Citalopram Use During Breastfeeding
Citalopram can be used during breastfeeding, but it requires careful monitoring of the infant for adverse effects, and other SSRIs like sertraline or paroxetine may be preferred as first-line agents.
FDA Labeling and Key Safety Information
The FDA label explicitly states that citalopram is excreted in human breast milk and documents two case reports of infants experiencing excessive somnolence, decreased feeding, and weight loss while breastfeeding from citalopram-treated mothers 1. In one case, the infant recovered completely after the mother discontinued citalopram; the other case lacked follow-up 1. The FDA emphasizes that the decision to continue or discontinue breastfeeding or citalopram therapy must weigh the risks of infant exposure against the benefits of treatment for the mother 1.
Evidence-Based Recommendations
Relative Safety Profile Among SSRIs
- Citalopram shows higher excretion into breast milk compared to other SSRIs, with higher relative infant doses reported than for sertraline, paroxetine, or fluvoxamine 2, 3
- The highest infant plasma concentrations among SSRIs have been documented for fluoxetine, citalopram, and venlafaxine 3
- Paroxetine and sertraline are considered more suitable first-line agents for breastfeeding mothers when initiating antidepressant treatment in the postpartum period 3, 4
Clinical Safety Data
- A prospective controlled study of 31 breastfeeding women taking citalopram (average dose 25.3 mg/day, range 10-60 mg/day) found no statistically significant difference in adverse event rates compared to depressed non-medicated mothers or healthy controls 5
- However, suspected adverse effects have been reported in infants exposed to citalopram through breast milk, particularly at higher maternal doses 3, 4
- High doses of citalopram should be used with caution during breastfeeding 2
Practical Clinical Approach
When Citalopram May Be Appropriate
- If the mother was successfully treated with citalopram during pregnancy, continuing the same medication during breastfeeding is reasonable to maintain therapeutic stability 3
- When antidepressant treatment is clearly indicated, the benefits of both treating maternal depression and continuing breastfeeding generally outweigh the risks of infant drug exposure 2
Monitoring Requirements
Monitor the breastfed infant for the following signs:
- Excessive somnolence or sedation 1
- Decreased feeding or poor weight gain 1
- Irregular breathing patterns 6
- Sleep disturbances 6
- Abnormal muscle tone (hypotonia or hypertonia) 6
Important Caveats
- Withdrawal effects may occur in infants who were exposed to citalopram in utero, manifesting as irritability, sleep disorders, and tone abnormalities in the first few weeks postpartum 6
- These withdrawal symptoms should be distinguished from ongoing exposure effects through breast milk 6
- Premature infants and those with metabolic disorders may be more vulnerable to drug exposure through breast milk 4
Alternative Considerations
If initiating new antidepressant treatment postpartum, consider sertraline or paroxetine as first-line options rather than citalopram, given their lower excretion into breast milk and more favorable safety profiles 2, 3, 4. Fluoxetine should also not be a first-choice agent when starting treatment during breastfeeding 2, 4.