Antipsychotics and Lactation

  • Joshua Niforatos
  • Carol Swetlik
  • Adele VigueraEmail author


Clinical decisions regarding breastfeeding and antipsychotics should be based on a careful assessment of risks and benefits to both mother and infant, bearing in mind the serious detrimental effects of untreated mental illness and the many health and emotional benefits of breastfeeding. A thoughtful risk/benefit assessment is recommended, and ideally, such a discussion should occur in advance of delivery with the patient, her psychiatrist, and her infant’s pediatrician. In this chapter, a brief overview of general pharmacological and clinical considerations, regarding the use of antipsychotics during breastfeeding, will be presented. Commonly used first- and second-generation antipsychotics (FGAs and SGAs) will be critically evaluated to determine whether neonatal exposure through breast milk poses a significant risk in terms of adverse effects. At present, while there is an absence of high-quality studies to make definitive recommendations regarding antipsychotics and breastfeeding, most first-generation and second-generation antipsychotics appear to pose minimal risk to the infant. Clinically, antipsychotic use during breastfeeding should not be discouraged, and close clinical monitoring of the infant is indicated.


Antipsychotics Breastfeeding Lactation Postpartum period Adverse effects Polypharmacy 


  1. 1.
    Centers for Disease Control and Prevention. Breastfeeding report card—United States; 2014. Available from: Accessed on 30 Jan 2018.Google Scholar
  2. 2.
    American Academy of Pediatrics. Breastfeeding policy statement. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–41.CrossRefGoogle Scholar
  3. 3.
    Santucci AK, Singer LT, Wisniewski SR, Luther JF, Eng HF, Sit DK, Wisner KL. One-year developmental outcomes for infants of mothers with bipolar disorder. J Clin Psychiatry. 2017;78:1083–90.PubMedCrossRefGoogle Scholar
  4. 4.
    Shao P, Ou J, Peng M, Zhao J, Chen J, Wu R. Effects of clozapine and other atypical antipsychotics on infants development who were exposed to as fetus: a post-hoc analysis. PLoS One. 2015;10:e0123373.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Jones JR, Kogan MD, Singh GK, Dee DL, Grummer-Strawn LM. Factors associated with exclusive breastfeeding in the United States. Pediatrics. 2011;128:117–1125.CrossRefGoogle Scholar
  6. 6.
    Viguera AC, Cohen LS, Whitfield T, Reminick AM, Bromfield E, Baldessarini RJ. Perinatal use of anticonvulsants: differences in attitudes and recommendations among neurologists and psychiatrists. Arch Womens Ment Health. 2010;13:175–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Rasmussen ML, Strøm M, Wohlfahrt J, Videbech P, Melbye M. Risk, treatment duration, and recurrence risk of postpartum affective disorder in women with no prior psychiatric history: a population-based cohort study. PLoS Med. 2017;14:e1002392.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Shen H, Magnusson C, Rai D, Lundberg M, Lê-Scherban F, Dalman C, Lee BK. Associations of parental depression with child school performance at age 16 years in Sweden. JAMA Psychiat. 2016;73:239–46.CrossRefGoogle Scholar
  9. 9.
    Bodén R, Lundgren M, Brandt L, Reutfors J, Andersen M, Kieler H. Risks of adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for bipolar disorder: population based cohort study. BMJ. 2012;345:e7085.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Morgan VA, Croft ML, Valuri GM, Zubrick SR, Bower C, McNeil TF, Jablensky AV. Intellectual disability and other neuropsychiatric outcomes in high-risk children of mothers with schizophrenia, bipolar disorder and unipolar major depression. Br J Psychiatry. 2012;200:282–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Misri S, Corral M, Wardrop AA, Kendrick K. Quetiapine augmentation in lactation: a series of case reports. J Clin Psychopharmacol. 2006a;26:508–11.PubMedCrossRefGoogle Scholar
  12. 12.
    Oberlander TF, Reebye P, Misri S, Papsdorf M, Kim J, Grunau RE. Externalizing and attentional behaviors in children of depressed mothers treated with a selective serotonin reuptake inhibitor antidepressant during pregnancy. Arch Pediatr Adolesc Med. 2007;161:22.PubMedCrossRefGoogle Scholar
  13. 13.
