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

Sertraline Safety During Breastfeeding

Sertraline is one of the safest antidepressants for use during breastfeeding and is generally recommended when antidepressant therapy is needed for a breastfeeding mother. 1

Safety Profile

• Sertraline transfers into breast milk in very small amounts, with infants receiving approximately 0.95% of the weight-adjusted maternal dose 2
• It has one of the lowest relative infant doses among SSRIs, making it a preferred choice for breastfeeding women 3
• The FDA drug label acknowledges that sertraline passes into breast milk but does not contraindicate its use during breastfeeding 4

Recommendations for Use

• For women already taking sertraline who become pregnant or wish to breastfeed, continuation of therapy is generally recommended 1
• For women starting treatment while breastfeeding:
  • Begin with low doses and increase slowly while monitoring the infant 1
  • Target the lowest effective dose to minimize infant exposure 1
  • When possible, time breastfeeding to avoid peak milk concentration of the medication 1

Factors Affecting Infant Exposure

• CYP2C19 metabolism status affects sertraline clearance (poor metabolizers have 42% reduced clearance) 2
• Breast milk fat content significantly impacts milk-to-plasma ratio (doubling fat content increases the ratio by 95%) 2
• Premature infants may be at higher risk for adverse effects due to:
  • Limited metabolic capacity
  • Immaturity of the blood-brain barrier 5

Monitoring Recommendations

• Monitor breastfed infants for potential adverse effects, including:
  • Irritability
  • Poor feeding
  • Uneasy sleep 1
• More careful monitoring is warranted if:
  • The infant was born premature
  • The infant had low birth weight at birth 1
  • The mother is taking higher doses of sertraline

Special Considerations

• While rare, cases of serotonergic overstimulation have been reported in breastfed infants, particularly in premature infants 5
• If adverse effects occur in the infant, switching to a different SSRI may be considered, as individual infants may tolerate one SSRI better than another 6
• The benefits of breastfeeding generally outweigh the minimal risks associated with sertraline exposure through breast milk 3

Clinical Decision Making

• When considering sertraline for a breastfeeding mother:
  • Evaluate the severity of maternal depression (untreated depression poses risks to both mother and infant)
  • Consider the gestational age and health status of the infant (term vs. preterm)
  • Start with lower doses (25-50mg) when initiating therapy during breastfeeding 1
  • Increase dose gradually based on maternal response and infant monitoring

In conclusion, sertraline represents one of the safest options among antidepressants for breastfeeding women, with extensive clinical experience supporting its use in this population.