What are safe antidepressant options for breastfeeding patients?

From the Guidelines

Sertraline (Zoloft) is the preferred antidepressant for breastfeeding patients due to its minimal transfer into breast milk, with typical doses ranging from 50-200 mg daily. Several antidepressants are considered relatively safe for breastfeeding patients, with selective serotonin reuptake inhibitors (SSRIs) generally being the first-line options 1. Other reasonable options include paroxetine (Paxil) at 20-50 mg daily, escitalopram (Lexapro) at 10-20 mg daily, and citalopram (Celexa) at 20-40 mg daily. Fluoxetine (Prozac) is also used but may accumulate in infant serum due to its longer half-life. The relative infant dose is a valuable guide to the safety of a drug taken by a breastfeeding woman, with a dose < 10% considered the preferred option 1. When starting antidepressants while breastfeeding, it's best to begin at a lower dose and gradually increase as needed while monitoring both mother and infant. Mothers should observe their infants for unusual irritability, poor feeding, or changes in sleep patterns. The benefits of treating maternal depression typically outweigh the minimal risks to the infant, as untreated depression can negatively impact mother-infant bonding and maternal care capabilities 1.

Some key points to consider when prescribing antidepressants to breastfeeding patients include:

• The mother's previous response to antidepressants, if applicable
• The potential for adverse effects in the infant, such as unusual irritability or changes in sleep patterns
• The need for close monitoring of both mother and infant
• The importance of treating maternal depression to prevent negative impacts on mother-infant bonding and maternal care capabilities.

In terms of specific medications, sertraline and paroxetine are considered to have lower concentrations in breast milk compared to other antidepressants 1. However, the choice of medication should be individualized based on the mother's specific needs and medical history.

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:
  • Sertraline: considered one of the safest antidepressants during breastfeeding 3, 4, 5, 6
  • Paroxetine: considered a suitable first-line agent for breastfeeding patients 4, 5, 6
• 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