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Q: Mother on Haldol breastfeeding newborn infant - Is it safe? ( Answered 3 out of 5 stars,   1 Comment )
Question  
Subject: Mother on Haldol breastfeeding newborn infant - Is it safe?
Category: Health > Medicine
Asked by: myspace-ga
List Price: $50.00
Posted: 28 Aug 2006 18:27 PDT
Expires: 27 Sep 2006 18:27 PDT
Question ID: 760318
My wife has been taking Haldol 1.5mg once every night for the past
year to treat Bipolar Disorder.
During this time, she got pregnant and just gave birth to our baby. 
Now that it is time for her to breastfeed, we are getting conflicting
information on how safe it is for her to breastfeed while she is on
Haldol.  The only information we have till date is from Tom Hale's
book "Medications and Mothers Milk, 2004" which suggests that it is OK
to Breastfeed since Haldol falls under lactation category L2.
We would like to have more information on Haldol's effects on
Breastfeeding for newborns.  In other words, is it safe for my wife to
breastfeed our child when he is on Haldol?  If it isn't, what other
medications for Bipolar Disorder would be safe for her to use while
she breastfeeds?
Answer  
Subject: Re: Mother on Haldol breastfeeding newborn infant - Is it safe?
Answered By: boquinha-ga on 29 Aug 2006 19:55 PDT
Rated:3 out of 5 stars
 
Hello myspace-ga!

This must be a difficult decision for you and your wife, especially
since so much conflicting information is out there. It is especially
difficult to find good data on medicines and medical treatments during
pregnancy and breastfeeding because there are few people willing to
take a chance with pregnant women or babies. I have assembled a number
of opinions and resources to help you with this decision. As you will
see, most of the recommendations are fairly nebulous, failing to
clearly support or oppose Haldol?s use while breastfeeding. Ultimately
you will need to discuss all of the available information with your
wife?s doctor, and maybe even seek a second opinion. This answer is
not intended to substitute for the opinion of a qualified health
professional that you trust. If you have any specific concerns or
questions you should discuss them with him or her. Here is what I?ve
found.

- - - - - - - - - - - - - - - - - - - -

SUPPORTING HALDOL

Here is general advice regarding any medications taken while
breastfeeding. According to this information, Haldol and the other
antipsychotics are among those that should be safe to take, when
monitored by a physician. Lithium, incidentally, is one
mood-stabilizing drug used commonly in treating bipolar disorder that
should NOT be used while breastfeeding.

?Most medications have not been tested in nursing women, so no one
knows exactly how a given drug will affect a breastfed child. Since
very few problems have been reported, however, most over-the-counter
and prescription drugs, taken in moderation and only when necessary,
are considered safe.

Even mothers who must take daily medication for conditions such as
epilepsy, diabetes, or high blood pressure can usually breastfeed.
They should first check with the child's pediatrician. To minimize the
baby's exposure, the mother can take the drug just after nursing or
before the child sleeps.?
http://www.childbirthsolutions.com/articles/postpartum/breastfeedingfaq/index.php


Dora Kohen, Professor of Women?s Mental Health at the Lancashire
Postgraduate School of Medicine and Health (in the U.K.) is a
perinatal psychiatrist. She has this to say about psychiatric (or
?psychotropic?) medications in lactating mothers.

?Adverse effects of psychotropic medication on breast-fed infants have
not been studied in controlled and systematic research. Existing
information comes from small case series and single case reports.
These limited data confirm that psychotropics are excreted into breast
milk and that the infant is exposed to them. In recent decades
sufficient data have accumulated to allow psychiatrists to prescribe
tricyclic antidepressants, selective serotonin reuptake inhibitors,
conventional antipsychotics [such as Haldol], carbamazepine and sodium
valproate to breast-feeding mothers with safety. There are not
sufficient data on atypical antipsychotics to allow women to
breast-feed safely. Mothers on clozapine or lithium should not
breast-feed. It is good practice to recommend that breast-feeding
mothers requiring psychotropic medication be on a low dose of one
single drug.?
http://apt.rcpsych.org/cgi/content/abstract/11/5/371


