Paroxetine and sertraline are the Selective Serotonin Reuptake Inhibitors (SSRIs) of choice. Recommendations apply to full term and healthy infants only.
Paroxetine and sertraline are the SSRIs of choice during breastfeeding.
More evidence is available on the use of SSRIs during breastfeeding than other antidepressant groups and limited data show encouraging outcomes when considering longer term effects on infants.
However, they all have relatively long half-lives. This could result in accumulation and increased risk of side-effects due to an infant’s underdeveloped clearance capacities, particularly in the neonatal period.
Paroxetine and sertraline have shorter half-lives and pass into milk in smaller amounts compared to others, and are therefore preferred.
Recommendations apply to any indication the medicine is being used for such as generalised anxiety disorder, obsessive compulsive disorder or neuropathic pain.
Choice considerations
Untreated or inadequately treated depression can have adverse effects on the mother and infant and it is important that the mother receives effective treatment and does not stop taking it suddenly.
Treatment choice should primarily focus on controlling the mother’s symptoms. Suitability in breastfeeding is a secondary consideration.
There is no need to change an SSRI used successfully during pregnancy to a preferred choice in breastfeeding as long as the infant has been born full term and healthy.
Discontinuation syndrome
SSRIs can cause discontinuation symptoms if stopped abruptly, and occurs most commonly with paroxetine. This may make it more difficult for a breastfeeding mother to stop treatment and should be considered when making medicine choices.
Neonatal withdrawal syndrome
A specific withdrawal syndrome has been reported in infants exposed to SSRIs later in pregnancy, most commonly with paroxetine.
Symptoms include poor adaptation, jitteriness, irritability, poor gaze, agitation, hypotonia, and gastro- intestinal disturbances. Symptoms typically last 1 to 2 days (potentially longer with fluoxetine), but should resolve without intervention. Continuing breastfeeding may relieve withdrawal effects.
It may be difficult to distinguish between neonatal withdrawal symptoms and potential side-effects from SSRI exposure through breast milk. Symptoms common to both include agitation, jitteriness, hypotonia, and gastro-intestinal disturbances. Sedation has only been reported after exposure through breast milk. If symptoms do not resolve a few days after birth, consider that side-effects may be the potential cause.
Effect on breastfeeding
Those taking an SSRI may have more difficulty breastfeeding, particularly with establishing breastfeeding. The underlying disease state may contribute to this and additional breastfeeding support may be required.
Specific recommendations
Preferred choice
This is a preferred choice antidepressant due to low levels in breast milk and favourable drug properties.
Infant monitoring
As a precaution, monitor for irritability, restlessness, drowsiness, constipation, poor feeding and adequate weight-gain.
Further information
Significant published evidence shows that paroxetine passes into breast milk in very small amounts (ranging from 0.1%–4.3% of the weight-adjusted maternal dose) with maternal doses up to 60mg daily.
In one study, paroxetine was detected in infant serum as 5% of the maternal serum level. In other studies paroxetine has not been detectable in infant serum.
In most cases short or longer-term infant side-effects have not been reported. However, there have been occasional reports of irritability, insomnia, restlessness, poor feeding, sedation and constipation. A single case of severe hyponatraemia has been described, although causality was not proven. Side-effects are reported more often when paroxetine is also taken during pregnancy.
Preferred choice
This is a preferred choice antidepressant due to low levels in breast milk and favourable drug properties.
Infant monitoring
As a precaution, monitor for agitation, restlessness, insomnia, drowsiness or other sleep disturbances, diarrhoea, poor feeding and adequate weight-gain.
Further information
Significant published evidence shows sertraline passes into breast milk in very small amounts (0.2–2.4% of the weight-adjusted maternal dose) with maternal doses up to 200mg daily. In many cases, the amount in breast milk was negligible. One study found no correlation between dose and milk levels.
Levels of sertraline (or the active metabolite norsertraline) in infant serum are very small (on average 2% of maternal serum levels for sertraline) or undetectable with maternal doses up to 200mg. In a few cases, the infant serum level was reported as greater than 10%.
Generally, infant side-effects have not been reported. Six-month follow-up studies show normal weight gain and neurological development.
There have been occasional reports of jitteriness, restlessness, agitation, poor feeding, diarrhoea, sleep disturbances, insomnia, and sedation. One case reported toxicity in a preterm infant (hyperthermia, effects on muscle tone, tremor, shivering and irritability); the mother had been taking 150mg sertraline during pregnancy and the infant was found to have genetically reduced sertraline metabolism.
