Safe Antidepressants for Breastfeeding
Sertraline and paroxetine are the preferred first-line antidepressants for breastfeeding mothers, as they transfer into breast milk in the lowest concentrations and produce undetectable or very low infant plasma levels. 1
Primary Recommendations
Sertraline should be considered the single best first-line agent for lactating mothers requiring antidepressant therapy, transferring to breast milk in low concentrations with consistently undetectable infant plasma levels and relative infant doses <1%. 1, 2
Paroxetine is the alternative first-line agent when sertraline is not tolerated or ineffective, similarly producing undetectable infant plasma levels and low breast milk concentrations. 1, 3
Both medications are the most commonly prescribed antidepressants during breastfeeding and have the most robust safety data supporting their use. 1, 2
For mothers already taking sertraline at delivery, maintain the therapeutic dose during breastfeeding rather than discontinuing either the medication or breastfeeding. 1, 2
Dosing Strategy for Sertraline
Start with 25-50 mg daily and slowly titrate upward to the lowest effective dose (typical range 50-200 mg/day) while monitoring the newborn. 2
Sertraline remains safe across all therapeutic doses up to 200 mg daily, maintaining undetectable infant plasma levels even at maximum dosing. 1
Alternative SSRIs with Important Caveats
Avoid fluoxetine as a first-line agent during breastfeeding—it produces the highest infant plasma concentrations among all SSRIs and has been associated with more frequent reports of suspected adverse effects including excessive sedation, restlessness, and poor feeding. 1, 3
Use citalopram with caution—it produces higher infant plasma levels than sertraline or paroxetine and has been associated with nonspecific adverse effects (irritability, decreased feeding) more frequently. 1, 3
Escitalopram (the active enantiomer of citalopram) shows that exclusively breastfed infants receive approximately 3.9% of the maternal weight-adjusted dose, with reports of excessive sedation, restlessness, agitation, poor feeding, and poor weight gain in exposed infants. 4
Venlafaxine produces higher infant plasma concentrations compared to sertraline and paroxetine, making it a less preferred option. 1
Non-SSRI Option: Bupropion
Bupropion is present in human milk at very low or sometimes undetectable levels and can be considered for mothers with comorbid conditions requiring treatment for co-occurring depression. 1, 5
Maintain therapeutic bupropion doses during breastfeeding if needed, but monitor infants carefully for vomiting, diarrhea, jitteriness, sedation, and particularly seizures (two case reports exist, though causality uncertain). 1, 5
Bupropion has limited breastfeeding data (only 21 documented cases), making it less preferred than sertraline or paroxetine when SSRIs are appropriate. 5
Mandatory Infant Monitoring Protocol
Monitor all breastfed infants exposed to antidepressants for the following specific signs: 1
- Irritability and excessive crying
- Poor feeding or decreased appetite
- Unusual drowsiness or sedation
- Sleep disturbances
- Adequate weight gain and developmental milestones
Pay particular attention to premature infants or those with low birth weight, as they may be at higher risk for adverse effects. 6
Critical Clinical Principles
All antidepressants transfer into breast milk in low concentrations, but there is minimal evidence supporting any causal link between antidepressant use in breastfeeding mothers and adverse infant effects overall. 1
Most reported adverse effects in infants are nonspecific and resolve spontaneously. 1
Untreated maternal depression poses significant documented risks to both mother and infant, including harm to the mother-infant relationship, decreased breastfeeding initiation, and impaired infant emotional development. 2, 7
The benefits of breastfeeding for both mother and infant are well-documented and should not be discontinued due to antidepressant use when appropriate agents are selected. 1, 2
Common Pitfalls to Avoid
Do not switch from an effective antidepressant to sertraline during breastfeeding without careful risk-benefit analysis—if the mother is stable on another medication with adequate infant monitoring, continuing may be safer than risking maternal relapse. 6
Do not use fluoxetine as a first-line agent when initiating treatment during the postpartum period, given higher infant exposure and adverse effect reports. 3, 8
Do not avoid treatment altogether due to fear of medication risks—untreated depression carries substantial risks that often outweigh the minimal documented risks of appropriate antidepressant use during lactation. 2, 7