I believe that paroxetine should be of little concern during
breastfeeding.  It is highly protein bound, and has a very large
volume of distribution, so that less than 1% of the total amount in
the mother's body is actually in her circulation.  Thus very little is
available for excretion into the milk.  This very characteristic
(large volume of distribution) which makes it a good choice for
breastfeeding mothers actually makes it more of a concern during
pregnancy.

Bromazepam is probably not one of the best benzodiazepines for the
nursing mother as it has a long half life.  Another with a shorter
half life would be a better choice, though because benzodiazepines
have a longer half life in the young baby, the best approach may be to
avoid its use for at least a month.  However, the baby having received
it in utero may have developed liver enzymes to metabolize it more
rapidly.  Furthermore, benzodiazepines are used in very large doses in
premature babies.

This brings up the question of "If it is safe during pregnancy, is it
safe during lactation?"  The answer needs clarification.  With
psychoactive drugs, we are concerned about their effects on the
developing brain.  Thus, the argument that the mother is metabolizing
the drug for the fetus, actually does not hold, because the baby is
being affected, and it is not just accumulation which is the concern.

Why does the physician think it is okay to use these drugs during the
pregnancy?

Jack Newman, MD, FRCPC