General considerations

It is important to complete an individual risk assessment for your patient and to apply the principles of prescribing in breastfeeding when looking at the available information and making treatment decisions.

This article includes the most commonly used medicines for insomnia. Other medicines are available for other sleep disorders and may need to be used for more specialist situations. Contact our specialist service for further advice.

Recommendations

The cause of the insomnia should be identified before a medicine is prescribed and, where possible, underlying factors should be treated. Good sleep hygiene should be established to raise awareness of behavioural, environmental and temporal factors that may be detrimental or beneficial to sleep.

Any decision to treat a sleep disorder with medication needs to be carefully considered, taking into account the usual sleep deprivation associated with a newborn infant.

Many different types of medicine can be used to treat insomnia in breastfeeding. This includes the benzodiazepines and antihistamines such as promethazine.

However, the ‘z- drugs’ (zolpidem and zopiclone) are preferred for the short-term management of insomnia during breastfeeding, as they have shorter half-lives than the benzodiazepines and appear to pass into breast milk in small amounts.

Melatonin can also be used in breastfeeding with caution.

Clinical considerations

The use of medicines to treat insomnia during breastfeeding should be approached with caution. Where possible use short-term, intermittent dosing, and the lowest effective dose to reduce infant exposure.

Monitor the infant closely for side effects, such as drowsiness. This may present as not waking up to feed/falling asleep whilst feeding, which may affect weight gain.

The National Institute for Healthcare Excellence (NICE) advises avoiding sharing a bed with the infant when sedating medication has been used, due to the increased risk of sudden unexpected death in infancy.

Specific recommendations

Patient Information

The NHS website provides advice for patients on the use of specific medicines in breastfeeding.

Contact us

Get in touch with the UK Drugs In Lactation Advisory Service (UKDILAS), our specialist breastfeeding medicines advice service if you need support in the following situations:

• you need further advice
• the medicine in question is not included here
• the infant is unwell or premature
• multiple medicines are being taken

About our recommendations

Recommendations are based on published evidence where available. However, evidence is generally very poor and limited, and can require professional interpretation. Assessments are often based on reviewing case reports which can be conflicting and lack detail.

If there is no published clinical evidence, assessments are based on: pharmacodynamic and pharmacokinetic principles, extrapolation from similar drugs, risk assessment of normal clinical use, expert advice, and unpublished data. Simulated data is now increasingly being used due to the ethical difficulties around gathering good quality evidence in this area.

Bibliography

Full referencing is available on request.