Wellbutrin (Bupropion) Safety in Breastfeeding with Cyclothymia
Bupropion can be used cautiously during breastfeeding for cyclothymia, but the infant must be monitored carefully for seizures, vomiting, diarrhea, jitteriness, and sedation, as there have been 2 case reports of seizures in breastfed infants despite generally low drug transfer into breast milk. 1
Evidence for Breastfeeding Safety
Drug Transfer and Infant Exposure
- Bupropion is present in human milk and has been detected in infant serum, though typically at very low or sometimes undetectable levels 1, 2
- In a lactation study of 10 women, the average daily infant exposure (assuming 150 mL/kg daily consumption) was only 2% of the maternal weight-adjusted dose 2
- Two separate studies found no quantifiable serum levels of bupropion or hydroxybupropion in breastfed infants at steady state 3
Adverse Events in Breastfed Infants
- Critical concern: Despite low transfer, there have been 2 case reports of seizures in breastfed infants whose mothers were taking bupropion 1, 2
- One documented case involved a 6.5-month-old infant who presented with severe emesis and tonic seizure-like symptoms; the infant had detectable bupropion in urine and serum at concentrations lower than therapeutic adult ranges, suggesting infants may have higher susceptibility to epileptogenic effects 4
- The FDA label notes that postmarketing reports have described seizures in breastfed infants, though the relationship to bupropion exposure remains unclear 2
- Most cases (21 total documented) showed no adverse events 1
Specific Considerations for Cyclothymia
Treatment Appropriateness
- For cyclothymic depression (a soft bipolar spectrum disorder), bupropion appears beneficial and should preferably be used in conjunction with lithium or other mood stabilizers such as valproate 5
- Bupropion is particularly relevant for cyclothymic patients as it carries lower risk of inducing rapid cycling compared to tricyclic antidepressants 5
Clinical Monitoring Protocol
The American Academy of Pediatrics recommends maintaining the therapeutic dose while breastfeeding, with careful infant monitoring for: 1
- Seizures (highest priority given case reports)
- Vomiting
- Diarrhea
- Jitteriness
- Sedation
- Appropriate weight gain and developmental milestones 6
Risk-Benefit Framework
When to Consider Use
- The developmental and health benefits of breastfeeding should be weighed against the mother's clinical need for bupropion and potential infant risks 2
- Untreated cyclothymia/depression poses its own risks, including negative impact on infant emotional development 7
Caution Advised
- Overall recommendation from guidelines: caution is advised during breastfeeding based on very limited data (21 cases) 1
- The seizure risk, while rare, represents a serious potential adverse outcome that cannot be dismissed 4, 8
Practical Management Algorithm
- If bupropion is clinically necessary: Maintain therapeutic dose (do not reduce, as this may compromise maternal mental health) 1
- Add mood stabilizer: Consider lithium or valproate co-administration for cyclothymic depression 5
- Implement intensive monitoring: Watch infant closely for any neurological symptoms, particularly in first 6 months 1, 4
- Educate mother: Ensure she understands warning signs requiring immediate medical attention (seizure activity, excessive sedation, poor feeding) 1
- Document baseline: Establish infant's normal behavior patterns to detect changes 6