Results of a Medline search performed by Dr. Ivan Goldman are
available on the following site. It includes abstracts of articles
discussing various psychiatric medications in pregnancy. Most of the
abstracts state that because post-partum depression is a significant
concern in any mother, especially those with bipolar disorder or other
forms of depression, that continuing a psychiatric medication while
breastfeeding is usually indicated, with the caveat that the infant
should be relatively healthy.
http://www.psycom.net/depression.central.breastfeeding.html


According to information presented on this site, Haldol is ?probably?
safe to use during breastfeeding.
http://www.babycenter.com/general/baby/babybreastfeed/8790.html

- - - - - - - - - - - - - - - - - - - -

OPPOSING HALDOL

Psychcentral.com is a site with a lot of information on psychiatric
disorders including bipolar disorder. There are also information
sheets on various medications. The sheet on Haldol includes this
blanket statement: ?Since this medicine is excreted in human breast
milk, you should NOT breastfeed while taking this medicine.? There are
a number of websites that use this exact same statement when
discussing Haldol.
http://psychcentral.com/meds/haldol.html

- - - - - - - - - - - - - - - - - - - -

ON THE FENCE

In September of 2001 the American Academy of Pediatrics (AAP)
published a paper with the title ?The Transfer of Drugs and Other
Chemicals Into Human Milk.? Many medications were mentioned, and
antipsychotics were mentioned specifically as a class. Most of them,
including Haldol, were listed as ?drugs for which the effect on
nursing infants is unknown but may be of concern.? Haldol specifically
has been shown in some small studies to affect childhood development
as measured by certain criteria.

?Anti-anxiety drugs, antidepressants, and neuroleptic drugs have been
placed in Table 4 ?Drugs for Which the Effect on Nursing Infants is
Unknown but May Be of Concern.? These drugs appear in low
concentrations (usually with a milk-to-plasma ratio of 0.5-1.0) in
milk after maternal ingestion. Because of the long half-life of these
compounds and some of their metabolites, nursing infants may have
measurable amounts in their plasma and tissues, such as the brain.
This is particularly important in infants during the first few months
of life, with immature hepatic and renal function. Nursing mothers
should be informed that if they take one of these drugs, the infant
will be exposed to it. Because these drugs affect neurotransmitter
function in the developing central nervous system, it may not be
possible to predict long-term neurodevelopmental effects.?
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;108/3/776


Perinatology.org, a site dedicated to health issues regarding newborns
echoes the AAP concern.
http://www.perinatology.com/exposures/druglist2.htm#Haloperidol


The Drug and Lactation Database (LactMed) has information on many
medications and breastfeeding. Haldol appears to be a safe medication
overall during breastfeeding, but there are potential side effects of
which parents and physicians should be aware. The AAP is listed as
saying that the potential effects of Haldol in breastfed babies are
?concerning.?

?Limited information indicates that maternal doses of haloperidol up
to 10 mg/day produce low levels in milk and do not affect the
breastfed infant. Very limited long-term follow-up data indicate no
adverse developmental effects when haloperidol is used alone. However,
combinations of antipsychotic agents can negatively affect
development. Monitor the infant for developmental milestones,
especially if other antipsychotics are used concurrently.?

The article goes on to describe the possible effects of Haldol on
breastfed infants, citing a few small studies.

?In one breastfed infant, there were no sedative effects and the baby
fed well during maternal intake of 5 mg orally twice daily. The mother
took haloperidol during 6 weeks of breastfeeding and, at 6 and 12
months of age, the baby had achieved all milestones of growth and
development.

One infant was breastfed for 5 weeks beginning at 2 weeks of age
during maternal haloperidol (dose not stated) and imipramine (150 mg
daily) therapy. The infant showed normal development when tested once
between 1 and 4 months and once between 12 and 18 months of age.

In a small prospective study on the long-term effects of
antipsychotics in breastfed infants, a decline in developmental scores
was found at 12 to 18 months of age in 2 of the 4 infants of mothers
taking both chlorpromazine and haloperidol. The other 2 infants and
all infants exposed to either drug alone developed normally.?
http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~gZpo4j:1


Oregon State has a nice chart with information on psychiatric
medications and their pregnancy classes. It also includes
recommendations for breastfeeding mothers. Haldol is listed as
?controversial? during breastfeeding, citing evidence that a small,
but still detectible amount of medication ends up in the breast milk.
http://pharmacy.oregonstate.edu/drug_policy/pages/tidbits/articles/tb20.pdf


Here is one source suggesting that if Haldol is necessary, a nursing
mother may want to consider discontinuing breastfeeding because of the
theoretical risk to the infant.