    Altshuler LL, Hendrick V, Cohen LS. Course of mood and anxiety disorders during pregnancy and the postpartum period. J Clin Psychiatry. 1998;59(Suppl 2):29–33.PubMedGoogle Scholar
  14. 14.
    Hummels H, Bertholee D, van der Meer D, Smit JP, Wilffert B, ter Horst P. The quality of lactation studies including antipsychotics. Eur J Clin Pharmacol. 2016;72:1417–25.PubMedCrossRefGoogle Scholar
  15. 15.
    Llewellyn A, Stowe Z. Psychotropic medications in lactation. J Clin Psychiatry. 1998;59(Suppl 2):41–52.PubMedGoogle Scholar
  16. 16.
    Pacchiarotti I, León-Caballero J, Murru A, Verdolini N, Furio MA, Pancheri C, Valentí M, Samalin L, Roigé ES, González-Pinto A, Montes JM. Mood stabilizers and antipsychotics during breastfeeding: focus on bipolar disorder. Eur Neuropsychopharmacol. 2016;26:1562–78.PubMedCrossRefGoogle Scholar
  17. 17.
    Uguz F. Second-generation antipsychotics during the lactation period: a comparative systematic review on infant safety. J Clin Psychopharmacol. 2016;36:244–52.PubMedCrossRefGoogle Scholar
  18. 18.
    Chad L, Pupco A, Bozzo P, Koren G. Update on antidepressant use during breastfeeding. Can Fam Physician. 2013;59:633–4.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Grijalva J, Vakili K. Neonatal liver physiology. Semin Pediatr Surg. 2013;22(4):185–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Klinger G, Stahl B, Fusar-Poli P, Merlob P. Antipsychotic drugs and breastfeeding. Pediatr Endocrinol Rev. 2013;10:308–17.PubMedGoogle Scholar
  21. 21.
    Larsen ER, Damkier P, Pedersen LH, Fenger-Gron J, Mikkelsen RL, Nielsen RE, Linde VJ, Knudsen HE, Skaarup L, Videbech P, Danish Psychiatric Society; Danish Society of Obstetric and Gynecology; Danish Paediatric Society; Danish Society of Clinical Pharmacology. Use of psychotropic drugs during pregnancy and breast-feeding. Acta Psychiatr Scand Suppl. 2015;(445):1–28.CrossRefGoogle Scholar
  22. 22.
    Gentile S. Antipsychotic therapy during early and late pregnancy. A systematic review. Schizophr Bull. 2008;36:518–44.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Mendhekar DN, Andrade C. Uneventful use of haloperidol and trihehexyphenidyl during three consecutive pregnancies. Arch Womens Ment Health. 2011;14:83–4.PubMedCrossRefGoogle Scholar
  24. 24.
    Whalley LJ, Blain PG, Prime JK. Haloperidol secreted in breast milk. Br Med J (Clin Res Ed). 1981;282(6278):1746–7.CrossRefGoogle Scholar
  25. 25.
    Yoshida K, Kumar RC, Smith B, Craggs M. Psychotropic drugs in breast milk: no evidence for adverse effects on prepulse modulation of startle reflex or on cognitive level in infants. Dev Psychobiol. 1998;32:249–56.PubMedCrossRefGoogle Scholar
  26. 26.
    McAllister-Williams RH, Baldwin DS, Cantwell R, Easter A, Gilvarry E, Glover V, Green L, Gregoire A, Howard LM, Jones I, Khalifeh H, Lingford-Hughes A, McDonald E, Micali N, Pariante CM, Peters L, Roberts A, Smith NC, Taylor D, Wieck A, Yates LM, Young AH, endorsed by the British Association for Psychopharmacology. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum. J Psychopharmacol. 2017;31:519–32.PubMedCrossRefGoogle Scholar
  27. 27.
    Odhejo Y, Jafri A, Mekala HM, Hassan M, Khan AM, Dar SK, Ahmed R. Safety and efficacy of antipsychotics in pregnancy and lactation. J Alcohol Drug Depend. 2017;5:1–7.CrossRefGoogle Scholar
  28. 28.
