Benzodiazepines during breastfeeding

Using benzodiazepines in breastfeeding should be approached with caution, and the lowest effective doses should be used.

Shorter-acting agents, such as lorazepam and oxazepam, are preferred, where this is clinically appropriate

• however, choice should primarily be directed at adequately treating the condition first, with safety in breastfeeding a secondary consideration (1)
• lorazepam during breastfeeding
  • can be used with caution during breastfeeding, but infant monitoring is still required
  • as a precaution, monitor the infant closely for drowsiness, slowed breathing rate, poor feeding (including not waking to feed) and adequate weight gain
  • there is limited published evidence of use in breastfeeding, which shows very small amounts are found in breast milk
  • evidence from nursing mothers indicates that lorazepam does not cause any adverse effects in breastfed infants with usual maternal dosages (2)
  • is a preferred choice because it is a shorter-acting benzodiazepine, and therefore there is less risk of accumulation in the infant
• oxazepam during breastfeeding
  • can be used with caution during breastfeeding, but infant monitoring is still required.
  • as a precaution, monitor the infant closely for drowsiness, slowed breathing rate, poor feeding (including not waking to feed) and adequate weight gain
  • there is limited published evidence of use in breastfeeding, which shows very small amounts are found in breast milk.
  • is a preferred choice because it is a shorter-acting benzodiazepine. It is also the least lipid soluble, which accounts for its low levels in milk

Management of anxiety and sleeping disorders during breastfeeding

• benzodiazepines should be used with caution for anxiety and sleeping disorders in breastfeeding
• benzodiazepines generally have long half-lives and could potentially accumulate in the breastfed infant following prolonged administration, leading to possible sedation and increased risk of apnoea
• advised to use, where possible, short-term, intermittent dosing to reduce infant exposure.
  • ‘z’ drugs, such as zopiclone and zolpidem, are preferred for sleeping disorders as they have shorter half-lives and appear to pass into the breast milk in small amounts.
  • withdrawal effects may occur in infants if a mother suddenly stops breastfeeding

Use of premedication during breastfeeding

• benzodiazepines are used for premedication and for conscious sedation during surgery
• following short-term therapy (1-2 doses) for these indications, breastfeeding can be resumed as soon as the mother has recovered sufficiently from the procedure

Use of benzodiazepines in maternal epilepsy during breastfeeding

• benzodiazepines are also used for epilepsy
• choice of benzodiazepine will depend on the clinical condition and should primarily be based on suitability for the patient rather than safety during breastfeeding.
• combination therapy may pose an increased risk to the infant, especially when adverse effects such as drowsiness are additive (1)
• withdrawal effects may occur in infants if a mother suddenly stops breastfeeding

References:

1. NHS Specialist Pharmacy Service (February 2024). Using benzodiazepines during breastfeeding.
2. Drugs and Lactation Database (LactMed®) [Internet]. Bethesda (MD): National Institute of Child Health and Human Development; 2006-. Lorazepam. [Updated 2024 Jan 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK501231.