What is the best management plan for a breastfeeding mother with postpartum depression and upper respiratory tract infection symptoms?

Management of Postpartum Depression and URTI in a Breastfeeding Mother

For this 38-year-old breastfeeding mother with postpartum depression and bacterial sinusitis, initiate escitalopram 5mg daily (increasing to 10mg after 2 weeks) with co-amoxiclav for the infection, while continuing breastfeeding with close infant monitoring.

Postpartum Depression Management

Antidepressant Selection for Breastfeeding

• Escitalopram is an appropriate choice for postpartum depression in breastfeeding mothers, though sertraline and paroxetine transfer to breast milk in lower concentrations than other antidepressants 1
• The patient's previous trial of sertraline failed due to significant weight gain, drowsiness, and no mood improvement, making escitalopram a reasonable alternative 1
• Escitalopram may pass into breast milk, requiring discussion about the best way to feed the baby during treatment 2
• Monitor the infant's early development carefully, ensuring appropriate weight gain and developmental milestones 1

Dosing and Monitoring Protocol

• Start escitalopram 5mg daily for 2 weeks, then increase to 10mg daily as planned 2
• Weekly reviews during the first month are essential to monitor mood and suicidal ideation 2
• ECG in 4 weeks post-commencement is appropriate given potential cardiac effects 2
• Check renal function and sodium levels in 3-4 weeks, as elderly people and potentially postpartum women may be at risk for hyponatremia 2

Critical Safety Monitoring

Watch for worsening symptoms including: 2

• Attempts to commit suicide or thoughts about suicide or dying
• New or worse depression, anxiety, or panic attacks
• Acting aggressive, violent, or on dangerous impulses
• Feeling agitated, restless, angry, or irritable
• Other unusual changes in behavior or mood

Treatment Duration

• Optimal treatment duration for an initial episode of major depression is 4 to 12 months 1
• Given this is recurrent postpartum depression (previous episode 4-5 months ago), consider prolonged treatment 1
• Do not stop escitalopram abruptly - stopping too quickly may cause anxiety, irritability, mood changes, headache, sweating, nausea, dizziness, or electric shock-like sensations 2

Upper Respiratory Tract Infection Management

Antibiotic Treatment

• Co-amoxiclav is appropriate for bacterial sinusitis with dental infection given the clinical findings of maxillary tenderness, gum swelling, dental caries, and throat erythema 3
• The patient completed amoxicillin previously for similar symptoms, suggesting possible treatment failure or reinfection requiring broader coverage 3
• Co-amoxiclav is compatible with breastfeeding 3

Supportive Care

• Bonjela for mouth ulcers, applied to affected areas 3-hourly as needed, maximum 6 applications per 24 hours 3
• Continue ibuprofen and paracetamol as needed for pain and fever 3
• Dental review is essential given visible dental caries and gum infection contributing to symptoms 3

Breastfeeding Considerations

Benefits of Continued Breastfeeding

• Breastfeeding is recommended for all individuals with postpartum depression for multiple benefits 1
• Breastfeeding reduces the risk of developing type 2 diabetes in mothers with previous gestational diabetes and may confer metabolic benefits 1
• Breastfeeding is associated with reduced infant mortality, fewer respiratory infections, and reduced asthma risk in children 1

Medication Timing and Infant Monitoring

• Consider timing feeding or pumping to achieve the lowest medication concentration in breast milk 1
• Monitor infant for any signs of adverse effects including feeding difficulties, excessive drowsiness, or developmental concerns 1
• The decision to breastfeed while taking medications should be made collaboratively with close infant monitoring 1

Psychiatric Referral and Support

• Proceed with psychiatric referral to Dr. David Kodyle and Asian Mental Health Services as planned 1
• Consider referral to a reproductive psychiatrist if concerns arise about medication safety in breastfeeding 1
• Utilize online support resources such as Mother Helpers 1
• Postpartum care should include psychosocial assessment and support for self-care 1

Sleep and Fatigue Management

• The patient's sleep is disrupted with baby waking 1-2 hourly for feeds, contributing to fatigue and difficulty concentrating 4
• Low prolactin levels associated with some antidepressants may increase risk of postpartum depression symptoms, though this is more relevant to dopamine agonists than SSRIs 4
• Prioritize sleep and nutrition as part of mental wellness strategies 1

Common Pitfalls to Avoid

• Do not use MAOIs within 2 weeks of escitalopram due to risk of serotonin syndrome 2
• Avoid pimozide (Orap) with escitalopram due to serious heart problems 2
• Be cautious with NSAIDs, aspirin, or warfarin as escitalopram may increase bleeding risk 2
• Watch for serotonin syndrome symptoms: agitation, hallucinations, coordination problems, racing heartbeat, fever, nausea, vomiting, or muscle rigidity 2

Contraception Planning

• A contraceptive plan should be discussed and implemented given the importance of planned pregnancy for optimal preconception care if future pregnancies are desired 1
• Long-acting reversible contraception may be ideal for individuals with mental health conditions 1