What are the recommendations for a child whose mother took a Selective Serotonin Reuptake Inhibitor (SSRI) during pregnancy or is breastfeeding?

Management of Infants Exposed to SSRIs During Pregnancy or Breastfeeding

Infants exposed to SSRIs in utero should be monitored for neonatal adaptation syndrome for at least 48 hours after birth, with early follow-up arranged after discharge, while mothers should continue SSRI treatment at the lowest effective dose during both pregnancy and breastfeeding, with sertraline or paroxetine preferred for nursing mothers. 1, 2, 3

Immediate Neonatal Management

Monitoring Requirements

• Monitor all SSRI-exposed newborns for at least 48 hours after birth for signs of neonatal adaptation syndrome, which occurs in approximately one-third of exposed infants. 2
• Arrange early follow-up within the first week after hospital discharge, as symptoms may emerge over several days. 1, 4

Clinical Presentation of Neonatal Adaptation Syndrome

Watch for the following constellation of symptoms that typically appear within hours to days after birth: 1, 2

• Central nervous system signs: continuous crying, irritability, jitteriness, restlessness, tremors, shivering, seizures
• Motor abnormalities: hypertonia or rigidity
• Respiratory symptoms: tachypnea or respiratory distress
• Feeding issues: poor sucking, feeding difficulties
• Metabolic disturbances: hypoglycemia
• Sleep disturbances

Expected Clinical Course

• Most symptoms resolve spontaneously within 1-2 weeks without intervention. 1, 2
• In rare cases (particularly with paroxetine exposure), symptoms may persist through 4 weeks of age. 1
• Severe cases requiring intervention are uncommon (approximately 1 in 313 quantifiable cases). 5

Treatment for Severe Cases

• For severely affected infants, a short-term course of chlorpromazine has provided measurable relief of symptoms. 1, 2, 4
• Most cases require only supportive care in special care nurseries. 5
• No neonatal deaths have been attributed to SSRI exposure alone. 5

Maternal SSRI Management During Pregnancy

Continuation vs. Discontinuation

• Continue SSRI treatment during pregnancy at the lowest effective dose rather than discontinuing, as medication withdrawal may have harmful effects on the mother-infant dyad. 1, 2, 4
• Untreated maternal depression carries significant risks including premature birth, decreased breastfeeding initiation, and harm to the mother-infant relationship. 2, 4
• Women who discontinue antidepressants during pregnancy show significant increases in relapse of major depression. 2

Specific Risks to Consider

• Persistent pulmonary hypertension of the newborn (PPHN) has a possible association with late pregnancy SSRI exposure, with a number needed to harm of 286-351. 2, 4
• Avoid paroxetine specifically in the first trimester due to FDA pregnancy category D classification related to cardiac malformation concerns. 4
• No increased risk of cardiac malformations has been demonstrated with first-trimester sertraline use in large population-based studies. 4

Breastfeeding Recommendations

Preferred SSRIs During Lactation

• Sertraline and paroxetine are the preferred first-line agents for breastfeeding mothers due to their favorable safety profiles. 3, 4
• Paroxetine is the only SSRI with infant-to-maternal plasma concentration ratios consistently <0.10. 1, 3
• Sertraline, paroxetine, and fluvoxamine are minimally excreted in breast milk, providing the infant <10% of the maternal daily dose (normalized for weight). 1, 3

Counseling Approach

• Mothers taking SSRIs who desire to breastfeed should be counseled about both risks and benefits, but continuation of both breastfeeding and medication is generally recommended. 1, 3, 4
• The benefits of treating maternal depression and continuing breastfeeding typically outweigh the minimal risks of SSRI exposure through breast milk. 3
• Monitor breastfed infants for diminished suck, sleep disturbances, and decreased growth. 1

Long-Term Neurodevelopmental Considerations

Reassuring Evidence

• Several reviews have not identified adverse neurodevelopmental outcomes among infants born to women treated with SSRIs during pregnancy. 1, 4

Conflicting Research Findings

While guideline-level evidence is reassuring, some research studies suggest potential concerns that warrant awareness:

• Some studies report lower scores on gross motor (mean difference 1.1-1.2 points), social-emotional, and adaptive behavior subscales at ages 10 months to 2.5 years. 6, 7
• Other research indicates increased internalizing and anxious behaviors at ages 3 and 6 years, even when controlling for maternal depression. 8
• However, studies on early cognitive development generally indicate no negative effects, with difficulties appearing primarily in later development. 9

Important caveat: These research findings conflict with guideline recommendations and may reflect residual confounding from maternal depression severity rather than direct medication effects. The American Academy of Pediatrics guidelines, which synthesize the totality of evidence, do not identify adverse neurodevelopmental outcomes and recommend continuing treatment. 1, 4

Clinical Algorithm Summary

1. During pregnancy: Continue SSRI at lowest effective dose; prefer sertraline over paroxetine in first trimester 4
2. At delivery: Monitor infant for 48+ hours for neonatal adaptation syndrome 2
3. If symptoms develop: Provide supportive care; consider chlorpromazine only for severe cases 1, 2
4. Before discharge: Arrange early follow-up within first week 1, 4
5. For breastfeeding: Continue SSRI; prefer sertraline or paroxetine 3, 4
6. Ongoing monitoring: Watch for feeding difficulties, sleep disturbances, or decreased growth in breastfed infants 1