants. One case of a reduction in platelet serotonin |
| Fluvoxamine5,12,15,47–54 | Undetectable to half the maternal plasma level | 1-2% | Neonatal jaundice, severe diarrhoea, mild vomiting, decreased sleep and agitation | None reported. In a study of 78 infants of mothers taking an SSRI or venlafaxine, no difference in weight was noted at 6 months compared with the 'normative' weight. |
| MAOIs55,56 | No published data available at the time of writing | Isoniazid = 1.2-18% | None reported | None reported but not assessed |
| Mianserin5,57 | Not assessed | Not assessed | None reported | None reported but not studied |
| Mirtazapine5,12,58,59 | Undetectable or low. There was one case of higher mirtazapine plasma levels. Elimination rates may differ between individual infants | 0.5–4.4% | In a study of 54 infants exposed to mirtazapine in utero, the incidence of poor neonatal adaptation syndrome was significantly diminished in those who were breastfed. | None reported. In a study of eight infants, weights for three were observed to be between the 10th to 25th percentiles; all three were noted to also have a low birth weight. |
| Moclobemide5,60,61 | Low | 3.4% | None reported | None reported but not studied |
| Paroxetine2,5,12,15,24,39,47,62-71 | Undetectable or low | 0.5-2.8% | Vomiting and irritability which were attributed to severe hyponatraemia. In a study of 72 infants, adverse effects were noted in nine infants. Insomnia, restlessness and constant crying were most commonly reported. | None reported. In a study of 78 infants of mothers taking an SSRI or venlafaxine, no difference in weight was noted at 6 months compared with the 'normative' weight. Breastfed infants of 27 women taking paroxetine reached the usual developmental milestones at 3, 6 and 12 months, similar to a control group. |
| Reboxetine5,12,72 | Undetectable or low | 1-3% | None reported | In a study of four infants, three reached normal milestones. The fourth had developmental problems thought not to be related to reboxetine. |
| Sertraline5,12,24,39,66,73-81 | Undetectable or low. There was one report of an unusually high infant serum level (half maternal serum level). The infant was reported to be “clinically thriving” | 0.5-3% | Serotonergic overstimulation reported in a preterm infant also exposed to sertraline in utero. Symptoms included hyperthermia, shivering, myoclonus, tremor, irritability, high-pitched crying, decreased suckling reflex and reactivity. Withdrawal symptoms (agitation, restlessness, insomnia and an enhanced startle reaction) developed in a breastfed neonate, after abrupt withdrawal of maternal sertraline. The neonate was exposed to sertraline in utero. | None reported. In a study of 78 infants of mothers taking an SSRI or venlafaxine, no difference in weight was noted at 6 months compared with the 'normative' weight. |
| Trazodone5,82,83 | Not assessed | 2.8% | None reported | None reported |
| Tricyclic antidepressants (TCAs)5,15,84–92 | Undetectable or low Nortriptyline, Amitriptyline 1-3% Clomipramine | N/A - RID varies by specific TCA | Adverse effects have not been reported in infants exposed to nortriptyline, clomipramine, imipramine, dosulepin and desipramine through breast milk. Severe sedation and poor feeding reported with amitriptyline Poor suckling, muscle hypotonia, drowsiness and respiratory depression reported with doxepin | None reported. A study of 15 children did not show a negative outcome in regard to cognitive development in breastfed children 3-5 years postpartum. |
| Venlafaxine5,12,24,39,66,93-100 | Undetectable to up to 37% of maternal plasma levels | 6-9% (>10% reported in one case)101 | Lethargy, jitteriness, rapid breathing, poor suckling and dehydration in an infant also exposed in utero. Symptoms subsided over a week on breastfeeding. Authors suggested that breastfeeding may have helped manage infant withdrawal symptoms postpartum. | None reported. In a study of 78 infants of mothers taking an SSRI or venlafaxine, no difference in weight was noted at 6 months compared with the 'normative' weight. |
| Vortioxetine102 | 1.1-1.7% | 1.1-1.8% | None reported | None reported but not studied |
| Drug | Infant plasma concentration (or proportion of maternal plasma concentration, where noted) | Estimated daily infant dose as proportion of maternal dose (RID) | Acute adverse effects in infant | Developmental effects in infant |
