Wellbutrin (Bupropion) for Low Libido in Breastfeeding Mothers
Bupropion can be used cautiously during breastfeeding for low libido, but the infant must be monitored carefully 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-Based Safety Profile
Drug Transfer and Infant Exposure
- Bupropion is present in human milk and has been detected in the serum of breastfed infants, though typically at very low or sometimes undetectable levels 1, 3
- The average daily infant exposure to bupropion and its active metabolites is approximately 2% of the maternal weight-adjusted dose 3, 4
- In one study of 10 breastfeeding women, the calculated average dosage of bupropion in breast milk was 6.75 microg/kg/day, representing only 0.14% of the standard adult dose corrected for body weight 4
- Two mother-infant pairs showed neither infant had quantifiable serum levels of bupropion or its metabolite at steady state 5
Serious Adverse Events
- Critical concern: There have been 2 case reports of seizures in breastfed infants whose mothers were taking bupropion 1, 3
- One documented case involved a 6.5-month-old infant who presented with severe emesis and tonic seizure-like symptoms while exposed to bupropion XL 150 mg/d (and escitalopram 10 mg/d) through breastfeeding 6
- The seizure-like symptoms occurred at serum concentrations lower than the reported therapeutic range, suggesting infants may have higher susceptibility to the epileptogenic effects of bupropion compared to adults 6
Clinical Management Algorithm
If Bupropion is Clinically Necessary:
Step 1: Dosing Strategy
- Maintain the therapeutic dose while breastfeeding (do not reduce dose as this may compromise maternal treatment efficacy) 1, 2
- Consider that lower doses (150 mg vs. 300 mg) may be more effective for sexual desire improvement in women with hypoactive sexual desire disorder 7
Step 2: Infant Monitoring Protocol
- Monitor the infant carefully for seizures (most critical), vomiting, diarrhea, jitteriness, and sedation 1, 2, 3
- Ensure appropriate weight gain and developmental milestones are being met 1, 2
- Establish a baseline of the infant's normal behavior patterns to detect changes 2
- Watch particularly closely during the first 6 months 2
Step 3: Maternal Education
- Educate the mother to recognize warning signs requiring immediate medical attention: seizure activity, excessive sedation, and poor feeding 2
- Explain that while the absolute risk is low, seizures represent a serious potential adverse outcome that cannot be dismissed 2
Important Caveats
Drug Interaction Concerns
- If the mother is taking other medications that lower seizure threshold or inhibit cytochrome P450 2D6, the risk may be increased 8, 6
- Avoid combining bupropion with other antidepressants during breastfeeding unless absolutely necessary, as polytherapy safety data are extremely limited 6
Evidence Limitations
- The safety data are based on very limited cases (21 cases in the literature) 1, 2
- The relationship between bupropion exposure and reported seizures is not definitively established but cannot be ruled out 3
Risk-Benefit Framework
- The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for bupropion and any potential adverse effects on the breastfed child 3
- Benefits of treating maternal depression or low libido may outweigh potential risks in many cases, but this must be weighed against the rare but serious risk of infant seizures 1
Guideline Consensus
The American Academy of Pediatrics recommends that if bupropion is needed during breastfeeding, the therapeutic dose should be maintained while breastfeeding, and the infant should be monitored carefully for potential adverse effects 1, 2. The American College of Obstetricians and Gynecologists notes caution is advised during breastfeeding based on rare seizure reports 1.