Quetiapine is the preferred second-generation, and haloperidol the preferred first-generation antipsychotic when breastfeeding full term, healthy infants.
This article includes the most commonly used antipsychotic medicines. For more specialist situations, or other antipsychotics, contact our specialist service for advice.
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.
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
Use with caution
Oral haloperidol can be used with caution during breastfeeding, but infant monitoring is required.
Infant monitoring
Monitor the infant for potential side-effects including drowsiness, irritability, restlessness, gastro-intestinal disturbances, urinary retention (producing fewer wet nappies), rash, extrapyramidal symptoms, not feeding as normal or gaining weight as expected, and attainment of developmental milestones.
Further information
Limited evidence indicates that oral doses of up to 10mg daily result in variable, yet small to moderate amounts in milk (0.3 to 12% of the weight-adjusted maternal dose).
Haloperidol has been detected in breastfed infant serum, at levels which could be significant, and in urine. However, most studies have not reported side-effects in breastfed infants. One infant developed hypersomnia, poor feeding and slowing in motor movements when exposed to haloperidol and risperidone via milk.
In three infants exposed to chlorpromazine and haloperidol, a decline in developmental scores was reported at 12 to 18 months of age. Other studies have found no developmental problems at 18 months and, in one case 8 years.
Second Generation Antipsychotics
Use with caution
Oral quetiapine can be used with caution during breastfeeding, but infant monitoring is required.
Infant monitoring
Monitor the infant for potential side-effects including drowsiness, irritability, restlessness, gastro-intestinal disturbances, fever, extrapyramidal symptoms, not feeding as normal or gaining weight as expected, and attainment of developmental milestones.
Further information
Moderate evidence shows that oral doses up to 400mg daily result in negligible amounts in milk (0.4% of the weight-adjusted maternal dose).
Infant serum levels of quetiapine are low ranging from 0.6 to 7.3% of the maternal serum level.
Most studies have not reported short or long term side-effects in breastfed infants. Two infants showed mild developmental delays however, infant quetiapine levels were undetectable and an antidepressant was also taken whilst breastfeeding; causality to the medicines in milk was unlikely.
Use with caution
Oral aripiprazole can be used with caution during breastfeeding and with infant monitoring, but other antipsychotics are preferred.
Infant monitoring
Monitor the infant for potential side-effects including drowsiness, irritability, restlessness, constipation, extrapyramidal symptoms, not feeding as normal or gaining weight as expected, and attainment of developmental milestones.
Milk supply may also be affected.
Further information
Very limited evidence shows that doses up to 15mg daily result in variable, yet small amounts in breast milk (0.7 to 8.3% of the weight-adjusted maternal dose).
In most cases, infant side-effects have not been reported. There are some unverified reports of drowsiness in breastfed infants. Weight loss and poor infant weight gain have also been described. No long term problems have been noted.
Use with caution
Oral olanzapine can be used with caution during breastfeeding, but infant monitoring is required.
Infant monitoring
Monitor the infant for potential side-effects including drowsiness, irritability, restlessness, constipation, urinary retention (producing fewer wet nappies), rash, extrapyramidal symptoms, not feeding as normal or gaining weight as expected, and attainment of developmental milestones.
Further information
Moderate evidence indicates that oral doses up to 20mg daily result in very small amounts in breast milk (0.13 to 4% of the weight-adjusted maternal dose).
Undetectable infant serum levels have been reported in the majority of studies.
Most studies have not reported any short or long term side-effects in breastfed infants. However, somnolence, lethargy, poor sucking, irritability, tremor, constipation and poor weight gain have been occasionally reported. There have been isolated reports of decreased intellectual development, speech delay and motor development delay.
Use with caution
Oral risperidone can be used with caution during breastfeeding, but infant monitoring is required.
Infant monitoring
Monitor the infant for potential side-effects including drowsiness, irritability, restlessness, gastro-intestinal disturbances , rash, extrapyramidal symptoms, not feeding as normal or gaining weight as expected, and attainment of developmental milestones.
Further information
Limited evidence shows that oral doses up to 6mg daily result in very small amounts in milk (2.3 to 4.7% of the weight-adjusted maternal dose, which includes the active metabolite).
Infant plasma levels have been reported as undetectable or very low.
Most studies do not report any short or long term side-effects in breastfed infants. There have been some cases of sedation, poor feeding, slow motor movements and constipation when other sedating medicines were also taken.
Seek further advice
Clozapine is used for treatment resistant schizophrenia. Contact us for specialist advice.
Seek further advice
Depot antipsychotic injection use in breastfeeding requires specific pharmacokinetic considerations. Contact us for specialist advice.
Patient Information
The NHS website provides advice for patients on the use of specific medicines in breastfeeding.