10 - General principles of prescribing psychotropi

General principles of prescribing psychotropics in breastfeeding

734 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 7 Drug choice in breastfeeding The long-­term benefits of breastfeeding on a child’s physical health and cognitive development are well known. Women are generally encouraged to breastfeed for at least 6 months. One factor that may influence a mother’s decision to breastfeed is the safety of a drug taken while breastfeeding. With some notable exceptions, most psychotropic drugs should be continued in breastfeeding women because of the benefits of breastfeeding and the lack of evidence of harm for most drugs. However, current evidence suggests that for a few drugs the woman should be advised not to breastfeed if such medications are the best and only option for her care. Data on the safety of psychotropic medication in breastfeeding are largely derived from small studies or case reports and case series. Reported infant and neonatal outcomes in most cases are limited to short-­term acute adverse effects. Long-­term safety cannot therefore be guaranteed for the psychotropics mentioned here. The information presented must be interpreted with caution with respect to the limits of the data from which it is derived and the need for such information to be regularly updated. There are two distinct clinical scenarios. In the first, the mother will have been taking the psychotropic drug(s) during pregnancy and often up until birth. In these people, the same psychotropic(s) should be continued during breastfeeding to mitigate withdrawal symptoms in the neonate (but see exceptions later). In the second, the mother is newly prescribed a psychotropic after the child has been born but wishes to breastfeed. Decisions in this scenario are rather more complex and the reader is referred to the tables in this section. Infant exposure All psychotropics are excreted in breast milk to varying degrees. The most direct measure of infant exposure is, of course, infant plasma levels but these data are rarely available. Instead, many publications report only drug concentrations in breast milk and in maternal plasma. Maternal plasma levels of antipsychotics may be a useful estimate of infant exposure.1 Breast milk drug concentrations can be used to estimate the daily infant dose (by assuming a milk intake of 150mL/kg/day). The infant weight-­adjusted dose when expressed as a proportion of the maternal weight-­adjusted dose is known as the relative infant dose (RID). The RID should be used as a guide only, as values are estimates and these estimates vary widely in the literature for individual drugs. Drugs with an RID below 10% are usually regarded as safe in breastfeeding. Where measured, infant plasma levels below 10% of average maternal plasma levels have also been proposed as being safe in breastfeeding.2 General principles of prescribing psychotropics in breastfeeding ■ ■The safety of individual drugs in breastfeeding should be taken into account when prescribing psychotropic medication for women considering pregnancy. ■ ■Discussions about the safety of drugs in breastfeeding should be held as early as ­possible – ideally before conception or early in pregnancy. Decisions about the use of drugs in pregnancy should include the discussion about breastfeeding. Switching drugs at the end of pregnancy or in the days after birth is not advisable because of the high risk of relapse.