    Rummel-Kluge C, Komossa K, Schwarz S, Hunger H, Schmid F, Kissling W, Davis JM, Leucht S. Second-generation antipsychotic drugs and extrapyramidal side effects: a systematic review and meta-analysis of head-to-head comparisons. Schizophr Bull. 2010;38:167–77.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Cohen LS, Viguera AC, McInerney KA, Freeman MP, Sosinsky AZ, Moustafa D, Marfurt SP, Kwiatkowski MA, Murphy SK, Farrell AM, Chitayat D. Reproductive safety of second-generation antipsychotics: current data from the Massachusetts General Hospital National Pregnancy Registry for Atypical Antipsychotics. Am J Psychiatry. 2015;173:263–70.PubMedCrossRefGoogle Scholar
  30. 30.
    Barnas C, Bergant A, Hummer M, Saria A, Fleischhacker WW. Clozapine concentrations in maternal and fetal plasma, amniotic fluid, and breast milk. Am J Psychiatry. 1994;151:945. Scholar
  31. 31.
    Mendhekar DN. Possible delayed speech acquisition with clozapine therapy during pregnancy and lactation. J Neuropsychiatry Clin Neurosci. 2007;19:196–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Dev V, Krupp P. The side effects and safety of clozapine. Rev Contemp Pharmacother. 1995;6:197–208.Google Scholar
  33. 33.
    Becker MA, Mayor GF, Elisabeth JS. Psychotropic medications and breastfeeding. Primary Psychiatry. 2009;16:42–51.Google Scholar
  34. 34.
    Ambresin G, Berney P, Schulz P, Bryois C. Olanzapine excretion into breast milk: a case report. J Clin Psychopharmacol. 2004;24:93–5.PubMedCrossRefGoogle Scholar
  35. 35.
    Brunner E, Falk DM, Jones M, Dey DK, Shatapathy CC. Olanzapine in pregnancy and breastfeeding: a review of data from global safety surveillance. BMC Pharmacol Toxicol. 2013;14:38.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Croke S, Buist A, Hackett LP, Ilett KF, Norman TR, Burrows GD. Olanzapine excretion in human breast milk: estimation of infant exposure. Int J Neuropsychopharmacol. 2002;5:243–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Gardiner SJ, Kristensen JH, Begg EJ, Hackett LP, Wilson DA, Ilett KF, Kohan R, Rampono J. Transfer of olanzapine into breast milk, calculation of infant drug dose, and effect on breast-fed infants. Am J Psychiatry. 2003;160:1428–31.PubMedCrossRefGoogle Scholar
  38. 38.
    Kirchheiner J, Berghöfer A, Bolk-Weischedel D. Healthy outcome under olanzapine treatment in a pregnant woman. Pharmacopsychiatry. 2000;33:78–80.PubMedCrossRefGoogle Scholar
  39. 39.
    Lutz UC, Wiatr G, Orlikowsky T, Gaertner HJ, Bartels M. Olanzapine treatment during breast feeding: a case report. Ther Drug Monit. 2008;30:399–401.PubMedCrossRefGoogle Scholar
  40. 40.
    Gilad O, Merlob P, Stahl B, Klinger G. Outcome of infants exposed to olanzapine during breastfeeding. Breastfeed Med. 2011;6:55–8.PubMedCrossRefGoogle Scholar
  41. 41.
    Reis M, Källén B. Maternal use of antipsychotics in early pregnancy and delivery outcome. J Clin Psychopharmacol. 2008;28:279–88.PubMedCrossRefGoogle Scholar
  42. 42.
    Hill RC, McIvor RJ, Wojnar-Horton RE, Hackett LP, Ilett KF. Risperidone distribution and excretion into human milk: case report and estimated infant exposure during breast-feeding. J Clin Psychopharmacol. 2000;20:285–6.PubMedCrossRefGoogle Scholar
  43. 43.
    Aichhorn W, Stuppaeck C, Whitworth AB. Risperidone and breast-feeding. J Psychopharmacol. 2005;19:211–3.PubMedCrossRefGoogle Scholar
  44. 44.
