Z drugs (zolpidem and zopiclone) in breastfeeding

• cause of the insomnia should be identified before a medicine is prescribed and, where possible, underlying factors should be treated
• good sleep hygiene should be established to raise awareness of behavioural, environmental and temporal factors that may be detrimental or beneficial to sleep

Any decision to treat a sleep disorder with medication needs to be carefully considered, taking into account the usual sleep deprivation associated with a newborn infant

• use of medicines to treat insomnia during breastfeeding should be approached with caution
  • where possible use short-term, intermittent dosing, and the lowest effective dose to reduce infant exposure
• the ‘z- drugs’ (zolpidem and zopiclone) are preferred for the short-term management of insomnia during breastfeeding, as they have shorter half-lives than the benzodiazepines and appear to pass into breast milk in small amounts (1):
  • zolpidem
    • estimated infant dose < 0.02% the maternal dose (2)
    • stated by the American Academy of Pediatrics (AAP) as safe for lactation (2)
  • zopiclone
    • estimated infant dose about 3.2% of maternal dose (2)
    • unlikely toxicity but effects of chronic exposure unknown (2)
  • melatonin can also be used in breastfeeding with caution
• monitor the infant closely for side effects, such as drowsiness.
• may present as not waking up to feed/falling asleep whilst feeding, which may affect weight gain
• note that NICE advises to avoid sharing a bed with the infant when sedating medication has been used, due to the increased risk of sudden unexpected death in infancy

Reference:

• NHS Specialist Pharmacy Service (March 8th 2024). Treating insomnia during breastfeeding
• Miller MA, Mehta N, Clark-Bilodeau C, Bourjeily G. Sleep Pharmacotherapy for Common Sleep Disorders in Pregnancy and Lactation. Chest. 2020 Jan;157(1):184-197.