What is a safe Selective Serotonin Reuptake Inhibitor (SSRI) for a nursing mother?

Safe SSRIs for a Nursing Mother

Sertraline and paroxetine are the safest SSRIs for breastfeeding mothers due to their consistently low transfer into breast milk and minimal infant exposure. 1, 2

Evidence-Based Recommendations

• Paroxetine is the only SSRI for which the ratio of infant to maternal plasma concentrations is consistently low and uniformly <0.10, according to the American Academy of Pediatrics 1
• Sertraline and paroxetine provide the infant with <10% of the maternal daily dose (normalized for weight), making them the preferred options for breastfeeding mothers 1, 2
• Studies have demonstrated that mothers receiving clinical doses of sertraline experience substantial blockade of serotonin transport, while nursing infants show unaltered serotonin uptake, confirming its safety 3
• For women already taking sertraline who wish to breastfeed, continuation of treatment is generally recommended if clinically indicated 1

Specific SSRI Safety Profiles

First-Line Options:

• Sertraline:

  • Shows minimal excretion in breast milk with relative infant dose (RID) <1% 4
  • Clinical studies show no appreciable effect on peripheral or central serotonin transport in nursing infants 3
  • Drug and metabolite concentrations in infants are typically at or below detection limits 3

• Paroxetine:

  • Secreted in human milk at low levels 5
  • Shows small excretion into breast milk in comparative studies 4
  • Never been associated with unsafe reports in breastfed infants 6

Second-Line Options:

• Fluvoxamine:
  • Shows minimal excretion into breast milk 4
  • Provides the infant <10% of the maternal daily dose 1
  • Has relatively low transfer but less data compared to sertraline and paroxetine 4

Use with Caution:

• Citalopram:

  • Shows higher excretion into breast milk compared to paroxetine and sertraline 4
  • Case reports document detectable levels in infant serum with potential side effects like uneasy sleep 7
  • High doses should be used with caution in breastfeeding women 4

• Fluoxetine:

  • Has higher excretion into breast milk and should not be the first alternative when starting treatment postpartum 4
  • Longer half-life increases potential for accumulation in infants 2

Clinical Management Approach

• Use the lowest effective dose of the medication to reduce infant exposure 1
• Arrange early follow-up after hospital discharge for infants exposed to SSRIs 1
• Monitor breastfed infants for potential adverse effects including irritability, poor feeding, or sleep disturbances 6
• Consider that the benefits of treating maternal depression typically outweigh the minimal risks of SSRI exposure through breast milk 1
• For mothers taking citalopram or fluoxetine, consider avoiding breastfeeding during peak drug absorption phases to minimize infant exposure 7

Risk-Benefit Assessment

• Untreated maternal depression can negatively impact breastfeeding initiation and continuation 1
• Untreated depression poses risks to both mother and infant development 2
• The positive effects of breastfeeding generally outweigh the risks of SSRI exposure when appropriate medications are selected 4

Remember that while sertraline and paroxetine are considered the safest options, all mothers taking SSRIs who desire to breastfeed should be counseled about both risks and benefits 1, 6.