?Haloperidol, when given to lactating women, is found in significant
amounts in their milk. Breastfed children sometimes show
extrapyramidal symptoms. If the use of haloperidol during lactation
seems indicated, the benefit for the mother should clearly outweigh
the risk for the child. Consider termination of breastfeeding.?
http://en.wikipedia.org/wiki/Haloperidol#Pregnancy_and_lactation

- - - - - - - - - - - - - - - - - - - -

OTHER INFORMATION

There is an article on Medscape.com by Dr. Mohammad Masud Iqbal with
the title ?Effects of Antimanic Mood-Stabilizing Drugs on Fetuses,
Neonates, and Nursing Infants.? The article is quite long, but here is
a summary of his recommendations regarding mood stabilizers while
breastfeeding.

* Lithium: Should be avoided by breastfeeding mothers.
* Depakote: Generally safe for breastfeeding, but monitoring of infant
serum concentrations is advisable.
* Tegretol: Considered safe.
* Lamictal: There is a risk of life-threatening rashes in infants.
Breastfeeding should be discontinued if this is observed.
* Topamax: The potential for adverse reactions while breastfeeding is unknown.
* Antipsychotics (including Haldol): Should be used for breastfeeding
only ?when the potential benefits justify the possible risks to the
infant.?
http://www.medscape.com/viewarticle/410736


Here is some information on antipsychotic medications in general
(including Haldol), including recommendations regarding breastfeeding.

?Risks During Breastfeeding 
* Antipsychotic medications pass into breast milk and, depending on
the dose, may cause drowsiness in the baby.

Recommendations During Breastfeeding
* Do NOT stop taking your medication. The period following childbirth
is a vulnerable time for women taking antipsychotics. Doses may need
to be increased rather than decreased at this time.
* Ask your doctor about the safest type of antipsychotic medication
for breastfeeding.
* It may not be a possibility, but ask your doctor if you can time
your dose with breastfeeding times, lower the dose of the drug, or use
a short-acting drug immediately after a feeding.
* If you are taking clozapine, both you and your baby should be
carefully monitored.?
http://www.camh.net/About_Addiction_Mental_Health/Drug_and_Addiction_Information/Safe_Baby/safe_baby_substance_antipsychoti.html


Here is an opinion provided by a psychiatrist at BipolarWorld.net. He
indicates that there aren?t any antipsychotic medications that are
completely ?safe? during breastfeeding, but that Depakote has been
endorsed by the American Academy of Pediatrics. But even this
recommendation is controversial at best.

?Most sources seem to agree:  Haldol and other old generation
antipsychotics are not regarded as safe in breastfeeding.  And the
newer ones, like Zyprexa, have not been around long enough to be
studied well enough to make people think they're clearly okay.  Some
of them have clear information indicating that they're not safe in
breastfeeding. . . . None, old generation or new, are clearly safe. .
. .

Depakote is listed as ?safe? in breastfeeding.  If you have bipolar
disorder, there is some evidence that Depakote can have an
antipsychotic effect.  This is not a standard maneuver, [and] you'd
have to discuss [it] in detail with your doctor (I've heard some
express some doubt about this safety rating:  too few patients in the
sample, even though the American Academy of Pediatrics has approved
it) but that's about the only option you could try that I know of. 
Otherwise, as you've probably been told, you'd have to ?stop
breastfeeding.??
http://www.bipolarworld.net/Phelps/ph_2002/ph861.htm

Here is some additional information from Dr. Phelps at BipolarWorld.net.

?The American Academy of Pediatrics has okayed Depakote for use while
breastfeeding.  Some experts think that was based on too little
information and aren't quite so sure it's okay.  We know lithium is
not okay, and as for the rest of the medications we usually consider,
there is even less information to go on than for Depakote.  You will
see Tegretol on some lists as okay; it has also been approved by the
AAP but surfing around today I find more skepticism about its safety
than with Depakote.  I fear the problem here, as regards these
different opinions, is just too little information to go on.

