Lorazepam and oxazepam are the preferred benzodiazepines during breast feeding, if clinically appropriate. Recommendations apply to full term, healthy infants.
This article includes the most commonly used benzodiazepines. Other benzodiazepines are available, and may need to be used for more specialist situations. Contact our specialist service for further advice.
Recommendations
Using benzodiazepines in breastfeeding should be approached with caution, and the lowest effective doses should be used.
Shorter acting agents, such as lorazepam and oxazepam, are preferred, where this is clinically appropriate.
However, choice should primarily be directed at adequately treating the condition first, with safety in breastfeeding a secondary consideration.
Benzodiazepines should be used with caution for anxiety and sleeping disorders in breastfeeding. They generally have long half-lives and could potentially accumulate in the breastfed infant following prolonged administration, leading to possible sedation and increased risk of apnoea.
Where possible use short-term, intermittent dosing to reduce infant exposure.
The ‘z’ drugs, such as zopiclone and zolpidem are preferred for sleeping disorders as they have shorter half-lives and appear to pass into the breast milk in small amounts.
Withdrawal effects may occur in infants if a mother suddenly stops breastfeeding.
Premedication
Benzodiazepines are used for premedication and for conscious sedation during surgery. Following short-term therapy (1-2 doses) for these indications, breastfeeding can be resumed as soon as the mother has recovered sufficiently from the procedure.
Epilepsy
Benzodiazepines are also used for epilepsy. Choice will depend on the clinical condition and should primarily be based on suitability for the patient rather than safety during breastfeeding.
Combination therapy may pose an increased risk to the infant, especially when adverse effects such as drowsiness are additive.
Withdrawal effects may occur in infants if a mother suddenly stops breastfeeding.
Specific recommendations
Preferred choice
Lorazepam can be used with caution during breastfeeding, but infant monitoring is still required.
Infant monitoring
As a precaution, monitor the infant closely for drowsiness, slowed breathing rate, poor feeding (including not waking to feed) and adequate weight gain.
Further information
There is limited published evidence of use in breastfeeding which shows very small amounts are found in breast milk.
Lorazepam is a preferred choice because it is a shorter acting benzodiazepine, and therefore there is less risk of accumulation in the infant.
Preferred choice
Oxazepam can be used with caution during breastfeeding, but infant monitoring is still required.
Infant monitoring
As a precaution, monitor the infant closely for drowsiness, slowed breathing rate poor feeding (including not waking to feed) and adequate weight gain.
Further information
There is limited published evidence of use in breastfeeding which shows very small amounts are found in breast milk. Oxazepam is a preferred choice because it is a shorter acting benzodiazepine. It is also the least lipid soluble, which accounts for its low levels in milk.
Use with caution
Diazepam (orally, rectally or parenterally) can be used with caution during breastfeeding, but infant monitoring is still required.
Infant monitoring
As a precaution, monitor the infant closely for drowsiness, slowed breathing rate poor feeding (including not waking to feed) and adequate weight gain.
Further information
There is limited published evidence of use in breastfeeding. Diazepam passes into breast milk in variable amounts, but these are usually small.
The long half-life of diazepam and its active metabolites increases the risk of accumulation in breastfed infants. Adverse effects reported include sedation and poor feeding and weight loss.
Long term use should be avoided during breastfeeding if possible. Short-term therapy (1-2 doses) is not considered to pose a significant risk to the infant.
Use with caution
Clobazam can be used with caution during breastfeeding, but infant monitoring is still required.
Infant monitoring
As a precaution, monitor the infant closely for drowsiness, slowed breathing rate poor feeding (including not waking to feed), and adequate weight gain.
Further information
There is very limited published evidence of use in breastfeeding which shows it is excreted in milk in small amounts.
The long half-life increases the risk of accumulation in breastfed infants. Long term use should be avoided during breastfeeding if possible.
Use with caution
Clonazepam can be used with caution during breastfeeding, but infant monitoring is still required.
Infant monitoring
As a precaution, monitor the infant closely for drowsiness, slowed breathing rate poor feeding (including not waking to feed), and adequate weight gain.
Further information
There is limited published evidence of use during breastfeeding, which shows it is excreted in milk in small amounts.
The long half-life increases the risk of accumulation in breastfed infants. Apnoea and cyanosis have been reported in one infant, and decreased weight in another; both infants were exposed to clonazepam during both pregnancy and breastfeeding. Adverse effects, or detectable serum levels, have not been reported in other infants exposed via breast milk only
Long term use should be avoided during breastfeeding if possible.
Use with caution
Midazolam can be used with caution during breastfeeding but infant monitoring is still required.
Infant monitoring
As a precaution, monitor the infant closely for drowsiness, slowed breathing rate poor feeding (including not waking to feed), and adequate weight gain.
Further information
There is limited published evidence of use in breastfeeding which shows very small amounts are found in breast milk.
Midazolam is used for short-term indications only, has a very short half-life, and therefore is considered not to pose a significant risk to the infant.
Use with caution
Nitrazepam can be used with caution during breastfeeding, but infant monitoring is still required. Zopiclone or zolpidem are suitable alternatives for sleeping disorders.
Infant monitoring
Monitor the infant closely for drowsiness, slowed breathing rate, poor feeding (including not waking to feed) and adequate weight gain.
Further information
There is limited published evidence of use during breastfeeding which shows very small amounts are found in breast milk.
The long half-life increases the risk of accumulation in breastfed infants. Long term use should be avoided during breastfeeding if possible.
Use with caution
Temazepam can be used with caution during breastfeeding, but infant monitoring is still required.
Infant monitoring
Monitor the infant closely for drowsiness, slowed breathing rate, poor feeding (including not waking to feed) and adequate weight gain.
Further information
There is limited published evidence of use during breastfeeding which shows very small amounts are found in in breast milk.
Temazepam has a moderate half-life compared to other benzodiazepines. However, there is still some risk of accumulation in breastfed infants. Long term use should be avoided during breastfeeding if possible.
Patient Information
The NHS website provides advice for patients on the use of specific medicines in breastfeeding.
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.