|---|---|---|---|---|
| Amisulpride5,96,103-105 | 10.5% of maternal plasma concentration* | 4.7-10.7% | None reported | None reported |
| Aripiprazole5,106-111 (may lead to reduced milk supply112,113) | 4% of maternal plasma concentration* | 0.9-8.3% | None reported | None reported |
| Asenapine | No published data available at the time of writing | — | — | — |
| Brexpiprazole (may lead to reduced milk supply112) | No published data available at the time of writing | — | — | — |
| Butyrophenones5,15,39,84,104,114-117 (e.g., Haloperidol) | Not reported Haloperidol = 0.2-12% | — | One case of hypersomnia, poor feeding and slowing in motor movements. Mother was also taking risperidone. Effects noted when haloperidol dose was increased. | Delayed development was noted in three infants exposed to a combination of haloperidol and chlorpromazine in breast milk. Normal development has also been reported. |
| Cariprazine | No published data available at the time of writing | — | — | — |
| Clozapine5,15,39,84,115,118-121 NB avoid | 6.5% of maternal plasma concentration* | 1.4% | Sedation, agranulocytosis, decreased sucking reflex, irritability, seizures and cardiovascular instability | There is one report of delayed speech acquisition. The infant was also exposed to clozapine in utero. |
| Iloperidone | No published data available at the time of writing | — | — | — |
| Lurasidone | No published data available at the time of writing | — | — | — |
| Lumateperone | Published data not available | — | — | — |
| Olanzapine5,15,39,104,122-134 | Undetectable or low One case of plasma levels decreasing over 5 months (infant's capacity to metabolise olanzapine 'developed rapidly' around 4 months) | 1.0-1.6% | Somnolence, drowsiness, irritability, tremor, insomnia, lethargy, poor suckling and shaking One case of jaundice and sedation. Infant was exposed in utero and had cardiomegaly. | One case of lower developmental age than chronologic age. Mother was taking additional psychotropic medication. One case of speech delay and one of motor developmental delay. Two cases of failure to gain weight. Normal development has also been reported. |
| Paliperidone | No specific data available (see risperidone) | — | — | — |
| Phenothiazines5,15,84,114-116 (e.g., Chlorpromazine) | Variable Chlorpromazine = 0.3% | — | Lethargy | Delayed development in three infants exposed to a combination of chlorpromazine and haloperidol |
| Pimavanserin | No published data available at the time of writing | — | — | — |
| Quetiapine5,97,131,135–144 | Undetectable | 0.09-0.1% | Excessive sleep. Mother was also taking mirtazapine and a benzodiazepine. In a small study of quetiapine augmentation of maternal antidepressant, there were two cases of mild developmental delays, thought not to be related to quetiapine. | — |
| Risperidone5,117,145–149 | Risperidone undetectable 9-hydroxyrisperidone low | Risperidone = 2.8-9.1% 9-hydroxyrisperidone = 3.46-4.7% | One case of hypersomnia, poor feeding and slowing in motor movements. Mother was also taking haloperidol. Effects noted when haloperidol dose was increased. | None reported |
| Sertindole | No published data available at the time of writing | — | — | — |
| Sulpiride5,150–154 | Not reported | 2.7-20.7% | None reported | None reported but not assessed |
| Thioxanthenes5,15,116,155-157 (e.g., Zuclopenthixol, Flupentixol) | Not reported Zuclopenthixol = 0.4-0.9% Flupentixol = 0.7-1.75% | — | None reported | None reported for flupentixol; not assessed for zuclopenthixol |
| Ziprasidone5,23,116,158 | Not reported | 0.07-1.2% | None reported | None reported |
| Note: A proportion of the drug detected may have been due to placental transfer following in utero exposure. *Based on milk/plasma ratio. | ||||
| Drug | Infant plasma concentration | Estimated daily infant dose as proportion of maternal dose (RID) | Acute adverse effects in infant | Developmental effects in infant |
|---|---|---|---|---|
