Can I breastfeed while taking a Selective Serotonin Reuptake Inhibitor (SSRI)?

Breastfeeding While Taking SSRIs

Yes, breastfeeding is generally considered safe while taking SSRIs, with paroxetine and sertraline being the preferred agents due to their minimal transfer into breast milk. 1, 2, 3

Safety Profile of SSRIs During Breastfeeding

• Sertraline and paroxetine are considered the safest SSRIs during breastfeeding due to their low transfer into breast milk and minimal infant exposure 1, 2
• Most SSRIs produce very low or undetectable plasma concentrations in nursing infants 2
• The American Academy of Pediatrics notes that paroxetine is the only SSRI for which the ratio of infant to maternal plasma concentrations is consistently low and uniformly <0.10 4
• Sertraline transfers in low concentrations into breast milk and is considered one of the preferred antidepressants during breastfeeding 1, 5

Specific SSRI Recommendations

• Paroxetine and sertraline are most suitable as first-line agents for breastfeeding mothers 2, 3
• Fortinguerra et al documented that paroxetine, sertraline, and fluvoxamine are minimally excreted in human milk and provide the infant <10% of the maternal daily dose (normalized for weight) 4
• For women already taking sertraline who become pregnant or wish to breastfeed, continuation of treatment is generally recommended if clinically indicated 1
• If starting treatment while breastfeeding, begin with low doses of sertraline and slowly increase with careful monitoring of the infant 5

Monitoring and Precautions

• Monitor breastfed infants for potential adverse effects including:

  • Irritability 5
  • Poor feeding 5
  • Uneasy sleep 5
  • These effects are more concerning in premature infants or those with low birth weight 5

• When possible, reduce infant exposure by:

  • Using the lowest effective dose of the medication 1, 5
  • Timing breastfeeding to avoid peak milk concentration of the medication 5
  • Arranging early follow-up after hospital discharge for infants exposed to SSRIs 1

Considerations for Specific SSRIs

• Fluoxetine and citalopram have been associated with higher infant plasma levels and occasional adverse effects, but may still be acceptable if the mother was already successfully treated with these medications during pregnancy 2, 6
• One study of fluoxetine found that most breastfed infants had no meaningful changes in serotonin transport, though one infant with measurable plasma fluoxetine levels showed a substantial decline in serotonin levels 6
• Venlafaxine may also produce higher infant plasma levels and should be used with caution 2

Risk-Benefit Assessment

• Untreated maternal depression can adversely affect:

  • Mother's functioning 6
  • Mother-infant relationship 6
  • Child's subsequent development 6, 7
  • Breastfeeding initiation and continuation 1

• The benefits of treating maternal depression typically outweigh the minimal risks of SSRI exposure through breast milk 7

• In women suffering from major depression who respond to pharmacological treatment, continuation of an SSRI during breastfeeding should be encouraged to prevent maternal complications and preserve maternal-infant bonding 7

Important Clinical Caveat

• A mother taking an SSRI who desires to nurse her infant should be counseled about both risks and benefits 4
• For women already taking an SSRI, switching to a different medication solely for breastfeeding should be carefully evaluated, as the risks of switching from an effective treatment may outweigh potential benefits 5
• Monoamine oxidase inhibitors (MAOIs) should generally be avoided during breastfeeding 3