    Ilett KF, Hackett LP, Kristensen JH, Vaddadi KS, Gardiner SJ, Begg EJ. Transfer of risperidone and 9-hydroxyrisperidone into human milk. Ann Pharmacother. 2004;38:273–6.PubMedCrossRefGoogle Scholar
  45. 45.
    Lee A, Giesbrecht E, Dunn E, Ito S. Excretion of quetiapine in breast milk. Am J Psychiatry. 2004;161:1715–6.PubMedCrossRefGoogle Scholar
  46. 46.
    Misri S, Reebye P, Kendrick K, Carter D, Ryan D, Grunau RE, Oberlander TF. Internalizing behaviors in 4-year-old children exposed in utero to psychotropic medications. Am J Psychiatry. 2006b;163:1026–32.PubMedCrossRefGoogle Scholar
  47. 47.
    Lutz UC, Hiemke C, Wiatr G, Farger G, Arand J, Wildgruber D. Aripiprazole in pregnancy and lactation: a case report. J Clin Psychopharmacol. 2010;30:204–5.PubMedCrossRefGoogle Scholar
  48. 48.
    Nordeng H, Gjerdalen G, Brede WR, Michelsen LS, Spigset O. Transfer of aripiprazole to breast milk: a case report. J Clin Psychopharmacol. 2014;34:272–5.PubMedCrossRefGoogle Scholar
  49. 49.
    Schlotterbeck P, Leube D, Kircher T, Hiemke C, Gründer G. Aripiprazole in human milk. Int J Neuropsychopharmacol. 2007;10:433.PubMedCrossRefGoogle Scholar
  50. 50.
    Watanabe N, Kasahara M, Sugibayashi R, Nakamura T, Nakajima K, Watanabe O, Murashima A. Perinatal use of aripiprazole: a case report. J Clin Psychopharmacol. 2011;31:377–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Gentile S. A safety evaluation of aripiprazole for treating schizophrenia during pregnancy and puerperium. Expert Opin Drug Saf. 2014;13:1733–42.PubMedCrossRefGoogle Scholar
  52. 52.
    Hale TW. Pharmacology review: drug therapy and breastfeeding: antidepressants, antipsychotics, antimanics, and sedatives. NeoReviews. 2004;5:e451–6.CrossRefGoogle Scholar
  53. 53.
    Cuomo A, Goracci A, Fagiolini A. Aripiprazole use during pregnancy, peripartum and lactation. A systematic literature search and review to inform clinical practice. J Affect Disord. 2018;228:229–37.PubMedCrossRefGoogle Scholar
  54. 54.
    Uguz F. Breastfed infants exposed to combined antipsychotics. Am J Ther. 2016;23:e1962–4.PubMedCrossRefGoogle Scholar
  55. 55.
    Teoh S, Ilett KF, Hackett LP, Kohan R. Estimation of rac-amisulpride transfer into milk and of infant dose via milk during its use in a lactating woman with bipolar disorder and schizophrenia. Breastfeed Med. 2011;6:85–8.PubMedCrossRefGoogle Scholar
  56. 56.
    O’Halloran SJ, Wong A, Joyce DA. A liquid chromatography-tandem mass spectrometry method for quantifying amisulpride in human plasma and breast milk, applied to measuring drug transfer to a fully breast-fed neonate. Ther Drug Monit. 2016;38:493–8.PubMedCrossRefGoogle Scholar
  57. 57.
    Nonacs M, Wang B, Viguera AC, Cohen LS. Psychiatric illness during pregnancy and the postpartum period. In: Stern T, Fava M, Wilens TE, Rosenbaum JP, editors. The Massachusetts General Hospital comprehensive clinical psychiatry. 2nd ed. London: Elsevier; 2016. p. 343–52.Google Scholar
  58. 58.
    Brucker MC, King TL. The 2015 US Food and Drug Administration pregnancy and lactation labeling rule. J Midwifery Womens Health. 2017;62:308–16.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Joshua Niforatos
    • 1
  • Carol Swetlik
    • 1
  • Adele Viguera
    • 2
    Email author
  1. 1.Cleveland Clinic Lerner College of MedicineCase Western Reserve UniversityClevelandUSA
  2. 2.Department of Psychiatry, Neurological InstituteCleveland ClinicClevelandUSA

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