Ketamine and esketamine during breastfeeding: a systematic review of human pharmacokinetic, infant and lactation outcomes.
Miriam Olivola, Vassilis Martiadis, Tiziano Prodi et al.
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In 30 seconds
This systematic review synthesised human evidence on ketamine and esketamine transfer into breast milk, infant exposure and outcomes, and breastfeeding outcomes after postpartum exposure. Sixteen reports were included; pooling was not undertaken because studies were not comparable. Three reports measured milk pharmacokinetics in nine participants exposed to racemic ketamine. Relative infant doses were 0.34% to 0.77% for ketamine and 0.29% to 0.95% for norketamine. No study measured infant plasma concentrations or long-term neurodevelopment, and repeated intranasal esketamine exposure was not quantified.
Key findings
- Across three reports involving nine participants, ketamine relative infant doses ranged from 0.34% to 0.77%, and norketamine from 0.29% to 0.95%.
- No included study measured infant plasma concentrations or long-term neurodevelopment.
- Perioperative studies showed no consistent adverse breastfeeding signal, but these secondary outcomes did not assess infant exposure.
- No study quantified exposure during repeated intranasal esketamine.
Why it matters
The review provides a human evidence base for considering milk transfer after single or intermittent racemic ketamine exposure, while making clear that low measured relative infant doses do not establish infant systemic exposure or safety. Distinguishing these questions is important when interpreting evidence for postpartum use, particularly because chronic treatment and repeated intranasal esketamine remain unaddressed.
What to keep in mind
Milk pharmacokinetic evidence came from only nine participants. No study measured infant plasma concentrations or long-term neurodevelopment, and repeated intranasal esketamine and chronic treatment were not covered.