Is it safe to use lorazepam and escitalopram (selective serotonin reuptake inhibitor (SSRI)) in breastfeeding mothers?

Safety of Lorazepam and Escitalopram During Breastfeeding

Both lorazepam and escitalopram can be used during breastfeeding with appropriate monitoring, though lorazepam should be used with more caution and for short-term use only.

Lorazepam in Breastfeeding

Lorazepam is a shorter-acting benzodiazepine compared to diazepam and can be considered for breastfeeding mothers when necessary 1. However, several important considerations should guide its use:

• Transfer to breast milk: Studies show that benzodiazepines, including lorazepam, have milk to plasma (M/P) ratios <1 and relative infant doses (RID) <10%, which are generally considered safe levels 2.

• Duration of use: Lorazepam should be used for short-term purposes only, not as a long-term medication during breastfeeding.

• Monitoring: Infants should be carefully observed for:

  • Sedation
  • Respiratory depression
  • Poor feeding
  • Weight loss
  • Decreased alertness

• Timing considerations: If possible, breastfeeding should be timed to avoid peak maternal serum drug concentration.

Cautions with Lorazepam

• Infants of mothers who have received benzodiazepines may experience withdrawal symptoms if the mother used benzodiazepines for several weeks before delivery 3.
• Sedation and inability to suckle have been reported in breastfed infants whose mothers were taking benzodiazepines 3.
• The FDA drug label notes that lorazepam has been detected in human breast milk and recommends careful consideration of risks versus benefits 3.

Escitalopram in Breastfeeding

Escitalopram transfers into breast milk but generally at low levels that are considered acceptable for most breastfeeding situations:

• Transfer to breast milk: Studies show that exclusively breastfed infants receive approximately 3.9% of the maternal weight-adjusted dose of escitalopram and 1.7% of desmethylescitalopram (its metabolite) 4.

• Monitoring: Infants should be monitored for:

  • Excessive sedation
  • Restlessness
  • Agitation
  • Poor feeding
  • Poor weight gain 4

• Safety profile: While there have been reports of excessive sedation, restlessness, and poor feeding in some infants, these adverse effects appear to be relatively uncommon.

Clinical Decision Algorithm

1. Assess maternal need: Determine if medication is clearly indicated for the mother's condition

2. For lorazepam:

   • Use only for short-term purposes (single doses or brief courses)
   • Start with the lowest effective dose
   • Consider alternative non-benzodiazepine options when possible
   • Time administration to minimize infant exposure (e.g., after breastfeeding)

3. For escitalopram:

   • Can be used for longer-term treatment if needed
   • Start with low doses and titrate slowly
   • Monitor infant carefully, especially if premature or low birth weight

4. Infant monitoring protocol:

   • Regular assessment of alertness, feeding patterns, and weight gain
   • Increased vigilance for premature infants or those with other risk factors
   • Consider discontinuation or medication change if adverse effects appear

Special Considerations

• Risk stratification: Increased vigilance is required for high-risk situations including:

  • Premature infants
  • Low birth weight infants
  • Infants with existing medical conditions
  • Mothers taking multiple medications

• Safe sleep practices: When the mother is taking medications that may affect alertness, the infant should be placed in a bassinet or with another alert support person when the mother wants to sleep 5.

• Avoid bed-sharing: The American Academy of Pediatrics recommends room-sharing without bed-sharing, especially when mothers are taking medications that may affect alertness 5.

By following these guidelines, the benefits of breastfeeding can usually be maintained while minimizing risks associated with maternal medication use.