Sometimes we use low doses of the new generation of antipsychotic
medications for manic symptoms, but these too have not been tested. .
. .  The old generation antipsychotics like Haldol are listed as
?probably okay,? particularly at low doses.?
http://www.bipolarworld.net/Phelps/ph_2001/ph371.htm


Psychiatrists providing consultation on HealthyPlace.com discuss the
need for women with bipolar disorder to remain on a mood stabilizer
during the post-partum period in order to combat post-partum
depression. Lithium is specifically mentioned as problematic. They
discuss potential side effects of the other antipsychotics as well.

?We often recommend that women with bipolar disorder remain on a mood
stabilizer during the postpartum period; however, the use of
medications during the postpartum period is complicated by the issue
of breastfeeding. All medications are secreted into the breast milk,
although their concentrations appear to vary. Lithium is found in the
breast milk at relatively high concentrations, and there have been
reports of toxicity in nursing infants exposed to lithium in the
breast milk. Symptoms of toxicity in these infants include lethargy,
poor muscle tone, and changes on the electrocardiogram. While there
are risks associated with breastfeeding on lithium, it is probably the
safest mood stabilizer to use in this setting. Other mood stabilizers,
like valproic acid [Depakote] and carbamazepine [Tegretol], may cause
liver damage in the nursing infant, which is a serious and potentially
life-threatening complication.?
http://www.healthyplace.com/communities/bipolar/women_breastfeeding_medications.asp


Depakote is the only medication for bipolar disorder that has been
approved by the AAP in breastfeeding mothers. This is information
given to a mother with a child 5  months old. It includes the
consideration that a mother may want to consider discontinue
breastfeeding if the medication is required to control severe bipolar
symptoms.

?The only mood stabilizer that is currently ?accepted? for use while
breastfeeding is Depakote.  Lithium gets into breast milk too much;
the data on carbamazepine (Tegretol, Carbatrol) are less clear but
don't look good.  And we have too little data on all the rest.  Even
the Depakote data are pretty slim, but it was enough for the American
Academy of Pediatrics; and to my knowledge there are no known ?horror
stories,? at least not in the published literature.

Then there's the line of thought you've probably heard plenty by now:
your son is probably better off with a mother who's not feeling like
she's going crazy than with breast milk anymore.  He got his good
antibodies from you already.  There's probably more benefit to be had,
but not if it costs him his mother's mental health.  If you can't get
controlled quickly on Depakote, time to strongly consider weaning and
getting on whatever you need for good symptom control.?
http://www.bipolarworld.net/Phelps/ph_2000/ph130.htm


Here is an article that discusses ?effective? mood stabilizers. There
is a table that has information on medications during pregnancy and
breastfeeding. There is some thought that fish oil, or omega-3 fatty
acids may be useful in treating bipolar disorder, although there is no
data to support this as of yet. The article is updated as of April of
2005.

?Valproate and carbamazepine have been listed by the American Academy
of Pediatrics as safe for breastfeeding but a more recent review by
Chaudron and Jefferson calls this into question because the number of
infants studied was so small, and there were some problems observed in
a few children among those small groups.  This leaves no mood
stabilizer clearly safe for use while breastfeeding.  Fish oil in the
doses used in research studies has not been studied.  There is reason
to think it might be safe -- possibly even beneficial -- in both
pregnancy and breastfeeding, at least at doses approximating human
historical fish consumption.?
http://www.psycheducation.org/depression/meds/moodstabilizers.htm

- - - - - - - - - - - - - - - - - - - -

A BRIEF SUMMARY

As you can see, there is no one medication that is clearly the best to
use for treating bipolar in breastfeeding mothers. There are concerns
about using Haldol while breastfeeding, but not enough clear data to
recommend against its use. The only medication that currently has
support from the AAP in these cases is valproic acid (Depakote), but
even this is not clearly supported in research. Lithium is generally
considered unsafe and carbamazepine (Tegretol) is also usually
considered unsafe in breastfeeding mothers. The other mood stabilizers
and atypical antipsychotics do not have enough data collected to make
a generalization to support or oppose their use. Again, if you have
specific concerns or questions, be sure to discuss them with a
qualified health practitioner that you trust.

