Antidepressant use while breastfeeding

Consider the advice for antidepressant use while breastfeeding in accordance with the Principles of psychotropic use while breastfeeding.

The placental transfer and fetal exposure to antidepressants in utero is much greater than breastmilk exposure. Therefore, if a patient has taken an antidepressant during pregnancy, and delivered a healthy neonate, continue the antidepressant while breastfeeding. Do not switch to another antidepressant with a lower breastmilk concentration.

If an antidepressant is started while breastfeeding for a new-onset disorder, use a selective serotonin reuptake inhibitor (SSRI) other than fluoxetine. Fluoxetine passes into breastmilk to a greater extent than other SSRIs and has a long half-life with the potential to accumulate in the breastfed infant. Fluoxetine has been associated with low weight gain, irritability, difficulty settling and infant gastrointestinal dysfunction. Sertraline has the most safety data in breastfeeding and is recommended first line.

No adverse neurological or developmental adverse outcomes have been observed in infants exposed to SSRIs or venlafaxine in breastmilk. Isolated cases of irritability, sleep disturbance and colic, which remitted when breastfeeding or the antidepressant was stopped, have been reported.

Except for doxepin, tricyclic antidepressants (TCAs) are considered safe while breastfeeding. Avoid doxepin; there have been isolated case reports of sedation and respiratory depression in infants. Neurodevelopmental effects of TCA breastmilk exposure are unknown—data are limited.

Although data on desvenlafaxine, duloxetine, mirtazapine and reboxetine are limited, these antidepressants are considered safe while breastfeeding. Moclobemide has very low transfer into breastmilk and may be used with caution. Agomelatine, mianserin, phenelzine, tranylcypromine and vortioxetine have not been adequately studied.

For advice on antidepressant use in females of childbearing potential, see here.