1-7 August is breastfeeding week

When talking about breastfeeding and antidepressants, the first and most important thing to remember is that the effective treatment of postpartum depression is critical.

  • Impaired mother-baby bonding
  • The mother cannot always act responsibly which presents in risky behaviour such as not always using car seats
  • Reduced talking and reading to children
  • More harsh punishment
  • Delayed cognitive development in the child

Often doctors and other health care providers look uncertain when asked advice whether it is safe to use an antidepressant whist breastfeeding. It is difficult to get information about the safety of psychotropic drugs because:

  • There are no randomized controlled trails
  • Information is based on observation of exposure and small laboratory studies
  • Studies vary, such as the diagnosis of the mother, the dose of the drug used, how long the baby has been exposed etc.
  • Adverse effects (such as poor sleep, irritability, poor feeding) can also be due to other causes such as a viral infection

When deciding to continue with breastfeeding or not the following points can help:

• The benefits of breastfeeding outweigh the small risks of infant exposure to antidepressants
• All psychotropic medications (including mood stabilizers and benzodiazepines) are excreted in breast milk in varying amounts
• Use caution to expose the infant to medications through breastfeeding if:
The infant is premature, low birth weight or sick
There are other contra indications to breastfeeding such as mother with COVID-19, HIV, untreated TB, Influenza with fever, on chemo
Mothers who are on methadone, use illicit drugs, and smoke
The mother has problems with the breasts e.g. mastitis or the infant has other medical problems e.g. a hernia
• Formula feeding is a reasonable alternative for woman who choose not to breastfeed, or who have increased mood and anxiety symptoms due to difficulties with breast feeding

Choosing an antidepressant:

  • Keep using the same medication that was used in the pregnancy- because the risk was much greater in the pregnancy than it is for the breastfeeding infant
  • Using the same medication will also prevent withdrawal in the neonate
  • If choosing an antidepressant in the post-partum period, choose one that worked in the past
  • Choose an antidepressant with shorter half life and greater protein binding
  • Avoid using many psychotropics together (polypharmacy)
  • Begin with the lowest dose and go up slowly
  • The most preferable antidepressants seem to be sertraline and paroxetine
  • But if the mother was using fluoxetine or citalopram in the pregnancy, do not switch
  • Escitalopram, venlafaxine and duloxetine all appear to be safe, but the exposure to the infant is higher
  • Mirtazapine may be compatible with breast feeding
  • No clear information for agomelatine, bupropion and trazodone
  • Tricyclic antidepressants such as amitriptyline, clomipramine and imipramine seem to be safe during breast feeding

Other tips for mothers with postpartum depression who are breast feeding:

  • Consider psychotherapy. With Zoom and other electronic platforms, you might not even need to leave your baby
  • Try to take your antidepressant after the last feed of the night. This means that the longest possible time will go by before the baby feeds again which will limit the exposure of the baby
  • Sleep enough
  • Be kind to yourself. Do not beat yourself up if you struggle to breast feed. It is perfectly ok to give your baby bottle feeds

Remember: Postpartum depression is a temporary condition

Dr. Melane Van Zyl

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