- - - - - - - - - - - - - - - - - - - -

I hope that you find this information useful. I wish you and your wife
well as you make some difficult decisions. From one breastfeeding mom
to another, I know how difficult these kind of decisions can be. I?ve
personally found it helpful to seek out alternative treatments
(vitamins, diet, exercise, therapy, etc.) in order to continue
breastfeeding comfortably. There is a remarkable wealth of information
out there, but of course, even with alternative options it is still
good to research carefully and discuss any potential decisions with
your health care practitioner. I ache for those making such emotional
and loving decisions. I really do wish you well. If you have any need
of further clarification, please let me know how I can help.

Sincerely,
Boquinha-ga


Search terms:

haldol breastfeed
haloperidol breastfeed
bipolar breastfeed
AAP haldol breastfeeding

Request for Answer Clarification by myspace-ga on 15 Sep 2006 17:50 PDT
Hello,

Thanks for the response.  I appreciate the effort and time you spent
on researching this question.  However, most of the information that
is presented below is something that we were already aware of by a
prior google search for "Haldol" & "lactation" and similar terms. 
Probably, it is my fault that I should have specifically asked for
supporting research documents rather than general opinion on Haldol
and other anti-depressants that are available on numerous websites by
a quick Google search.  These sites are of limited value since they
issue blanket statements supporting or opposing medications with scant
regard to important factors such as the dosage of the ingested drug.
It would be much more useful for us if you could include references to
research articles specifically supporting or opposing Haldol.

Clarification of Answer by boquinha-ga on 17 Sep 2006 08:10 PDT
Hello again!

Thank you for your kind response. It?s always refreshing to deal with
respectful customers such as yourself. I appreciate your comments.
You?re right?I have addressed the question as asked and I understand
that you are seeking further information in order to do what?s best
for your family and I respect that (sometimes it seems customers think
we can read minds, so I especially appreciate your responsible
comments). I?ve worked hard to provide you with the best resources
available on this topic. Unfortunately, as one of the sources points
out, ?Adverse effects of psychotropic medication on breast-fed infants
have not been studied in controlled and systematic research. Existing
information comes from small case series and single case reports.? I
have included a link referencing 3 of these small reports. Larger
studies and clinical trials are nonexistent when dealing with
antipsychotic medications and pregnant or nursing mothers. From a
researcher?s standpoint, the potential risks involved with such a
study do not outweigh the benefits. More plainly stated, no one really
wants to experiment with drugs in babies. Nearly all of the
information on the topic comes ?after the fact? based on individual
experiences, not on trials.

Also, so you know, my husband is a physician and so we have access to
additional resources. We?ve used those, too, but again there are no
concrete studies on the topic for the reasons stated above. Of course
the standard disclaimer applies: this answer is not intended to
substitute for the opinion of a qualified health professional that you
trust.

So, at this point, position papers from the AAP and various
professional opinions are the major sources available upon which you
can base a judgment. Maybe in the future there will be more extensive
and reliable case reports that patients can use to make informed
decisions. Again, I appreciate your kind, respectful comments. I
sincerely do wish you well with what must be a difficult and
frustrating situation.

Sincerely,
Boquinha-ga
myspace-ga rated this answer:3 out of 5 stars

Comments  
Subject: Re: Mother on Haldol breastfeeding newborn infant - Is it safe?
From: boquinha-ga on 23 Sep 2006 13:29 PDT
 
Hello myspace-ga,

Thank you for taking the time to rate my answer. I'm a bit mystified
as to how it rates as a 3-star answer when I have provided you with
what you've asked. I've tried to be thorough in my research and
presentation to you. Part of the issue is that some of what you seek
does not exist for reasons I've explained--people simply don't do drug
testing on nursing babies. Surely, a customer wouldn't rate an answer
as average simply because the answer is not what the customer would
like or because such information does not exist. I hope that you and
your wife can make the best family decision possible for yourselves.

Sincerely,
Boquinha-ga

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