Quetiapine is the preferred second-generation, and haloperidol the preferred first-generation antipsychotic when breastfeeding full term, healthy infants.

General considerations

It is important to complete an individual risk assessment for your patient and to apply the principles of prescribing in breastfeeding when looking at the available information and making treatment decisions.

Other medicines

This article includes the most commonly used antipsychotic medicines. For more specialist situations, or other antipsychotics, contact our specialist service for advice.

See also our advice on the following:

Recommendations

Haloperidol is the preferred choice first-generation antipsychotic during breastfeeding, due to its favourable side effect profile.

Quetiapine is the preferred choice second-generation antipsychotic due to its low excretion into milk and favourable pharmacokinetics. Olanzapine is also favourable.

However, most antipsychotics can be used during breastfeeding if clinically indicated.

Co-sleeping advice

Sudden infant death syndrome (SIDS) is very rare, and breastfeeding reduces the risk. However it is more likely to happen in certain circumstances, including when parents have taken sedating medicines such as antipsychotics.

NICE therefore advises avoiding sharing a bed with the infant when sedating medicines are used. Further information can be found in Co-sleeping and SIDS: A guide for healthcare professionals (UNICEF UK).

Choice considerations

It is important that mental health conditions are effectively treated and medicines are not suddenly stopped.

Treatment choice should primarily focus on managing the underlying condition with suitability in breastfeeding as a secondary consideration.

There is no need to change an antipsychotic used successfully during pregnancy to a preferred choice in breastfeeding if the infant is full term and healthy.

Medicines from different pharmacological classes may be used in combination and their additive suitability in breastfeeding will need to be considered.

Neonatal withdrawal syndrome

Withdrawal symptoms and poor neonatal adaptation syndrome have been reported in infants exposed to antipsychotic medicines in pregnancy. This is more likely to occur for exposure near delivery or when more than one centrally acting medicine is used.

Continuing breastfeeding may theoretically help relieve withdrawal effects but does not reduce the risk completely.

Effect on breastfeeding

Use of antipsychotics may lead to more difficulties with breastfeeding, particularly establishing breastfeeding. The underlying disease state might contribute and additional breastfeeding support may be required.

Antipsychotics may increase prolactin levels which can cause milk secretion in non-breastfeeding patients. The clinical significance of this in those breastfeeding is unknown.

Aripiprazole can both increase and decrease prolactin levels. There have been multiple reports of reduced milk supply or an inability to breastfeed in patients taking aripiprazole. Where breastfeeding is established, this is less likely to have an effect.

Infant side effects and development

Antipsychotics have long half-lives, which increases the risk of accumulation in breastfed infants, and the risk of side-effects.

Monitoring the infant should quickly identify potential issues. However, further investigation is usually required before a cause can be attributed to the medicine.

There are limited data on the neurodevelopmental effects of long-term exposure of infants to antipsychotics during breastfeeding.

Most studies do not report any effects. However, there are reports of developmental delays, mainly when antipsychotics have been used with other psychotropic medicines. The data have limitations and the implications of these findings are unclear.

Specific recommendations

We provide advice for a first generation antipsychotic, haloperidol. As well as a number of second generation antipsychotics.

First Generation Antipsychotics

Second Generation Antipsychotics

Patient Information

The NHS website provides advice for patients on the use of specific medicines in breastfeeding.

Contact us

Get in touch with the UK Drugs In Lactation Advisory Service (UKDILAS), our specialist breastfeeding medicines advice service if you need support in the following situations:

  • you need further advice
  • the medicine in question is not included here
  • the infant is unwell or premature
  • multiple medicines are being taken

Bibliography

Full referencing is available on request.

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