Medications that cause sedation are of concern as they may cause sedation and poor feeding/weight gain in the breastfeeding infant. Caution should be used with these medications, especially if they are used in combination with other medications that can cause sedation and poor feeding. Generally, use the lowest effective doses of medication, utilize shared decision making, and monitor human milk fed infants closely if using sedatives and hypnotics in a lactating individual.

For more detailed information and references on specific medications, please refer to LactMed, e-lactancia, Infant Risk, or Mother to Baby.

Melatonin has very low oral bioavailability and occurs naturally in human milk. Watch for infant sedation with high doses. There is no absolute indication to pump and dump.

Antihistamines include diphenhydramine/Benadryl, doxylamine/Unisom, hydroxyzine/Vistaril. While infants should be closely monitored for side effects as noted below if these medications are used by a lactating individual, there is generally no absolute indication to pump and dump and shared decision making should be used with this medication.

• Hydroxyzine/Vistaril: Generally, this medication is less sedating than diphenhydramine. While infants should be closely monitored for sedation if this medication is used by a lactating individual, there is generally no absolute indication to pump and dump and shared decision making should be used with this medication.
• Diphenhydramine/Benadryl: Monitor for decreased milk production, infant sedation, or poor infant weight gain with longer term use or larger doses. While infants should be closely monitored for sedation and poor weight gain if diphenhydramine is used by a lactating individual, there is generally no absolute indication to pump and dump and shared decision making should be used with this medication.
• Doxylamine/Unisom: Generally, this medication is more sedating than diphenhydramine. Use with caution in parents with premature infants or infants with a history of apneas or respiratory issues and monitor for sedation. While infants should be closely monitored for sedation if this medication is used by a lactating individual and special precaution should be used with premature infants or those with respiratory disorders, there is generally no absolute indication to pump and dump and shared decision making should be used with this medication.

These medications should be used with caution and the infant should be monitored closely for signs of sedation, low tone, respiratory depression, and poor weight gain.

• • Zolpidem/Ambien: Milk transfer is low and it is rapidly eliminated from milk. While infants should be monitored for sedation, hypotonia, respiratory depression, and poor appetite with use of this medication by a lactating individual, there is no absolute indication to pump and dump and shared decision making should be used with this medication. Alternative medications may be preferred – particularly for those with premature infants, newborns, and infants at risk for apnea.
  • Zaleplon/Sonata: Milk levels are known to be low and it has a short half-life so it is unlikely this would affect an older infant. Alternatives may be preferred for preterm infants, those at risk for apnea, and newborns. While infants should be monitored for sedation, hypotonia, respiratory depression, and poor appetite with use of this medication by a lactating individual, there is no absolute indication to pump and dump and shared decision making should be used with this medication. Alternative medications may be preferred – particularly for those with premature infants, newborns, and infants at risk for apnea.
  • Eszopiclone/Lunesta: Evidence is limited. There is no absolute indication to pump and dump, but alternatives are preferred due to the lack of evidence on this medication.

Benzodiazepines should be used with caution. Commonly used benzodiazepines for sleep include:

• • Temazepam/Restoril: This medication has low milk transfer and a relatively short half-life. Taking this medication right after a feed at bedtime may help minimize any risk to the infant. While infants should be monitored for sedation with use of this medication by a lactating individual, there is no absolute indication to pump and dump and shared decision making should be used with this medication.
  • Lorazepam/Ativan: This medication has low milk transfer and a relatively short half-life. While infants should be monitored for sedation with use of this medication by a lactating individual, there is no absolute indication to pump and dump and shared decision making should be used with this medication.
  • Alprazolam/Xanax: There are reports of infant side effects, including sedation, with the long term or regular use of alprazolam in lactating individuals. Alternative medications with a shorter-acting benzodiazepine without active metabolites are preferred.

Commonly used TCAs include amitriptyline/Elavil, doxepin/Silnore, mirtazepine/Remeron. There has been one case report of infant sedation with low dose amitriptyline (1). The anti-cholinergic properties of tricyclic antidepressants have been observed to decrease milk production, especially with higher doses although data is limited. Nortriptyline is less anti-cholinergic than amitriptyline. While infant should be closely monitored for side effects (such as sedation) with use of this class of medication by the lactating individual and parents should be informed of the risk to milk production, there is not an absolute indication to pump and dump and shared decision making should be used with these medications.

The anti-cholinergic properties of trazodone may decrease milk production, especially with higher doses although data is limited. Milk levels are low and it is unlikely to adversely impact the breastfeeding infant when lower doses are used (such as doses under 100 mg  used as a sleep aid). While infants should be closely monitored for sedation with the use of this medication by the lactating individual and parents should be informed of the theoretical risk to milk production, there is not an absolute indication to pump and dump and shared decision making should be used with these medications.

Infants should be monitored for drowsiness and insufficient weight gain with chronic use of higher doses. Low blood levels of gabapentin have been found in the breastfeeding infants of mothers taking this medication (2). While the infant should be closely monitored for side effects (such as drowsiness and insufficient weight gain) with use of this medication by the lactating parent, there is not an absolute indication to pump and dump and shared decision making should be used with these medications.

Data is limited and an alternative is preferred.

Antipsychotics include quetiapine/Seroquel, olanzapine/Zyprexa, risperidone/Risperdal. These medications generally have low penetration into the milk with available case reports showing no adverse events. These medications may increase serum prolactin level and might increase milk production. Quetiapine has low milk penetration and RID is extremely low so this medication may be preferred in the lactating individual. There is no absolute indication to pump and dump.

Doses up to 15 mg daily result in low milk levels. An alternative medication may be preferred until there is more data on aripiprazole, especially in preterm and newborn infants. Aripiprazole may lower serum prolactin in a dose-dependent manner and Lactmed cites case reports of decreased milk production and lactation cessation. There are also reports of galactorrhea and gynecomastia. Alternative medications should be considered due to the lack of data on the use of aripiprazole during lactation. Infants should be monitored closely for poor weight gain, dehydration, or sedation with the use of this medication and lactating individuals should be counseled on the high risk of decreased milk production.