Is escitalopram (Lexapro) safe during breastfeeding?

From the Guidelines

Escitalopram (Lexapro) is generally considered safe during breastfeeding, with minimal exposure to the infant and rare adverse effects. Only small amounts of the medication pass into breast milk, typically less than 10% of the maternal dose, resulting in minimal exposure to the infant 1. Most breastfed infants whose mothers take escitalopram show no adverse effects. The typical adult dose ranges from 10-20 mg daily, and no dosage adjustment is needed specifically for breastfeeding mothers. If you're breastfeeding while taking escitalopram, monitor your baby for unusual drowsiness, feeding difficulties, or irritability, though these effects are rare.

Key Considerations

• The benefits of treating maternal depression or anxiety often outweigh the minimal risks to the breastfed infant, as untreated maternal mental health conditions can negatively impact infant development and the mother-child relationship 1.
• There is little evidence to support any causal link between antidepressant use in breastfeeding mothers and adverse effects in infants 1.
• Potential adverse effects in infants exposed to SSRIs via breast milk have been documented only in case reports and are recorded more often after exposure to fluoxetine and citalopram than other drugs 1.

Recommendations

• If you're concerned about taking escitalopram while breastfeeding, discuss with your healthcare provider, but in most cases, continuing both the medication and breastfeeding is the recommended approach.
• Clinicians should be aware that infants are at risk for manifesting clinical signs of drug toxicity or withdrawal over the first week of life and arrange for early follow-up after the initial hospital discharge 1.

From the FDA Drug Label

Data from the published literature report the presence of escitalopram and desmethylescitalopram in human milk (see Data). 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.

Escitalopram use during breastfeeding is not entirely safe. Infants exposed to escitalopram through breast milk may experience adverse reactions such as excessive sedation, restlessness, agitation, poor feeding, and poor weight gain.

• Key points to consider:
  • Escitalopram is excreted in human breast milk.
  • Breastfeeding infants should be monitored for adverse reactions.
  • The developmental and health benefits of breastfeeding should be weighed against the potential risks to the infant. 2

From the Research

Escitalopram and Breastfeeding

• Escitalopram is considered one of the most effective selective serotonin reuptake inhibitors for the treatment of major depression 3, 4.
• The available data seem to support the notion that escitalopram might be considered safe during breastfeeding, with no adverse effects reported in several studies 3, 4, 5, 6.
• A study found that the absolute infant dose of escitalopram via breast milk was 7.6 microg kg(-1) day(-1), and the total relative infant dose for escitalopram plus its demethyl metabolite was 5.3% as escitalopram equivalents, indicating a low risk of adverse effects in infants 6.
• Another study reported that two infants exposed to escitalopram during breastfeeding did not show any health problems, and all infants had met normal developmental milestones 5.
• However, it is essential to note that the amount of escitalopram passed to breast milk and delivered to the child correlates to the serum concentration of the mother, and the lowest possible effective serum concentration should be used 7.

Key Findings

• No major malformations or miscarriages were reported in studies examining the safety of escitalopram during pregnancy and breastfeeding 3, 4, 5.
• Mild withdrawal syndrome was reported in one newborn who was also exposed to a benzodiazepine, but not in infants exposed to escitalopram alone 5.
• The transfer of escitalopram and its metabolite into breast milk is relatively low, with a milk/plasma ratio of 2.2 for both escitalopram and demethylescitalopram 6.

Studies

• A comprehensive review of the available literature on the safety profile of escitalopram during pregnancy and breastfeeding found no adverse effects in the few studies evaluating its safety during breastfeeding 3.
• A case series reported maternal and neonatal outcomes in pregnant women treated with escitalopram during pregnancy and breastfeeding, with no major malformations or miscarriages reported 5.
• A study examining the transfer of escitalopram and its metabolite into breast milk found that the absolute infant dose was low, and no adverse effects were seen in the breastfed infants 6.