Are benzodiazepines (BZDs) safe to use while breastfeeding?

Benzodiazepines While Breastfeeding

Short-acting benzodiazepines like midazolam can be safely used during breastfeeding, particularly for single-dose procedural sedation, while longer-acting agents like diazepam should be avoided for chronic use due to significant milk transfer and accumulation risks. 1

Preferred Benzodiazepines for Breastfeeding

Midazolam (Safest Option)

• Midazolam is the preferred benzodiazepine for breastfeeding mothers due to extensive first-pass metabolism resulting in low systemic bioavailability after oral doses, meaning blood levels in the infant after breastfeeding are expected to be very low. 1, 2
• Breastfeeding can be resumed immediately after a single dose of midazolam as soon as the woman has recovered from the procedure—no waiting period is required. 1, 2

Other Short-Acting Benzodiazepines

• Lorazepam and temazepam are acceptable alternatives as they are shorter-acting benzodiazepines compared to diazepam. 1
• Research data confirm that for most benzodiazepines, the milk-to-plasma (M/P) ratios remain <1 and the relative infant dose (RID) values are <10%, which is considered safe. 3
• Lorazepam specifically has been studied and shows low transfer to breast milk, though the FDA label notes it has been detected in human milk and cautions about potential sedation and inability to suckle in neonates. 4

Benzodiazepines to Avoid or Use With Extreme Caution

Diazepam (Avoid for Chronic Use)

• Diazepam should only be considered as a one-off dose before a procedure, not for ongoing therapy. 1
• Diazepam has an active metabolite (desmethyl-diazepam) with a prolonged half-life and is known to be transferred in breast milk in significant levels. 1
• The long elimination half-life increases risk of accumulation in the infant. 5, 6

Critical Safety Precautions

Infant Monitoring Requirements

• Monitor the infant closely for signs of sedation, unusual drowsiness, poor feeding, or respiratory depression when any benzodiazepine is used during breastfeeding. 1
• If concerning symptoms are observed, contact a medical professional immediately. 1, 2

Co-Sleeping Prohibition

• Mothers taking benzodiazepines should avoid co-sleeping with their infant as their natural responsiveness may be inhibited, increasing risk of infant harm. 1, 2

Dosing Principles

• Use the lowest effective dose for the shortest duration possible when benzodiazepines are necessary during breastfeeding. 1
• Single doses pose minimal risk compared to chronic administration, particularly with long-acting agents. 5, 6

Clinical Decision Algorithm

For procedural sedation: Use midazolam as first choice; resume breastfeeding immediately after recovery. 1, 2

For short-term anxiety/insomnia (single doses): Midazolam, lorazepam, or temazepam are acceptable; avoid diazepam. 1

For chronic therapy: Strongly reconsider the need for benzodiazepines; if unavoidable, use shortest-acting agent at lowest dose with close infant monitoring, or consider discontinuing breastfeeding depending on severity of maternal condition. 5, 6

Important Caveats

• The FDA labels for temazepam and lorazepam state that caution should be exercised or that these drugs should not be administered to nursing women, reflecting conservative regulatory positions. 7, 4
• However, clinical guidelines based on pharmacokinetic data support judicious use of short-acting benzodiazepines, particularly for single doses. 1
• This represents a divergence between FDA labeling (which is cautious) and clinical practice guidelines (which are more permissive for short-acting agents). 1, 7, 4
• The general principle is that drug exposure through breast milk is small for most benzodiazepines, and maternal treatment can be compatible with breastfeeding when appropriate agents are selected. 3, 8