I am a lactating mother with anxiety currently taking sertraline; what other anxiety medications are effective and safe while breastfeeding?

Alternative Anxiety Medications Safe During Breastfeeding

If you are currently taking sertraline and need an alternative anxiety medication while breastfeeding, buspirone is the safest non-benzodiazepine option, with a relative infant dose of only 0.21-2.17% and no reported adverse effects in exposed infants.

First-Line Alternative: Buspirone

Buspirone represents the optimal alternative anxiolytic for breastfeeding mothers, with the most favorable safety profile among non-SSRI anxiety medications 1.

• Buspirone transfers into breast milk at exceedingly low levels, with the parent drug undetectable (<1.5 ng/mL) in all samples at doses ranging from 7.5-30 mg twice daily 1
• The relative infant dose ranges from 0.21-2.17%, well below the 10% safety threshold established by guidelines 1
• No adverse effects were reported in any breastfed infants exposed to buspirone through milk 1
• Buspirone offers the advantage of no dependence risk or respiratory depression compared to benzodiazepines 1

Benzodiazepines: Use with Significant Caution

While benzodiazepines can treat anxiety, they require careful consideration and monitoring in breastfeeding mothers.

Shorter-Acting Options (Preferred if Benzodiazepines Necessary)

• Lorazepam, midazolam, and temazepam are shorter-acting benzodiazepines than diazepam and represent better choices if a benzodiazepine is absolutely necessary 2
• Midazolam has extensive first-pass metabolism resulting in low systemic bioavailability, so infant blood levels after breastfeeding are expected to be low 2
• Breastfeeding can resume after a single dose of midazolam once the woman has recovered from the procedure 2

Longer-Acting Options (Use Only as One-Off Doses)

• Diazepam has an active metabolite (desmethyl-diazepam) with a prolonged half-life and transfers into breast milk in significant levels 2
• Diazepam may be considered only as a one-off dose before a procedure, not for ongoing anxiety management 2

Critical Safety Warnings for Benzodiazepines

• The FDA label for lorazepam explicitly states it should not be administered to breastfeeding women unless expected benefit outweighs potential risk to the infant 3
• Sedation and inability to suckle have occurred in neonates of lactating mothers taking benzodiazepines 3
• Infants must be observed for pharmacological effects including sedation and irritability 3
• Benzodiazepines have a small but significant risk of birth defects and should generally be avoided 4
• Mothers should avoid co-sleeping if taking benzodiazepines, as natural responsiveness may be inhibited 5

Other SSRI/SNRI Alternatives

If you need to switch from sertraline to another antidepressant with anxiolytic properties:

• Paroxetine and sertraline are considered the most suitable first-line agents for postpartum depression and anxiety 6
• Paroxetine produces very low or undetectable plasma concentrations in nursing infants 6
• Sertraline, paroxetine, nortriptyline, and imipramine are the most evidence-based medications for use during breastfeeding 7

SSRIs to Approach with More Caution

• Fluoxetine and citalopram may not be drugs of first choice if treatment is started in the postpartum period 8
• The highest infant plasma levels have been reported for fluoxetine, citalopram, and venlafaxine 6
• Suspected adverse effects have been reported in a few infants, particularly for fluoxetine and citalopram 6

Special Considerations for Young Infants

• Extra caution is required for infants less than 6 weeks of age (corrected for gestation) due to immature hepatic and renal function 5
• Preterm infants have the highest sensitivity to medications, followed by neonates, then young infants 5
• Monitor your infant for signs of drowsiness, poor feeding, or unusual sedation with any psychotropic medication 2

Clinical Decision Algorithm

1. If anxiety is mild-moderate and you can switch medications: Consider buspirone as the safest non-benzodiazepine anxiolytic option 1

2. If you need to remain on an SSRI: Continue sertraline or switch to paroxetine, both of which have excellent safety profiles during breastfeeding 6, 7

3. If benzodiazepines are absolutely necessary for acute anxiety: Use only shorter-acting agents (lorazepam, midazolam) at the lowest effective dose for the shortest duration, with close infant monitoring 2, 3

4. Avoid: Long-term benzodiazepine use, diazepam for ongoing treatment, and starting fluoxetine or citalopram in the postpartum period 3, 4, 8, 6

Key Pitfall to Avoid

Do not assume all benzodiazepines are equally safe during breastfeeding—the FDA explicitly warns against lorazepam use unless benefits clearly outweigh risks, and diazepam's long-acting metabolite makes it particularly problematic for ongoing use 3, 2. Buspirone offers anxiolytic effects without these concerns 1.