Is it safe to take Cipralex (escitalopram) while breastfeeding?

Escitalopram (Cipralex) and Breastfeeding

Escitalopram (Cipralex) can be used during breastfeeding with appropriate monitoring of the infant for potential side effects, as the benefits of breastfeeding generally outweigh the minimal risks of medication exposure.

Safety Profile in Breastfeeding

Escitalopram passes into breast milk in small amounts, with studies showing that:

• Exclusively breastfed infants receive approximately 3.9% of the maternal weight-adjusted dose of escitalopram and 1.7% of the maternal weight-adjusted dose of desmethylcitalopram (the metabolite) 1
• The FDA drug label acknowledges the presence of escitalopram in human milk but notes that the developmental and health benefits of breastfeeding should be considered alongside the mother's clinical need for the medication 1

Potential Infant Side Effects

While escitalopram is generally considered compatible with breastfeeding, there have been some reports of adverse effects in breastfed infants:

• Excessive sedation/somnolence
• Restlessness and agitation
• Poor feeding and weight gain
• Uneasy sleep 1, 2

In one case report, an infant whose mother was taking 40 mg/day of citalopram (the racemic form of escitalopram) experienced uneasy sleep. The symptoms normalized when the maternal dose was halved and two breastfeedings were replaced with formula 2.

Recommendations for Breastfeeding Mothers on Escitalopram

1. Monitoring:

   • Observe the infant for excessive sedation, restlessness, agitation, poor feeding, and poor weight gain 1
   • Regular weight monitoring is recommended, especially in younger infants

2. Dosing considerations:

   • Use the lowest effective dose possible 2
   • Consider timing medication intake immediately after breastfeeding or before the infant's longest sleep period to minimize exposure

3. Special precautions:

   • Extra caution should be taken with infants less than 6 weeks of age due to their immature hepatic and renal function
   • Older infants (>6 months) have more mature metabolism and are at lower risk for adverse effects

Risk-Benefit Assessment

When considering escitalopram during breastfeeding:

• The benefits of maternal mental health treatment are substantial for both mother and infant
• Untreated maternal depression can negatively impact mother-infant bonding and infant development
• The amount of escitalopram transferred to breast milk is relatively small
• Most infants tolerate maternal use of escitalopram without adverse effects

Practical Strategies to Minimize Infant Exposure

• Take medication immediately after breastfeeding to maximize clearance time before the next feeding
• Monitor infant for any changes in behavior, sleep patterns, or feeding
• If side effects occur, consider:
  1. Reducing the maternal dose if clinically appropriate
  2. Timing medication to avoid peak concentrations during feeding
  3. In severe cases, temporarily replacing some breastfeedings with formula

Conclusion

While escitalopram does pass into breast milk in small amounts, it is generally considered compatible with breastfeeding. The benefits of treating maternal depression typically outweigh the minimal risks to the breastfed infant. Close monitoring of the infant for potential side effects is recommended, and adjustments to dosing or feeding schedules can be made if concerns arise.