This is one section of the new book on chronic medical conditions and breastfeeding. It is available on Amazon as a kindle or paperback book .
I have updated the information in view of the information shared by Specialist Pharmacy Service October 2023 https://www.sps.nhs.uk/articles/treating-bipolar-disorder-during-breastfeeding/
“I was only diagnosed with bipolar during my first pregnancy so breastfeeding was very much uncertain and a lot of healthcare professionals maybe weren’t so keen but I fed my eldest until he was 13 months when he self-weaned as I was pregnant with my second. I would love to be able to help anyone I can, I am very passionate about breastfeeding and honestly think it has been a real stabilising factor in my mental health!”
“Medication to control the symptoms of bipolar disorder is complicated. If we add in the emotional turmoil that occurs post-delivery and lack of sleep, there may need to be regular review. Mothers have been known to come off their medication in order to breastfeed with dire consequences. We need to provide them with evidence-based information to understand the risks and benefits of the treatment regime. (A professional viewpoint)”
Description
Bipolar disorder is a mental health condition that affects moods. The latter can swing from one extreme of lethargy and depression to a feeling of being high and overactive hence the original name of manic depression.
During bouts of depression it is not uncommon to feel suicidal or worthless and it is important to recognise this and seek a place of safety or a person you trust as quickly as possible. During a manic phase there may be feelings of having lots of energy, ambitious plans and idea. It is not uncommon to spend large amounts of money on expensive, unwanted goods and some people ask their banks to block spending above a certain level to avoid debt. It is also common to not feel like eating or sleeping, to talk quickly and become easily annoyed. For some this phase is a positive experience and a time of creativity so may reject medication. It may also become a psychotic phase where things which do not exist may be seen and heard (voices controlling actions). It is a complex condition which may need adjustments. Around one in every 100 people will be diagnosed with it at some point in their life. It frequently develops between 15 and 19 years of age but rarely after 40. The incidence is the same in men and women. The pattern of mood swings in bipolar disorder varies widely. Some people only have a couple of episodes in their lifetime and are stable in between, while others have many episodes.
Diagnosis is made only after one episode of mania as well as the depression. In this state the mother may have an elated mood or alternatively she may feel irritable and angry. She may experience racing thoughts rapidly changing from one area to another. It may be impossible for her to be still, but the activity may be unproductive. It is reported to affect a higher proportion of intelligent people with gifted creativity.
Treatment
Anti-depressants: See Section on Depression
mood stabilisers :
carbamazepine: reaches relatively high levels in breastmilk but does not appear to affect growth or development. Sedation, poor feeding, withdrawal reactions and 3 cases of hepatic dysfunction have been reported but maybe due to placental transfer
valproate: If valproate is taken during pregnancy, around 1 in 10 babies are born with birth defects and up to 4 in 10 babies will have developmental problems. It is no longer recommended in pregnancy and has in consequence fallen out of use in breastfeeding. If this is the best suited drug it is compatible with breastfeeding, but the mother should take adequate contraceptive precautions. Valproic acid levels in breastmilk are low and infant serum levels range from undetectable to low. theoretically it is recommended that the baby should be monitored for jaundice and liver damage if clinical symptoms present (Hale online). Valproate can be used during breastfeeding in the management of bipolar disorder (SPS) but with adequate contraceptive methods.
Resources for healthcare professionals and patients https://www.rpharms.com/resources/pharmacy-guides/valproate-and-the-pregnancy-prevention-programme
- Patient card – to be given by pharmacists to all female patients who are dispensed valproate medicines to inform them of the risks
- Patient guide – to be provided to girls (of any age) and women of childbearing potential (or their parent/caregiver/responsible person) taking any medicine containing valproate
- Guide for healthcare professionals – for all prescribers, pharmacists, and other healthcare providers involved in the care of women and girls of childbearing potential using valproate medicines
- Annual risk acknowledgement form – (revised November 2019) for the specialist and patient (or their parent/caregiver/responsible person) to sign at initiation and at treatment reviews at least every year – the patient should receive a copy of the form; one copy should be filed in the specialist notes, and one copy sent to the patient’s GP.
lamotrigine: Relatively high plasma levels have been reported in breastfed babies. Neonates are particularly susceptible due to their inability to metabolise the drug if the dosage is not reduced to the pre-pregnancy dosage in the immediate post-partum period. Relative infant dose is quoted as 9.2-18.3%. Page-Sharp (2006) studied six breastfeeding women taking a mean dose of 400 mg per day of lamotrigine. Five of the babies were exclusively breastfed and the remaining one fed with half breastmilk and half artificial milk feeds. No adverse events were noted in any of the infants. In general infants should be monitored for sedation, feeding difficulties, adequate weight gain and developmental milestones.
lithium: Has historically been described as not compatible with breastfeeding unless baby can be monitored with monthly blood tests. However October 2023 SPS reported that “Lithium can also be used for the management of bipolar disorder, but must be with extreme caution, under specialist supervision, and with strict infant monitoring conditions.” Lactmed (https://www.ncbi.nlm.nih.gov/books/NBK501153) states that “Lithium excretion into breastmilk and concentrations in infant serum are highly variable, and that numerous reports exist of infants who were breastfed during maternal lithium therapy without any signs of toxicity or developmental problems. Most were breastfed from birth and some continued to nurse for up to 1 year of maternal lithium therapy. The baby would need regular blood tests to monitor, just as the mother does . The infant should be monitored for Neurobehavioral development, drowsiness, irritability, dry mouth or excessive salivation, thyroid function, vomiting, constipation, hydration, renal function, urination, tremor. The decisions should be taken with full information
.
Atypical antipsychotics:
risperidone (Risperidal™): Limited information indicates that maternal risperidone doses of up to 6 mg daily produce low levels in milk. Observe baby for drowsiness but no adverse events reported to date.
olanzapine (Zyprexa™): Maternal doses of olanzapine up to 20 mg daily produce low levels in milk and undetectable levels in the serum of breastfed infants. Monitor the baby for drowsiness and effective feeding.
quetiapine (Seroquel™): Maternal quetiapine doses of up to 400 mg daily produce low levels in milk. Monitor the baby for drowsiness and effective feeding.
ariprazole (Ablify ™): Limited information indicates that maternal doses of aripiprazole up to 15 mg daily produce low levels in milk. However, it inhibits prolactin levels and despite expert advice it may not be possible to achieve a full milk supply ((Mendhekar 2006, Nordeng 2014).
Choice of medication must be guided by clinical need, but it is usually, depending on the dose, possible to continue to breastfeed. If it is not possible, the mother and her family should be consulted in making an informed choice.
References
- Hale TW Medications and Mothers Milk Online access
- Mendhekar DN, Sunder KR, Andrade C. Aripiprazole use in pregnant schizoaffective woman. Bipolar Disord 2006; 8:229-300
- Nordeng H, Gjerdalen G. BRede WR, Michelsen LS, Spigset O. Transfer of aripiprazole to breast milk: a case report. J Clin Psychopharamcology 2014;34(2):272-75.
- Page-Sharp M, Kristensen JH, Hackett LP, Beran RG, Rampono J, Hale TW, Kohan R, Ilett KF, Transfer of lamotrigine into breastmilk, Ann Pharmacother, 2006;40:1470–1, Letter.
- SPS Treating bipolar disorder during breastfeeding https://www.sps.nhs.uk/articles/treating-bipolar-disorder-during-breastfeeding
Further information:
BiPolar UK www.bipolaruk.org
