Best SSRI for Breastfeeding Mothers
Sertraline is the first-line SSRI for breastfeeding mothers, with paroxetine as an equally acceptable alternative. 1, 2
Primary Recommendation: Sertraline
Sertraline should be considered the preferred agent because it is minimally excreted in breast milk, provides the infant with less than 10% of the maternal daily dose (normalized for weight), and consistently produces undetectable or very low infant plasma concentrations. 1, 2, 3
Supporting Evidence for Sertraline
- In a meta-analysis of 167 available infant sertraline levels, 87.4% (146 cases) were below the limit of detection, with no significant relationship found between maternal and infant serum sertraline concentrations. 4
- The infant-to-maternal plasma concentration ratio is consistently low, making it one of the safest antidepressants during lactation. 1, 5
- Multiple guideline organizations including the American Academy of Pediatrics and American Academy of Family Physicians recommend sertraline as first-line therapy. 1, 2
Equally Acceptable Alternative: Paroxetine
Paroxetine is the only SSRI for which the ratio of infant to maternal plasma concentrations is consistently low and uniformly <0.10. 3 It transfers into breast milk in the lowest concentrations alongside sertraline and produces undetectable infant plasma levels. 2
Practical Prescribing Approach
Starting and Titrating Sertraline
- Begin with low doses of 25-50 mg daily and slowly titrate upward while carefully monitoring the newborn. 1
- Use the lowest effective dose throughout the postpartum period. 1, 5
- When feasible, reduce infant exposure by avoiding breastfeeding at the time when antidepressant milk concentration is at its peak. 5
Infant Monitoring Protocol
Monitor all breastfed infants for: 2
- Irritability and excessive crying
- Poor feeding or decreased appetite
- Unusual drowsiness or sedation
- Sleep disturbances
- Adequate weight gain and developmental milestones
Arrange for early follow-up after initial hospital discharge for infants exposed to SSRIs, particularly monitoring over the first week of life. 1
SSRIs to Avoid or Use with Caution
Fluoxetine: Not Recommended
Fluoxetine should not be the first alternative when starting treatment during the postpartum period. 6 It produces the highest infant plasma concentrations among SSRIs and has been associated with more frequent reports of suspected adverse effects in infants. 2 The FDA label documents a case where an infant developed crying, sleep disturbance, vomiting, and watery stools, with plasma drug levels of 340 ng/mL fluoxetine and 208 ng/mL norfluoxetine. 7
Citalopram: Use with Caution
High doses of citalopram should be used with caution, as it produces higher infant plasma levels and has been associated with nonspecific adverse effects (irritability, decreased feeding) more often than sertraline or paroxetine. 2, 6
Critical Clinical Caveat for Preterm or Low Birth Weight Infants
Exercise heightened caution with preterm or low birth weight infants. 5 A case report documented serotonergic overstimulation in a preterm infant exposed to sertraline via breastmilk, with serum substance levels within the therapeutic range of adults despite low calculated daily intake, likely due to limited metabolic capacity and immaturity of the blood-brain barrier. 8 This emphasizes the need for careful monitoring, especially in vulnerable populations.
Risk-Benefit Considerations
Women already taking sertraline should be advised to breastfeed and continue the medication rather than discontinue either. 1, 5 The benefits of breastfeeding for both mother and infant are well-documented, and untreated maternal depression poses significant risks including premature birth, decreased breastfeeding initiation, and harm to the mother-infant relationship. 1
When to Consider Switching
A decision to switch to sertraline from ongoing and effective treatment should only be made after scrupulous evaluation of the potential risks and benefits of switching versus continuing the current medication while monitoring the infant carefully. 5 If a woman is stable on another SSRI, the risk of destabilization from switching may outweigh theoretical benefits.
Alternative Non-SSRI Option
If sertraline or paroxetine are not tolerated or ineffective, citalopram can be considered as an alternative SSRI. 1 For women with comorbid conditions or those who cannot tolerate SSRIs, bupropion is present in human milk at very low or undetectable levels in infant serum, though it has very limited breastfeeding data (only 21 cases) and two case reports of seizures in breastfed infants of uncertain causality. 1, 2