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
  • 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.
  • a precaution, monitor the infant closely for drowsiness, slowed breathing rate poor feeding (including not waking to feed) and adequate weight gain
  • 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

Reference:

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