What anxiety medications are safe for breastfeeding mothers?

Safe Anxiety Medications for Breastfeeding Mothers

Sertraline and paroxetine are the safest first-line anxiety medications for breastfeeding mothers due to their minimal transfer into breast milk and low risk of adverse effects in infants. 1, 2, 3

First-Line Options

• Sertraline (Zoloft) is considered one of the safest antidepressants during breastfeeding with very low infant plasma concentrations and minimal reported adverse effects 1, 2
• Paroxetine has similarly low infant exposure through breast milk and is recommended as a first-line agent for breastfeeding mothers 2, 3
• Both medications should be started at low doses and titrated slowly while monitoring the infant for any adverse effects such as irritability, poor feeding, or sleep disturbances 1

Second-Line Options (Use with Caution)

• Citalopram and fluoxetine have higher transfer rates into breast milk compared to sertraline and paroxetine, resulting in higher infant plasma levels 2, 4, 3
• These medications should be used with caution and careful infant monitoring, though they can still be considered if the mother was already taking them during pregnancy 2
• Venlafaxine also requires careful monitoring due to potentially higher infant exposure 2

Benzodiazepines in Breastfeeding

• Short-acting benzodiazepines like lorazepam and midazolam may be used for short-term anxiety management 5
• Midazolam has extensive first-pass metabolism resulting in low systemic bioavailability, making it relatively safer for occasional use 5
• Diazepam should be avoided for regular use as it has an active metabolite (desmethyl-diazepam) with a prolonged half-life and transfers significantly into breast milk 5
• The FDA label for lorazepam specifically states: "Lorazepam should not be administered to breast-feeding women, unless the expected benefit to the woman outweighs the potential risk to the infant" 6

Practical Recommendations

• When initiating treatment:

  • Start with low doses and increase gradually 1, 2
  • Monitor the infant for unusual drowsiness, poor feeding, or irritability 1
  • Use the lowest effective dose to minimize infant exposure 1

• To reduce infant exposure:

  • Consider timing breastfeeding to avoid peak medication concentrations in milk when possible 1
  • For mothers already on effective treatment during pregnancy, continuing the same medication is often preferable to switching 1, 2

Important Considerations and Monitoring

• Premature infants or those with low birth weight may be more susceptible to medication effects and require closer monitoring 1
• The benefits of treating maternal anxiety often outweigh the minimal risks to the breastfed infant 2, 7
• Untreated maternal anxiety can negatively impact infant development and mother-infant bonding 7
• Individual risk-benefit assessment should be performed for each mother-infant pair 2

Common Pitfalls to Avoid

• Discontinuing necessary medication due to unfounded fears about breastfeeding safety 2, 7
• Using medications with longer half-lives (like fluoxetine) as first-line agents in breastfeeding mothers 4, 3
• Failing to monitor the infant for potential adverse effects, especially when using medications with higher transfer rates 1
• Not considering the mother's previous medication response when selecting treatment 1, 2