Mood stabilizers during breastfeeding: a review.
BACKGROUND
The postpartum period is an exceptionally high-risk time for recurrence of depression, mania, or psychosis for women with bipolar disorder. Puerperal prophylaxis with mood stabilizers decreases this risk. To allow patients and clinicians to make informed decisions about mood-stabilizer use during breastfeeding, there is a need for a critical review and analysis of the data.


METHODS
A search of MEDLINE (1966-1998) and the Lithium Database, Madison Institute of Medicine, was conducted to obtain articles about lithium, valproate, carbamazepine, gabapentin, or lamotrigine use during lactation. Search terms used were pregnancy, teratogenesis, breastfeeding, lactation, breast milk levels and lithium, anticonvulsants, mood stabilizers. No other search restrictions were used. Unpublished data on gabapentin and lamotrigine were provided by the manufacturers.


RESULTS
The search revealed 11 cases of lithium use during breastfeeding, 8 of which reported infant serum levels. Two cases reported symptoms consistent with lithium toxicity in the infants. Thirty-nine cases of valproate use during breastfeeding were found, 8 of which reported infant serum levels. There was 1 report of thrombocytopenia and anemia in an infant. Fifty cases of carbamazepine use during breastfeeding were found, 10 of which reported infant serum levels. Two infants experienced hepatic dysfunction. One unpublished study of gabapentin in breast milk was found. Three reports of lamotrigine use during breastfeeding were found.


CONCLUSIONS
Available information remains limited to uncontrolled studies and case reports. Carbamazepine and valproate, but not lithium, have generally been considered compatible with breastfeeding. The overall paucity of data, data confounded by polypharmacy and infant age differences, and adverse reactions reported with all established mood stabilizers dictate a reassessment of these recommendations. We propose that a woman's historical response to medication and the clinical circumstances be the primary considerations when choosing a mood stabilizer during breastfeeding, rather than strict adherence to categorical assignments.
Chaudron
L H
LH
William S. Middleton Memorial Veterans Affairs Hospital and the University of Wisconsin Medical School, USA.
Jefferson
J W
JW
D000085:Acetates / Q000009:adverse effects / Q000097:blood / Q000627:therapeutic use; D000588:Amines; D000927:Anticonvulsants / Q000009:adverse effects* / Q000032:analysis / Q000627:therapeutic use; D001714:Bipolar Disorder / Q000097:blood / Q000188:drug therapy* / Q000517:prevention & control; D001942:Breast Feeding; D002220:Carbamazepine / Q000009:adverse effects / Q000097:blood / Q000627:therapeutic use; D003509:Cyclohexanecarboxylic Acids; D005260:Female; D000077206:Gabapentin; D006801:Humans; D007223:Infant; D007231:Infant, Newborn / Q000097:blood; D000077213:Lamotrigine; D008094:Lithium / Q000009:adverse effects* / Q000032:analysis / Q000627:therapeutic use; D016239:MEDLINE; D008895:Milk, Human / Q000737:chemistry; D011247:Pregnancy; D011248:Pregnancy Complications / Q000097:blood / Q000188:drug therapy*; D011644:Puerperal Disorders / Q000517:prevention & control; D014227:Triazines / Q000009:adverse effects / Q000097:blood / Q000627:therapeutic use; D014635:Valproic Acid / Q000009:adverse effects / Q000097:blood / Q000627:therapeutic use; D005680:gamma-Aminobutyric Acid
D000085:Acetates; D000588:Amines; D000927:Anticonvulsants; D003509:Cyclohexanecarboxylic Acids; D014227:Triazines; D002220:Carbamazepine; D005680:gamma-Aminobutyric Acid; D014635:Valproic Acid; D000077206:Gabapentin; D008094:Lithium; D000077213:Lamotrigine