Is escitalopram (selective serotonin reuptake inhibitor) safe to use during breastfeeding?

Safety of Escitalopram During Breastfeeding

Escitalopram is considered safe to use during breastfeeding, with minimal transfer to breast milk and low risk of adverse effects in breastfed infants. 1

Transfer into Breast Milk and Infant Exposure

• Escitalopram is excreted in human breast milk with a milk-to-plasma ratio of approximately 2.2 1
• Studies show 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 desmethylescitalopram (the active metabolite) 2
• The total relative infant dose for escitalopram plus its demethyl metabolite is approximately 5.3% of the maternal dose (as escitalopram equivalents), which is below the generally accepted 10% threshold for medication safety during breastfeeding 1
• Infant plasma concentrations are typically very low or undetectable (below 3 μg/L) compared to maternal plasma concentrations (around 24 μg/L) 1

Clinical Considerations and Monitoring

• Infants exposed to escitalopram through breast milk should be monitored for:

  • Excessive sedation or somnolence 2
  • Restlessness or agitation 2
  • Poor feeding 2
  • Poor weight gain 2

• In most studies, breastfed infants whose mothers were taking escitalopram showed normal development with no adverse effects 1, 3

• There have been rare reports of excessive somnolence, decreased feeding, and weight loss in infants breastfed by mothers taking racemic citalopram (which contains escitalopram) 2

Practical Recommendations

• If adverse effects are observed in the infant:

  • Consider reducing the maternal dose to the lowest effective dose 4
  • Consider timing breastfeeding to avoid the drug absorption phase (typically 4-8 hours after maternal dose) 4
  • In some cases, replacing 1-2 breastfeedings with formula during peak maternal drug concentrations may help reduce infant exposure 4

• Escitalopram may be preferred over racemic citalopram for breastfeeding mothers requiring an SSRI antidepressant, as the absolute infant dose is lower 1

Comparative Safety Among Antidepressants

• Several antidepressants have been studied during breastfeeding, with amitriptyline, nortriptyline, desipramine, clomipramine, and sertraline also showing favorable safety profiles 5

• The decision to use escitalopram during breastfeeding should consider:

  • The importance of treating maternal depression 6
  • The benefits of breastfeeding for both mother and infant 2
  • The potential risks of untreated maternal depression 6

Summary

• The available evidence supports escitalopram as a safe option during breastfeeding 1, 3
• The benefits of treating maternal depression while maintaining breastfeeding generally outweigh the minimal risks of infant exposure to escitalopram 6
• Regular monitoring of the infant for any adverse effects is recommended, particularly in younger infants 2