What anti-anxiety medications, such as selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines, are safe for breastfeeding mothers?

Safe Anti-Anxiety Medications During Breastfeeding

Paroxetine (Paxil) and sertraline (Zoloft) are the safest SSRIs for breastfeeding mothers with anxiety, as they have minimal excretion in breast milk and pose the lowest risk to infants. 1, 2

First-Line Options for Breastfeeding Mothers

SSRIs (Selective Serotonin Reuptake Inhibitors)

1. Paroxetine (Paxil)

   • Consistently shows low infant-to-maternal plasma concentration ratios (<0.10) 1
   • Minimal excretion in breast milk 2, 3
   • Considered a first-line agent for breastfeeding mothers 2
   • FDA label notes it's secreted in human milk, but clinical data supports its safety 4

2. Sertraline (Zoloft)

   • Produces very low or undetectable plasma concentrations in nursing infants 2
   • Recommended as a first-line agent for breastfeeding mothers 2, 5
   • Should be started at low doses with gradual increases 6
   • Most studies show infant exposure <10% of maternal dose 1

Second-Line Options (Use with Caution)

1. Fluvoxamine

   • Low relative infant dose 3
   • Minimal excretion into breast milk 3
   • Less data available compared to paroxetine and sertraline

2. Short-acting benzodiazepines (for short-term use only)

   • Midazolam: Extensive first-pass metabolism results in low bioavailability; breastfeeding can resume after a single dose 1, 7
   • Lorazepam: Shorter-acting than diazepam, making it preferable for limited use 1

Medications to Avoid or Use with Extreme Caution

1. Fluoxetine (Prozac)

   • Higher infant exposure compared to other SSRIs 2, 3
   • Longer half-life increases risk of accumulation 3
   • Adverse effects reported in some infants 2, 8

2. Citalopram (Celexa)

   • Higher excretion into breast milk compared to paroxetine and sertraline 3
   • Higher infant plasma levels reported 2
   • Suspected adverse effects reported in some infants 2

3. Diazepam (Valium)

   • Has an active metabolite with prolonged half-life 1
   • Known to transfer in breast milk in significant levels 1
   • Should only be considered as a one-off dose, not for regular use 1

Monitoring and Precautions

• Monitor infants for signs of drug exposure:

  • Irritability, poor feeding, sleep disturbance, tremors, jitteriness 1
  • Drowsiness, decreased alertness, respiratory depression 1

• Timing considerations:

  • When feasible, breastfeed when medication concentration in milk is lowest (typically before taking the next dose) 6

• Dosing recommendations:

  • Start with low doses and increase slowly 6
  • Use the lowest effective dose 6

Important Caveats

1. Benefits vs. Risks: The benefits of treating maternal anxiety often outweigh the potential risks to the infant, as untreated maternal depression/anxiety can negatively impact infant development 2

2. Continuation of Pre-existing Treatment: If a woman was already on an effective antidepressant during pregnancy, continuing the same medication during breastfeeding is often preferable to switching 6, 2

3. Special Populations: Extra caution is needed for premature infants or those with low birth weight, as they may be more susceptible to medication effects 6

4. Individual Assessment: While paroxetine and sertraline are generally recommended as first-line agents, individual factors such as prior response to medication should be considered 2

By following these guidelines and closely monitoring both mother and infant, anxiety can be effectively treated while maintaining the benefits of breastfeeding.