Despite sertraline being a known inhibitor of platelet function, no such effects have been detected in infants exposed via breast milk.
Use with Caution
Citalopram can be used with caution during breastfeeding, but sertraline or paroxetine are preferred.
Infant monitoring
As a precaution, monitor for irritability, restlessness, drowsiness, colic, poor feeding and adequate weight-gain.
Further information
Most evidence shows that citalopram passes into breast milk in negligible or small amounts (0.7–7.9% of the weight-adjusted maternal dose) with maternal doses up to 80mg daily. However, there have been 2 isolated cases reporting much higher levels (13.2% and 18.4% of the weight-adjust maternal dose).
Infant serum levels of citalopram are low (0.9–7% of the maternal serum level). In one isolated report the infant serum level was over 10% of the maternal serum level.
Citalopram has often been used during breastfeeding without any short or longer-term infant side- effects. There have been some case reports of colic, decreased feeding, irritability, restlessness and drowsiness.
Use with Caution
Escitalopram can be used with caution during breastfeeding, but sertraline or paroxetine are preferred.
Infant monitoring
As a precaution, monitor for irritability, restlessness, drowsiness, vomiting, poor feeding and adequate weight-gain.
Further information
Limited evidence shows that escitalopram passes into breast milk in small amounts (2.6%–7.7% of the weight-adjusted maternal dose) with maternal doses up to 20mg daily.
Infant serum levels have been reported as very low, and in some cases undetectable. A pharmacokinetic modelling study predicts infant serum levels to be around 1.7% of maternal serum levels.
Use of escitalopram is not usually associated with any side-effects. However, there have been some reports of irritability, restlessness, drowsiness, and vomiting. One case of necrotising enterocolitis, and one of convulsions have also been reported, although the association with breastfeeding was uncertain.
Use with Caution
Fluoxetine can be used with caution. It has been used during breastfeeding for many years, but sertraline or paroxetine are preferred.
Infant monitoring
As a precaution, monitor for irritability, restlessness, drowsiness, colic, gastro-intestinal disturbances, poor feeding, and adequate weight-gain.
Further information
Significant published evidence shows that fluoxetine passes into breast milk in variable amounts (ranging from 0.54%–10.8% of the weight-adjusted maternal dose) with maternal doses of up to 80mg daily. Some single case reports describe much higher levels; up to 20% of the weight-adjusted maternal dose.
Both fluoxetine and its active metabolite norfluoxetine have been detected in infant serum in low or undetectable levels. In one study, some infants had elevated serum levels greater than 10% of the maternal level. Exposure during pregnancy was thought to influence these higher levels.
Most published reports have not identified any side-effects, including longer-term neurodevelopment. However, infant side-effects are reported more often with fluoxetine compared to other SSRIs, which may reflect wider use. The very long half-life of fluoxetine (4–6 days), and norfluoxetine (4–16 days), greatly increases the risk of accumulation in breastfed infants.
Reported side-effects include colic, decreased sleep, vomiting, watery stools, hyperactivity, and decreased weight gain. Seizure-like activity, cyanosis, hyperglycaemia and glycosuria have also been reported, although causality has not been proven.
Two case reports of fluoxetine toxicity (tachypnoea, hypotonia, difficulty in arousing, jitteriness, and low- grade fever) have been described during breastfeeding. Exposure during pregnancy was thought to contribute and all symptoms resolved when breastfeeding was discontinued.
Patient Information
The NHS website provides advice for patients on the use of specific antidepressants in breastfeeding.
the antidepressant in question is not included in our advice
the infant is unwell or premature
multiple medicines are being taken
About our recommendations
Recommendations are based on published evidence where available. However, evidence is generally very poor and limited, and can require professional interpretation. Assessments are often based on reviewing case reports which can be conflicting and lack detail.
If there is no published clinical evidence, assessments are based on: pharmacodynamic and pharmacokinetic principles, extrapolation from similar drugs, risk assessment of normal clinical use, expert advice, and unpublished data. Simulated data is now increasingly being used due to the ethical difficulties around gathering good quality evidence in this area.
Bibliography
Full referencing is available on request.
Update history
Added links to other antidepressant pages.
Added statement from NICE relating to bed sharing