What are the preferred antidepressant medications for breastfeeding mothers?

Preferred Antidepressants for Breastfeeding Mothers

Sertraline and paroxetine are the preferred first-line antidepressants for breastfeeding mothers, as they transfer into breast milk in the lowest concentrations and consistently produce undetectable or very low infant plasma levels. 1, 2

First-Line Agents

Sertraline (Preferred)

• Sertraline is one of the safest antidepressants during breastfeeding, transferring to breast milk in low concentrations and consistently producing undetectable infant plasma levels 2, 3, 4
• Most commonly prescribed antidepressant during breastfeeding alongside paroxetine 1, 2
• In most cases, women already taking sertraline should be advised to continue breastfeeding and maintain their medication 3
• Start with low doses and slowly titrate upward, using the lowest effective dose 3
• No quantifiable amounts found in nursing infants in multiple studies, with no adverse effects reported 5

Paroxetine (Preferred)

• Transfers in lower concentrations than other antidepressants and produces undetectable infant plasma levels 1, 2
• Considered a suitable first-line agent alongside sertraline 4
• Minimal excretion into breast milk based on measured drug concentrations 6

Alternative Agents (Use with Caution)

Bupropion

• Present in human milk at very low or sometimes undetectable levels in infant serum 2
• Can be considered for postpartum depression, particularly with comorbid conditions 2
• Maintain therapeutic dose while breastfeeding if needed, with careful monitoring for vomiting, diarrhea, jitteriness, sedation, and/or seizures 2

Agents to Avoid as First-Line

Fluoxetine should not be the first choice:

• Produces the highest infant plasma concentrations among SSRIs 2, 4
• Associated with more frequent reports of suspected adverse effects in infants 2
• One case report documented an infant developing crying, sleep disturbance, vomiting, and watery stools, with infant plasma levels of 340 ng/mL fluoxetine and 208 ng/mL norfluoxetine 7
• Should not be the first alternative if treatment is started during the postpartum period 6

Citalopram requires caution:

• Produces higher infant plasma levels compared to sertraline and paroxetine 2, 4
• Associated with nonspecific adverse effects (irritability, decreased feeding) more often than sertraline or paroxetine 2
• High doses should be used with caution 6

Venlafaxine is less preferred:

• Produces higher infant plasma concentrations compared to sertraline and paroxetine 2, 4

Clinical Management Algorithm

For New Treatment Initiation:

1. Start with sertraline or paroxetine as first-line agents 1, 2
2. Begin with low doses and titrate slowly 3
3. Use the lowest effective dose 3
4. Monitor infant closely (see monitoring protocol below) 2

For Women Already on Antidepressants:

• If on sertraline or paroxetine: Continue medication and breastfeed 3, 4
• If on fluoxetine, citalopram, or venlafaxine during pregnancy: Breastfeeding can be allowed during continued treatment in the postpartum period, but perform individual risk-benefit assessment 4
• Switching medications: Only switch from ongoing and effective treatment after scrupulous evaluation of risks versus benefits of switching versus continuing with careful infant monitoring 3

Infant Monitoring Protocol

All breastfed infants should be monitored for: 2

• Irritability and excessive crying
• Poor feeding or decreased appetite
• Unusual drowsiness or sedation
• Sleep disturbances
• Adequate weight gain and developmental milestones

Higher risk infants requiring closer monitoring: 3

• Premature infants
• Low birth weight infants
• Newborns (infants older than 10 weeks are at lower risk) 5

Timing Strategies to Minimize Exposure

• When feasible, avoid breastfeeding at the time when antidepressant milk concentration is at its peak 3
• This strategy can reduce child exposure to the medication 3

General Safety Principles

• All antidepressants transfer into breast milk in low concentrations 1, 2
• Little evidence supports any causal link between antidepressant use in breastfeeding mothers and adverse effects in infants overall 2
• Most reported adverse effects in infants are nonspecific and resolve spontaneously 2
• No long-term neurodevelopmental data exist for most antidepressants used during lactation 2
• The positive effects of breastfeeding generally outweigh the risks for pharmacological effects in the infant when SSRI use is clearly indicated 6

Critical Caveat

Do not advise women to discontinue breastfeeding when antidepressant treatment is indicated for postpartum depression 4, 8. The risks of untreated maternal depression must be balanced against the benefits of breastfeeding and the minimal risks of infant medication exposure 8.