Wellbutrin (Bupropion) and Breastfeeding Safety
Direct Recommendation
Bupropion can be used cautiously during breastfeeding, but requires careful infant monitoring for seizures, vomiting, diarrhea, jitteriness, and sedation, as there have been 2 case reports of seizures in breastfed infants despite generally low drug transfer into breast milk. 1, 2
Evidence Quality and Strength
The evidence base for bupropion during breastfeeding is limited, with only 21 documented cases in the literature. 1, 2 Despite this limitation, the available data provides a framework for clinical decision-making:
Drug Transfer and Infant Exposure
- Bupropion is present in human milk and has been detected in infant serum, though typically at very low or sometimes undetectable levels. 1, 3
- The FDA label reports that average daily infant exposure (assuming 150 mL/kg daily consumption) is approximately 2% of the maternal weight-adjusted dose. 3
- In one study of 2 mother-infant pairs, neither infant had quantifiable serum levels of bupropion or its most active metabolite (hydroxybupropion) at steady state. 4
Safety Profile
Generally no adverse events have been reported in most breastfeeding cases, but the 2 seizure reports cannot be dismissed despite uncertain causality. 1, 2, 3 The FDA postmarketing reports describe seizures in breastfed infants, though the relationship between bupropion exposure and these seizures remains unclear. 3
Clinical Management Algorithm
If Bupropion is Clinically Necessary:
Maintain the therapeutic dose rather than reducing it, as subtherapeutic dosing may inadequately treat maternal depression while still exposing the infant. 2, 5
Establish baseline infant behavior patterns before initiating or continuing treatment to detect any changes. 5
Monitor the infant carefully for:
Educate the mother on warning signs requiring immediate medical attention, particularly seizure activity, excessive sedation, and poor feeding. 5
Intensify monitoring during the first 6 months when infants are most vulnerable to adverse effects. 5
Alternative Considerations
If treating postpartum depression or anxiety, sertraline should be considered first-line therapy due to minimal excretion in breast milk (providing the infant with less than 10% of the maternal daily dose) and low infant-to-maternal plasma concentration ratios. 6 Paroxetine is also considered a suitable first-line agent during breastfeeding. 6
However, bupropion may be preferred when:
- Co-occurring depression requires treatment and SSRIs have failed or are not tolerated 6
- The patient has a history of good response to bupropion 2
- Sexual side effects from SSRIs are problematic 6
Important Caveats
Risk-Benefit Framework
The decision to use bupropion during breastfeeding must weigh:
- Benefits of breastfeeding for both mother and infant, which are well-documented 6
- Risks of untreated maternal depression, which poses significant risks to the mother-infant dyad 6, 7
- The small but serious risk of seizures in the breastfed infant, which cannot be entirely dismissed despite limited data 1, 2, 3
Common Pitfalls to Avoid
- Do not discontinue breastfeeding unnecessarily. The absolute risk remains low, and most infants tolerate maternal bupropion use without adverse effects. 1, 2
- Do not reduce the dose below therapeutic levels in an attempt to minimize infant exposure, as this may inadequately treat maternal illness while still exposing the infant. 2, 5
- Do not fail to educate mothers about warning signs, as early recognition of problems is critical. 5
Guideline Consensus
Both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend that if bupropion is needed during breastfeeding, the therapeutic dose should be maintained with careful infant monitoring. 2, 5 The FDA label emphasizes that the developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for bupropion. 3