Medications for Postpartum Depression While Breastfeeding
Sertraline and paroxetine are the first-line antidepressants for treating postpartum depression in breastfeeding mothers, as they transfer into breast milk in the lowest concentrations and produce undetectable or very low infant plasma levels. 1
First-Line Agents
Sertraline is the preferred initial choice for most breastfeeding mothers with postpartum depression:
- Transfers to breast milk in low concentrations with consistently undetectable infant plasma levels 1, 2
- Decades of safety data support its use during lactation 3
- Start with low doses and slowly titrate upward to the lowest effective dose 2
- The FDA label confirms some sertraline passes into breast milk, but clinical evidence demonstrates safety 4
Paroxetine is an equally appropriate first-line option:
- Produces undetectable infant plasma levels similar to sertraline 1, 5
- Transfers in lower concentrations than other SSRIs 1
- Both sertraline and paroxetine are the most commonly prescribed antidepressants during breastfeeding 1
Alternative SSRIs (Use with Caution)
Fluoxetine should be avoided as a first choice:
- Produces the highest infant plasma concentrations among all SSRIs 1, 5
- Associated with more frequent reports of suspected adverse effects in infants 1, 6
- Only consider if the mother was already taking it successfully during pregnancy 5
Citalopram requires careful consideration:
- Produces higher infant plasma levels than sertraline or paroxetine 1, 5
- Associated with nonspecific adverse effects (irritability, decreased feeding) more frequently 1
- May be continued if already effective during pregnancy, but not recommended as initial therapy 5
Venlafaxine (SNRI) is not preferred:
- Produces higher infant plasma concentrations compared to sertraline and paroxetine 1
- Should be reserved for cases where SSRIs have failed 5
Non-SSRI Options
Bupropion can be considered, particularly with comorbid conditions:
- Present in human milk at very low or undetectable levels in infant serum 1
- Useful for individuals requiring treatment for co-occurring depression and other conditions 7
- Monitor infants carefully for vomiting, diarrhea, jitteriness, sedation, and seizures 1
- Maintain therapeutic dose while breastfeeding if needed 1
Infant Monitoring Protocol
All breastfed infants should be monitored for:
- Irritability and excessive crying 7, 2
- Poor feeding or decreased appetite 7, 2
- Unusual drowsiness or sedation 2
- Sleep disturbances 7
- Adequate weight gain and developmental milestones 7
Higher vigilance is required for:
- Premature infants 2
- Low birth weight infants 2
- Infants whose mothers take fluoxetine or citalopram 1, 6
Timing and Dosing Strategies
To minimize infant exposure:
- Begin with the lowest effective dose and titrate slowly 2
- When feasible, avoid breastfeeding at peak milk concentration times 2
- Most antidepressants transfer into breast milk in low concentrations overall 1
Critical Clinical Pitfalls
Do not discontinue effective treatment:
- Women already taking sertraline should continue the medication and breastfeed 2
- Switching from an effective antidepressant requires careful risk-benefit analysis 2
- Untreated maternal depression poses significant risks to infant well-being 6
Avoid abrupt discontinuation:
- Stopping SSRIs suddenly can cause withdrawal symptoms including anxiety, irritability, mood changes, headache, and electric shock-like sensations 4
- Taper gradually under medical supervision 4
Long-Term Safety Considerations
Current evidence limitations:
- No long-term neurodevelopmental data exist for most antidepressants used during lactation 1
- Little evidence supports any causal link between antidepressant use in breastfeeding mothers and adverse infant effects overall 1
- Most reported adverse effects are nonspecific and resolve spontaneously 7, 1
When to Avoid Breastfeeding
Absolute contraindications are rare, but consider formula feeding if: