What antidepressants are safe for breastfeeding mothers?

Safe Antidepressants for Breastfeeding

Sertraline and paroxetine are the preferred first-line antidepressants for breastfeeding mothers, as they transfer into breast milk in the lowest concentrations and produce undetectable or very low infant plasma levels. 1

Primary Recommendations

First-Line Agents

• Sertraline is one of the safest antidepressants during breastfeeding, transferring to breast milk in low concentrations and consistently producing undetectable infant plasma levels 1, 2, 3
• Paroxetine similarly transfers in lower concentrations than other antidepressants and produces undetectable infant plasma levels 1, 3
• Both medications are the most commonly prescribed antidepressants during breastfeeding and should be considered first-line agents 1, 4, 5

Practical Prescribing Approach for Sertraline

• Start with low doses and slowly titrate upward to the lowest effective dose 2
• Monitor the newborn carefully for adverse effects including irritability, poor feeding, or uneasy sleep, particularly if the infant was premature or had low birth weight 2
• Women already taking sertraline should be advised to continue the medication and breastfeed in most cases 2
• When feasible, reduce infant exposure by avoiding breastfeeding when milk concentrations are at peak levels 2

Alternative Agents with Caution

Use with Greater Caution

• Fluoxetine produces the highest infant plasma concentrations among SSRIs and has been associated with more frequent reports of suspected adverse effects in infants 1, 3, 5
• Citalopram also produces higher infant plasma levels and has been associated with nonspecific adverse effects (irritability, decreased feeding) more often than sertraline or paroxetine 1, 3, 5
• Venlafaxine produces higher infant plasma concentrations compared to sertraline and paroxetine 1, 3

However, if a mother was successfully treated with fluoxetine, citalopram, or venlafaxine during pregnancy, continuing the same medication during breastfeeding may be reasonable with careful infant monitoring, rather than switching to a different agent 3

Other Antidepressants

Tricyclic Antidepressants (TCAs)

• Amitriptyline, nortriptyline, desipramine, and clomipramine were not found in quantifiable amounts in nursing infants with no adverse effects reported 6
• Infants older than 10 weeks are at particularly low risk for adverse effects from TCAs, with no evidence of drug accumulation 6

Bupropion

• Present in human milk at very low or sometimes undetectable levels in infant serum 7
• Limited data (21 cases) show generally no adverse events, but 2 case reports of seizures in breastfed infants exist 7
• The American Academy of Pediatrics recommends maintaining therapeutic dose while breastfeeding if needed, with careful monitoring for vomiting, diarrhea, jitteriness, sedation, and/or seizures 7
• Use with caution during breastfeeding 7

General Principles

Key Safety Considerations

• All antidepressants transfer into breast milk in low concentrations 1
• Most antidepressants produce very low or undetectable plasma concentrations in nursing infants 3
• There is little evidence supporting any causal link between antidepressant use in breastfeeding mothers and adverse effects in infants overall 1
• Potential adverse effects documented in case reports are nonspecific (irritability, decreased feeding) and occur more frequently with fluoxetine and citalopram 1

Clinical Decision-Making

• When antidepressant treatment is indicated for postpartum depression, mothers should not be advised to discontinue breastfeeding 3
• Switching from an ongoing and effective antidepressant to sertraline should only occur after careful evaluation of risks versus benefits of switching versus continuing with close infant monitoring 2
• The benefits of treating maternal depression must be weighed against theoretical risks to the infant, recognizing that untreated maternal depression has severe repercussions on infant well-being 5

Important Caveats

• Avoid doxepin during breastfeeding, as adverse effects have been described in young infants exposed through breast milk 6
• No long-term neurodevelopmental data exist for most antidepressants used during lactation 1, 6
• Individual risk-benefit assessment should always be performed 3