The postpartum period can be a magical time when a mom finally gets to meet and spend time with their new baby. However, this time can also be challenging for many mothers. It is estimated that at least 1 in 7 mothers suffers from postpartum depression.1 Psychotherapy (counseling) is certainly useful during this time, but medication may also be necessary to adequately treat psychiatric illnesses. Needing and taking new medications while breastfeeding can bring about many questions. The InfantRisk Center is here to help you find answers.
Risks of NOT treating depression vs risks of taking antidepressants
Like any other medication, antidepressants have the potential to cause side effects (specific risks associated with medications are discussed in detail below). The side effects of these drugs have been the focus of many articles. Your provider’s first choice of antidepressants used are generally the ones with the lowest risk for harm.1
Importantly, the risks of not taking antidepressants when they are indicated can also cause serious risks to both mother and infant. Women who discontinue their antidepressants during or after pregnancy are three times more likely to develop another episode of depression when compared with women who continued to use antidepressants throughout the perinatal period.2 Similarly, one study found that adolescent mothers with untreated depression have a 20% increased frequency of suicide attempts.3
Untreated maternal depression can also affect the infant. One study found that infants of mothers with untreated depression had a lower social engagement score at 9 months when compared to infants of nondepressed mothers.4 Furthermore, results from 10 studies showed that maternal depression was associated with certain behavioral traits in infants including increased behavioral problems at age two, more difficult temperament, and less mature regulatory behavior.4 Other studies have demonstrated that untreated depression hindered the development of the maternal-infant relationship and caused difficulty bonding when compared to the relationship between infants and mothers who were not depressed.4 Therefore, while antidepressant use can carry some side effects, this is generally preferred to untreated depression.
How is the most appropriate antidepressant chosen during breastfeeding?
When a medication is necessary to treat depression, several factors are considered in prescribing an antidepressant. First, if a mom was successfully treated with a certain drug during pregnancy, she should continue that same drug. Similarly, if a mother has a history of successful treatment with a particular antidepressant outside of pregnancy, there is a good chance that it will work well postpartum.1 Second, specific side effects of different antidepressants should be considered as well as their relative infant dose (RID). The RID is the comparative amount of a medication that the infant receives through breastmilk relative to the dose of a medication that the mother receives.5 The current accepted RID threshold for safety is less than 10%.1
What are the side effects and RIDs of specific antidepressants?
The InfantRisk Center believes that all parents should be empowered to make evidence-informed decisions together with their healthcare providers. While we will report adverse effects of antidepressants below, please remember than many mothers successfully breastfeed healthy infants while on antidepressants. We simply want you to be aware of the risks and benefits, and will report the rare instances we have of infant harm to provide a balanced picture.
Selective Serotonin Reuptake Inhibitors (SSRIs)
In general, SSRIs are considered first-line for treating depression while breastfeeding, but SSRIs differ from each other in important ways. For example, sertraline (RID of 0.5%) and paroxetine (RID of 1-1.5%) typically have undetectable blood levels in infants when breastfeeding moms use them.1 Paroxetine is considered to be safe while breastfeeding, but should be avoided during pregnancy due to possible harmful effects that it can have on a growing fetus.1 Other antidepressants like citalopram (RID of 4-8%) and escitalopram (RID of 3.5-4%) are also considered safe while breastfeeding, but may cause mild side effects like drowsiness and irritability in breastfed infants. Fluoxetine has an RID of 6%, which is under the general cutoff of 10%, but is not an ideal choice for breastfeeding. It has a very long half-life (meaning it takes a long time for it to break down in the body), and can accumulate in infants. Infant blood levels of fluoxetine may reach more than half of maternal blood levels. It may take an infant a long time to metabolize (break down) these high levels of drug after discontinuing the drug or breastfeeding. Therefore, fluoxetine may lead to longer-lasting infant side effects.1
Tricyclic Antidepressants (TCAs)
TCAs have low RIDs of 1-2% and infant levels are usually either low or undetectable, however, these drugs are typically not first-line due to their numerous side effects in mothers and infants. For example, one case report of a breastfeeding mom who used amitriptyline showed that an infant developed extreme drowsiness, while many other infants tolerate it well.1 A different report where a breastfeeding mom used doxepin reported that her 8-week-old breastfed infant was found pale, limp, somnolent, and almost not breathing 4 days after doxepin dosage was increased from 10 mg daily to 25 mg three times a day (a 7-fold increase in dose). As a result, doxepin is typically avoided during breastfeeding. A TCA that is a good alternative to SSRIs is nortriptyline. It has few maternal adverse reactions, no active metabolites, and no reports of infant adverse events via breastfeeding thus far.1 Currently, TCA’s are commonly used in addition to other antidepressants. In these cases, the dose of the TCA is often much lower, which substantially reduces the risk of adverse effects to both mom and infant. Many mothers breastfeed successfully while taking TCAs without infant side effects.
