From the Guidelines
Sertraline (Zoloft) is the preferred antidepressant for breastfeeding patients due to its minimal transfer into breast milk, with a relative infant dose of less than 10%. Several antidepressants are considered relatively safe for breastfeeding patients, with selective serotonin reuptake inhibitors (SSRIs) generally being the first-line options 1.
Key Considerations
- The benefits of treating maternal depression typically outweigh the minimal risks to the infant, as untreated depression can negatively impact both mother and child 1.
- Infants should be monitored for irritability, poor feeding, or sedation, though these effects are rare with most recommended medications.
- Paroxetine (Paxil) and fluoxetine (Prozac) are also considered acceptable, though fluoxetine has a longer half-life and may accumulate in infant serum over time 1.
- For patients who don't respond to SSRIs, venlafaxine (Effexor) or duloxetine (Cymbalta) may be appropriate alternatives 1.
- Bupropion (Wellbutrin) is generally considered compatible with breastfeeding but has less data than SSRIs.
- Tricyclic antidepressants like nortriptyline and desipramine can be used but require more monitoring.
Treatment Approach
- Typical dosing for sertraline starts at 25-50mg daily and gradually increases to 50-200mg daily as needed.
- The mother's previous positive response to a particular antidepressant should be considered when selecting treatment.
- A "start low, go slow" approach to antidepressant therapy is recommended, especially in older persons 1.
From the FDA Drug Label
Data from the published literature report the presence of escitalopram and desmethylescitalopram in human milk. There are reports of excessive sedation, restlessness, agitation, poor feeding and poor weight gain in infants exposed to escitalopram, through breast milk. A study of 8 nursing mothers on escitalopram with daily doses of 10-20 mg/day showed that exclusively breast-fed infants receive approximately 3.9% of the maternal weight-adjusted dose of escitalopram and 1.7% of the maternal weight-adjusted dose of desmethylcitalopram. Caution should be exercised and breastfeeding infants should be observed for adverse reactions when Escitalopram is administered to a nursing woman.
Safe antidepressant options for breastfeeding patients are not explicitly stated in the provided drug label. However, the label does provide information on the use of escitalopram in breastfeeding women, indicating that it is excreted in human breast milk and may cause adverse reactions in infants, such as excessive sedation, restlessness, and poor feeding.
- Key points to consider:
- Escitalopram is excreted in human breast milk
- Infants may be at risk for adverse reactions, such as excessive sedation and poor feeding
- Breastfeeding infants should be monitored for adverse reactions when the mother is taking escitalopram 2
From the Research
Safe Antidepressant Options for Breastfeeding Patients
- The following antidepressants are considered safe for breastfeeding patients:
- Other antidepressants may also be safe, but with more caution:
- Fluoxetine: may be allowed during continued treatment in the postpartum period, but with individual risk-benefit assessment 4
- Citalopram: may be allowed during continued treatment in the postpartum period, but with individual risk-benefit assessment 4
- Venlafaxine: may be used during breastfeeding, but with careful monitoring of the infant for adverse effects 4, 7
- Antidepressants to avoid during breastfeeding:
- Monoamine oxidase inhibitors (MAOIs): should generally be avoided 5
Key Considerations
- When using antidepressants during breastfeeding, it is essential to:
- Start with low doses and slowly increase the dose, with careful monitoring of the newborn for adverse effects 3
- Choose the lowest effective dose 3
- Avoid breastfeeding at the time when the antidepressant milk concentration is at its peak, if feasible 3
- Perform individual risk-benefit assessments for each patient 4, 5