What sleep medicines are safe to use while breastfeeding?

Safe Sleep Medicines for Breastfeeding Mothers

Short-acting benzodiazepines like midazolam and non-sedating analgesics like paracetamol (acetaminophen) are the safest sleep aids for breastfeeding mothers, while diphenhydramine and doxylamine should be used with caution, and tramadol and oxycodone require careful monitoring of the infant for drowsiness. 1, 2

First-Line Options for Sleep in Breastfeeding Mothers

Non-Pharmacological Approaches (Preferred)

• Improve sleep hygiene practices
• Maintain consistent sleep schedule
• Create a comfortable sleep environment
• Practice relaxation techniques before bedtime
• Consider room-sharing without bed-sharing with infant 2

Safe Pharmacological Options

1. Midazolam (short-acting benzodiazepine)

   • Extensive first-pass metabolism results in low systemic bioavailability
   • Blood levels in infant after breastfeeding expected to be low
   • Breastfeeding can be resumed after a single dose as soon as mother has recovered 1

2. Paracetamol/Acetaminophen

   • Amount transferred to breast milk is significantly less than pediatric therapeutic dose
   • Has been used extensively during lactation
   • Safe for both short-term and long-term use 1

Second-Line Options (Use with Caution)

1. Diphenhydramine (Benadryl)

   • FDA label warns to consult healthcare professional before use while breastfeeding
   • Can cause marked drowsiness in mother
   • May cause infant irritability or sedation
   • Avoid alcohol and other sedatives when using 3

2. Doxylamine

   • FDA label recommends consulting healthcare professional before use
   • Take only at bedtime
   • Avoid alcoholic beverages 4

3. Melatonin

   • Limited but growing evidence suggests probable safety during breastfeeding
   • Clinical studies to date have not suggested major safety concerns
   • More research needed specifically for sleep disorders 5

Medications to Use with Extra Caution

1. Diazepam (Valium)

   • Has active metabolite (desmethyl-diazepam) with prolonged half-life
   • Known to be transferred in breast milk in significant levels
   • Consider only as one-off dose before a procedure
   • Not recommended for regular use as sleep aid 1

2. Tramadol

   • Observe infant for unusual drowsiness
   • FDA warning against use while breastfeeding, though UK guidelines allow cautious use
   • Restrict to inpatient use and limit total dose 1

3. Oxycodone

   • Greater risk of drowsiness in doses > 40 mg/day
   • Multiple reports of sedation, respiratory depression, and feeding difficulties in infants
   • Avoid repeated dosing 1

Important Safety Precautions

• Never co-sleep with infant after taking any sedative medication - significantly increases SIDS risk 2
• Monitor infant for signs of:
  • Unusual drowsiness
  • Poor feeding
  • Respiratory depression
  • Decreased alertness 1, 2
• If mother falls asleep while breastfeeding after taking sleep medication, infant should be placed on separate sleep surface immediately upon waking 2
• Avoid alcohol consumption during breastfeeding - increases SIDS risk and may impair maternal alertness 2

Clinical Decision Algorithm

1. First attempt non-pharmacological approaches
2. If medication needed:
   • For occasional use: Midazolam (single dose) or paracetamol
   • For short-term use with minimal sedation: Melatonin (with caution)
   • For antihistamine effect with sleep benefit: Diphenhydramine (with monitoring)
3. Avoid or use extreme caution with:
   • Long-acting benzodiazepines
   • Opioids (especially repeated doses)
   • Any medication combined with alcohol

Common Pitfalls to Avoid

• Overly restrictive advice - most medications can be used safely during breastfeeding at recommended doses 6, 7
• Unnecessarily discontinuing breastfeeding - medication use is one of the most common reasons for cessation of breastfeeding 7
• Failing to monitor infant - always observe for signs of sedation after using any potentially sedating medication 1
• Bed-sharing after sedative use - significantly increases risk of SIDS 2
• Assuming all medications in a class have similar safety profiles - individual drugs within classes may have different safety profiles 8