Is Lexapro (escitalopram) safe to use during breastfeeding?

Safety of Lexapro (Escitalopram) During Breastfeeding

Lexapro (escitalopram) can be used during breastfeeding, but infants should be monitored for excessive sedation, restlessness, agitation, poor feeding, and weight gain issues. 1

Transfer into Breast Milk and Infant Exposure

• Escitalopram is excreted in human breast milk, 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 active metabolite) 1
• The amount of medication that enters breast milk depends on maternal serum concentration and the pharmacologic properties of the medication 2

Safety Considerations

• The FDA drug label notes there have been reports of excessive sedation, restlessness, agitation, poor feeding, and poor weight gain in infants exposed to escitalopram through breast milk 1
• Compared to other SSRIs, escitalopram has been associated with higher infant plasma levels than some alternatives 3
• A comprehensive review of escitalopram safety during breastfeeding found no adverse effects reported in the few studies evaluating its safety during lactation 4

Monitoring Recommendations

• Infants exposed to escitalopram through breast milk should be closely monitored for:
  • Excessive sedation 1
  • Restlessness or agitation 1
  • Poor feeding patterns 1
  • Inadequate weight gain 1
• If these symptoms are observed, contact a healthcare provider for evaluation 1

Alternative Antidepressants During Breastfeeding

• If starting a new antidepressant during the postpartum period, sertraline and paroxetine are often considered first-line options for breastfeeding mothers due to their more favorable safety profiles 5
• Studies suggest that fluoxetine and citalopram (which is closely related to escitalopram) may be associated with a relatively higher risk of adverse events in breastfed infants, though these events are typically mild 5

Practical Recommendations

• When prescribing medications for breastfeeding patients, those with the lowest risk to the infant should be selected 2
• If the mother has been taking escitalopram during pregnancy, continuing the same medication during breastfeeding is often reasonable rather than switching to a different antidepressant 3
• Dosing should ideally be scheduled before the infant's longest sleep interval to minimize exposure 2
• If adverse effects are observed in the infant, consider:
  • Reducing the maternal dose if clinically appropriate 6
  • Replacing some breastfeeding sessions with formula 6
  • In severe cases, switching to an alternative antidepressant with lower milk transfer

Conclusion

When weighing the risks and benefits of escitalopram during breastfeeding, it's important to consider that untreated maternal depression can have significant negative effects on infant development and maternal-infant bonding. The benefits of breastfeeding and treating maternal depression often outweigh the potential minimal risks of medication exposure through breast milk.