SSRIs Are Safe During Breastfeeding with Specific Agent Selection
Yes, SSRIs are safe during breastfeeding, with sertraline and paroxetine recommended as first-line agents due to their minimal excretion in breast milk and consistently low or undetectable infant plasma levels. 1, 2
Preferred First-Line Agents
Sertraline and paroxetine should be your go-to SSRIs for breastfeeding mothers because they transfer into breast milk in the lowest concentrations among all antidepressants and produce undetectable or very low infant plasma levels. 2
- Sertraline provides the infant with less than 10% of the maternal daily dose (normalized for weight), making it exceptionally safe. 1, 3
- Paroxetine is the only SSRI with infant-to-maternal plasma concentration ratios consistently <0.10, demonstrating superior safety profile. 3
- Both medications are the most commonly prescribed antidepressants during lactation and have extensive real-world safety data. 1, 2
Practical Prescribing Approach
- Start sertraline at 25-50 mg daily and titrate slowly upward while monitoring the newborn for any adverse effects. 1
- Use the lowest effective dose to minimize infant exposure while maintaining maternal therapeutic benefit. 3
- Continue existing SSRI therapy rather than switching or discontinuing if a woman is already stable on sertraline when she begins breastfeeding. 1, 3
SSRIs to Use with Greater Caution
Fluoxetine and citalopram carry higher risk and should not be first-line choices:
- Fluoxetine produces the highest infant plasma concentrations among all SSRIs and has been associated with more frequent reports of suspected adverse effects in infants. 2
- Citalopram produces higher infant plasma levels than sertraline or paroxetine and has been associated with nonspecific adverse effects (irritability, decreased feeding) more frequently. 2, 4
- High doses of citalopram should be used with particular caution. 4
Infant Monitoring Protocol
Monitor all breastfed infants exposed to SSRIs for the following signs:
- Irritability, excessive crying, or jitteriness 2
- Poor feeding or decreased appetite 2
- Unusual drowsiness or sedation 2
- Sleep disturbances 2
- Adequate weight gain and developmental milestones 2
Arrange early follow-up after initial hospital discharge for infants exposed to SSRIs, particularly monitoring over the first week of life. 1, 3
Critical Risk-Benefit Context
The benefits of treating maternal depression and continuing breastfeeding outweigh the minimal risks of SSRI exposure through breast milk. 3, 4 Untreated maternal depression carries substantial documented risks including:
- Premature birth 1
- Decreased breastfeeding initiation 1
- Harm to the mother-infant relationship 1
- Significant risks to the mother-infant dyad overall 1
Important Clinical Caveats
Do not discontinue breastfeeding or SSRI treatment out of fear—counsel mothers that the well-documented benefits of breastfeeding combined with effective maternal mental health treatment far exceed the minimal risks of SSRI exposure. 1, 3
Special consideration for preterm infants: One case report documented serotonergic overstimulation in a preterm infant exposed to sertraline via breastmilk, likely due to limited metabolic capacity and immature blood-brain barrier. 5 While rare, this emphasizes the importance of close monitoring in premature infants.
Most reported adverse effects in infants are nonspecific and resolve spontaneously without intervention. 2