Safety of Tricyclic Antidepressants During Breastfeeding
Tricyclic antidepressants (TCAs) such as amitriptyline, nortriptyline, desipramine, and clomipramine are generally safe to use during breastfeeding as they are not found in quantifiable amounts in nursing infants and no adverse effects have been reported.
Evidence for Safety of TCAs During Breastfeeding
- Several TCAs have been studied in breastfeeding mothers and are considered preferred options:
- Amitriptyline, nortriptyline, desipramine, and clomipramine were not found in quantifiable amounts in nursing infants 1
- No adverse effects were reported in infants exposed to these medications through breast milk 1
- Infants older than 10 weeks appear to be at particularly low risk for adverse effects from TCAs 1
Specific TCA Recommendations
- Nortriptyline and amitriptyline are considered drugs of choice for breastfeeding women based on safety data 1
- These medications do not accumulate in infant serum, making them safer options 1
- While the FDA label for nortriptyline states that "safe use during lactation has not been established" 2, this reflects a lack of controlled trials rather than evidence of harm
Precautions and Monitoring
Monitor breastfed infants for:
- Sedation
- Poor feeding
- Irritability
- Weight gain issues
- Developmental milestones
Avoid doxepin during breastfeeding as adverse effects have been reported in young infants 1
Risk-Benefit Assessment
- The benefits of treating maternal depression often outweigh the minimal risks to the infant from TCA exposure through breast milk 3
- Untreated maternal depression can negatively impact:
- Mother-infant bonding
- Infant development
- Breastfeeding success
Practical Recommendations
- Select TCAs with established safety profiles (nortriptyline, amitriptyline, desipramine, clomipramine)
- Use the lowest effective dose
- Take medication immediately after breastfeeding to maximize clearance time before the next feeding 4
- Consider the age of the infant (younger infants under 6 weeks require more caution due to immature hepatic metabolism) 4
- Monitor the infant for any unusual symptoms
Alternative Options
- If TCAs are not suitable, SSRIs like paroxetine and sertraline are considered suitable first-line agents during breastfeeding 3
- Some concern exists for fluoxetine, citalopram, and venlafaxine, though they may be continued if the mother was already taking them during pregnancy 3
In conclusion, while any medication use during breastfeeding requires careful consideration, TCAs (particularly nortriptyline, amitriptyline, desipramine, and clomipramine) have established safety profiles that make them appropriate choices for treating depression in breastfeeding mothers.