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Women with depression who are taking medication may become pregnant,
give birth and desire to breastfeed their infant. Alternatively,
women with no prior history of depression may become depressed in the
post-partum period. The rapid decline in the levels of reproductive
hormones after delivery may play a role in the development of
depression in some women. In either case, if major depression has
been diagnosed after an appropriate evaluation, treatment with
medication should be considered. All antidepressants are excreted in
breast milk. Serum levels of antidepressants in infants of
breastfeeding mothers have been evaluated (
Wisner, 2002
).
Of the selective serotonin reuptake inhibitors (SSRIs), sertraline
has been recommended due to its lack of side effects in the infant and
unmeasurable drug levels in the infant. Fluoxetine and its active metabolite
(norfluoxetine) have long half lives.
Elevated levels of both of these compounds have been
found in infants of breastfeeding mothers who were taking fluoxetine.
This was more common in infants whose mother took fluoxetine during
pregnancy in addition to the post-partum period or were less than 6
weeks of age.
Apparent toxicity has been documented in an 11 day old infant, who was
born at 37 weeks gestation and was exposed to fluoxetine in utero and
after delivery. The infant presented with lethargy, hypotonia, fever,
and poor feeding. Measurable levels of norfluoxetine were present in
maternal milk and in the infant's serum.
Of the tricyclic antidepressants, nortriptyline has
been the most extensively studied. Levels are not measurable in
infants of breastfeeding mothers and follow-up of exposed infants to
preschool age shows no developmental problems (
Wisner, 2002
,
Birnbaum, 1999
,
Wisner, 1998
,
Hale, 2001
).
Due to the sensitivity of post-partum women to side effects of
antidepressants, it has been recommended that treatment be started at
1/2 of the recommended dosage and increased on a weekly basis with
close monitoring (
Wisner, 2002
).
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