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Desvenlafaxine and venlafaxine have an RID of 6.5%. Infants whose mothers take desvenlafaxine have serum levels that range from undetectable to 37% of maternal levels. These SNRIs have caused drowsiness and/or agitation in some cases. Overall, they have few adverse reactions and there is no evidence that suggests they hinder development.1
Bupropion
Bupropion has a low transfer rate through breastmilk with an RID of 1.4-10.6%. Although research on its effects during breastfeeding is scarce, two babies who were breastfed by mothers using bupropion developed seizures.1 It is unknown if the seizures were directly related to bupropion in milk. An increased risk for seizures is a known adverse effect of bupropion in adults and infants. Adults and children with seizure disorders should avoid bupropion. Bupropion should be avoided in breastfeeding mothers if they believe their infant is at a high risk for seizures. For example, infants with a previous or family history of seizures, some infant heart malformations, strokes, head injuries, or some brain tumors or infections may be at higher risk of future seizures and should not be exposed to bupropion. However, if other drugs are ruled out, it may still be possible to safely breastfeed infants with low seizure risks while on bupropion.6
Other Antidepressants
There are many other options for depression treatment. Most have not yet been studied in lactating women and their infants. For more information, please call the InfantRisk Center to speak to a nurse or download our app MommyMeds.
How can antidepressant use during pregnancy affect breastfeeding?
Mothers who took antidepressants during pregnancy may need more help with breastfeeding. Selective Serotonin Reuptake Inhibitors (SSRIs) can delay the onset of milk secretion if taken during the last trimester of pregnancy.1 In regards to the newborn, taking antidepressants during the third trimester can cause a transient discontinuation syndrome which can make breastfeeding more challenging as it may result in decreased sucking and feeding, irritability, sleep disorders, hyperreflexia, and tremors among other side effects.1 Symptoms of discontinuation syndrome typically present around 48 hours after birth and typically resolve after 24-48 hours.7 Additionally, simply having depression during or before pregnancy is often enough to warrant more assistance with breastfeeding.1 These mothers can prepare for a successful breastfeeding journey by alerting their lactation consultants and supportive networks that they may need additional help.
Take away message
The right antidepressant for a breastfeeding mother can vary greatly depending on how that particular person (and their infant) metabolize the medication. It is important to consider if they have ever been treated successfully with a certain antidepressant in the past because this has a higher chance of being successful, even while breastfeeding.1 For previously untreated moms, the safest options during breastfeeding include sertraline and paroxetine since they have been comprehensively studied, have few adverse effects in the baby, and appear in low concentrations in milk. Bupropion can be used with caution due to its potential to increase risk of seizures in the infant.1 In regards to doxepin and fluoxetine, alternatives should be explored first since the potential side effects of these antidepressants are severe as mentioned above.1 Overall, it is important to note that although antidepressants do carry side effects, the alternative of having untreated depression could hinder parenting, lead to substantial developmental risks in the infant and also negatively impact breastfeeding itself. If you have concerns about your mental health, please speak with your healthcare provider for help.
Diego Regalado, MS3
Christine D Garner, PhD, RD
Kaytlin Krutsch, PharmD
References
1. Anderson PO. Antidepressants and Breastfeeding. Breastfeed Med. 2021;16(1):5-7.
2. Womersley K, Ripullone K, Agius M. What are the risks associated with different Selective Serotonin Re-uptake Inhibitors (SSRIs) to treat depression and anxiety in pregnancy? An evaluation of current evidence. Psychiatr Danub. 2017;29(Suppl 3):629-644.
3. Bałkowiec-Iskra E, Mirowska-Guzel DM, Wielgoś M. Effect of antidepressants use in pregnancy on foetus development and adverse effects in newborns. Ginekol Pol. 2017;88(1):36-42.
4. Slomian J, Honvo G, Emonts P, Reginster JY, Bruyère O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Womens Health (Lond). 2019;15:1745506519844044.
5. Hotham N, Hotham E. Drugs in breastfeeding. Aust Prescr. 2015;38(5):156-159.
6. Uguz F. A New Safety Scoring System for the Use of Psychotropic Drugs During Lactation. American Journal of Therapeutics. 2021;28(1):e118-e126.
7. Hale TW, Kendall-Tackett K, Cong Z, Votta R, McCurdy F. Discontinuation syndrome in newborns whose mothers took antidepressants while pregnant or breastfeeding. Breastfeed Med. 2010;5(6):283-288.