| Carbamazepine5,15,159-169 | Generally low, although one report of an infant plasma level within adult therapeutic range | 1.1-7.3% | Adverse effects have not been reported for a number of infants. One case of cholestatic hepatitis, one of transient hepatic dysfunction with hyperbilirubinaemia and elevated GGT. Adverse effects in the first case resolved after discontinuation of breastfeeding and the second resolved despite continued feeding. One case of seizure-like activity, drowsiness, irritability and high-pitched crying. Mother was taking multiple agents. | Poor suckling, poor feeding and two cases of hyperexcitability. None reported. A prospective study of children of women with epilepsy found no adverse development at ages 6-36 months. A study of 199 infants exposed to antiepileptic medications in utero and through breast milk failed to show a difference in IQ at 3 years. A study of 181 children concluded that IQ was not adversely affected by anticonvulsant exposure through breast milk. |
| Lamotrigine5,162,167,170-181 | Up to 48% of maternal plasma levels182 | 9.2-18.3% | No adverse effects have been reported in a number of infants. Seven cases of thrombocytosis. One case of a severe cyanotic episode (preceded by mild episodes of an apnoea) requiring resuscitation. Neonatal serum concentration was in the upper therapeutic range. The infant was exposed in utero and the mother was taking a high dose (850mg/day). One case of normocytic normochromic anaemia and asymptomatic neutropenia. Three cases of rash (one attributed to eczema, one to soy allergy, and one resolved spontaneously). | No abnormalities reported. A prospective study of children of women with epilepsy found that breastfeeding while taking an anticonvulsant was not associated with adverse development at ages 6-36 months. A study of 199 infants exposed during breastfeeding showed no difference in IQ. A study of 181 children concluded that IQ was not adversely affected by anticonvulsant exposure in breast milk. |
| Lithium184 NB avoid | Up to 57% of maternal plasma levels | 12-30.1% | Early feeding problems, increased urea, raised creatinine and non-specific signs of toxicity. One case of elevated TSH (in utero exposure). One case of cyanosis, lethargy, hypothermia, hypotonia and a heart murmur (in utero exposure). | No adverse effects have been reported in others. None reported |
| Topiramate185,186 | Undetectable to 20% of maternal plasma levels | 3-35% | Diarrhoea | None reported but not assessed |
| Valproate5,15,159–162,167,187,188 | <2% of maternal plasma levels | 1.4-1.7% | Thrombocytopenia and anaemia which reversed on stopping breastfeeding. (In utero exposure) | A prospective study of children of women with epilepsy found no adverse developmental outcomes at ages 6-36 months. A study of 199 infants showed no difference in IQ at 3 years. A study of 181 children concluded that IQ was not adversely affected by anticonvulsant exposure through breast milk. |
| Drug | Infant plasma concentration | Estimated daily infant dose as proportion of maternal dose (RID) | Acute adverse effects in infant | Developmental effects in infant |
|---|---|---|---|---|
| Benzodiazepines5,15,39,189-196 | Clonazepam: undetectable to 10% of maternal plasma levels197 Clonazepam = 2.8% Diazepam = 0.88-7.1% Lorazepam = 2.6–2.9% Oxazepam = 0.28–1% | — | Sedation, lethargy, weight loss and mild jaundice. One case of persistent apnoea with clonazepam. Restlessness and mild drowsiness with alprazolam. In a telephone survey of 124 women, two reported CNS depression in their breastfeeding neonates. One child was exposed in utero. | None reported but not studied |
| Promethazine | No published data available at the time of writing | — | — | — |
| Zopiclone, Zolpidem and Zaleplon5,198–200 | Zolpidem: undetectable Zopiclone and Zaleplon: not reported | Zaleplon = 1.5% Zopiclone = 1.5% Zolpidem = 0.02-0.18% | None reported | None reported but not studied |
| Drug | Infant plasma concentration | Estimated daily infant dose as proportion of maternal dose (RID) | Acute adverse effects in infant | Developmental effects in infant |
|---|---|---|---|---|
| Atomoxetine | No published data available at the time of writing | — | — | — |
| Dexamfetamine202 | Undetectable to 14% of maternal plasma level | 2.4-10.6% | None reported | None reported but not assessed |
| Lisdexamfetamine | No published data available at the time of writing | — | — | — |
| Methylphenidate28,203–205 | Undetectable | 0.16-0.7% | None reported | None reported |
| Modafinil206,207 | Armodafanil = 1.5% Modafanil: not reported | Armodafanil = 4.85% Modafanil = 5.3% | None reported | None reported but not assessed |
Note: RID refers to Relative Infant Dose. Data primarily based on small studies or case reports.