Antipsychotics and breastfeeding

A review notes (1):

• 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 also has favourable pharmacokinetics in this clinical scenario
    
• 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

Risk of SIDS whilst using antipsychotics

• 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

Neonatal withdrawal syndrome and use of antipsychotics during breastfeeding

• withdrawal symptoms and poor neonatal adaptation syndrome have been reported in infants exposed to antipsychotic medicines in pregnancy
  • 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

General side effects with respect to use of antispychotics during breastfeeding

• use of antipsychotics may lead to more difficulties with breastfeeding, particularly establishing breastfeeding
  • 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
  • clinical significance of this in those breastfeeding is unknown
• aripiprazole can both increase and decrease prolactin levels
  • 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
• are limited data on the neurodevelopmental effects of long-term exposure of infants to antipsychotics during breastfeeding.
  • most studies do not report any effects
    • note though that 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 information with respect to haloperidol

• 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
    • 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

Specific information with respect to quetiapine

• 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

For full details see https://www.sps.nhs.uk/articles/using-antipsychotics-during-breastfeeding/

Reference:

1. NHS Speciality Pharmacy Service (July 14th 2025). Using antipsychotics during breastfeeding