Can I take antidepressants while breastfeeding?

Given the high prevalence of postpartum depression in the US (often cited as between 10-15% of postpartum women), and the myriad benefits of breastfeeding for both baby and mother, it's not a surprise that women in our clinic often ask about the safety of breastfeeding while taking antidepressants.

To answer this question, it's important to note that concentrations of psychotropics in breast milk have been found to vary widely. The amount of a psychotropic medication that an infant is exposed to depends on multiple factors, including dosage of the drug, rate of maternal drug metabolism, and frequency and timing of feedings. In the past, a technique called "pumping and dumping" was recommended. However, that has been found to be unnecessary; you can read more about why it is not a good idea to pump and dump in this post.

One of the main ways researchers have investigated antidepressant safety in lactation has been to look at infant plasma (i.e., blood) concentrations. The chart below from Berle and Spigset (2011) shows that of the most commonly prescribed SSRIs, sertraline and paroxetine have the lowest infant plasma concentrations: 

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Duloxetine (an SNRI) and bupropion (an NDRI) also had undetectable infant plasma levels, but there were fewer mother/ infant pairs studied. The SSRIs fluoxetine and citalopram had higher infant plasma concentrations; it's generally recommended that these be used with caution or avoided during breastfeeding. However, if a woman has been stable on these medications prior to and/ or during pregnancy, it may be fine to continue them during breastfeeding.

Another way to evaluate the safety of medications in lactation has been to look at adverse events. Scalia and Wisner did an extensive literature search to create clinical guidelines for antidepressant use during breastfeeding. They found that sertraline, paroxetine, and nortriptyline are the most evidence-based antidepressants in lactation, because levels are usually undetectable in infants, there have been no reports of short term adverse effects, and findings about them have been consistent among different laboratories. They also created the following decision-tree:

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As you can see, sertraline and paroxetine are generally considered to be the first-line agents if pharmacological treatment is necessary in lactation. Sertraline is often preferred over paroxetine because of paroxetine's greater anticholinergic side effects (including dry mouth, blurred vision, sedation, constipation, and memory impairment) and its shorter half life/ more significant discontinuation syndrome (marked by flu-like symptoms, insomnia, nausea, imbalance, and anxiety).

DON'T Pump and Dump!

Few things can be more painful for a mother than to discard her precious liquid gold. Successful breastfeeding often requires a great level of commitment and dedication, and seeing a woman throw away the product of that effort after a drink or two is really disturbing given the evidence that, in the great majority of cases, she wouldn’t need to do it. Current research says that occasional use of alcohol (1-2 drinks) does not appear to be harmful to the nursing baby. As long as the mother feels neurologically normal, the concentration of alcohol in breast milk is negligible. “That means if you are sober enough to drive, you are sober enough to breastfeed”, according to this article.

Sometimes a new mother finds herself in a situation where she may want to drink: it can be a date night (they’re so common in the postpartum period, right?), a wedding, or just to see how beer or wine tastes after 40 weeks of abstinence. While the harmful consequences of alcohol in pregnancy are well-established (the current recommendation is to completely avoid alcohol during pregnancy), its consumption in lactation remains unclear and women continue to receive very conflicting advice on it.

The American Academy of Pediatrics places emphasis on increasing breastfeeding in the United States and their Committee on Drugs considers alcohol compatible with breastfeeding.

The concentration of alcohol in the breast milk equilibrates with the mother’s blood concentration; it does not accumulate (it is not "trapped") in the milk. Pumping and dumping breast milk doesn't speed the elimination of alcohol from your body.

It is wise to avoid breast-feeding until alcohol has completely cleared your breast milk, which typically takes two to three hours for 12 ounces (355 milliliters) of 5 percent beer, 5 ounces (148 milliliters) of 11 percent wine or 1.5 ounces (44 milliliters) of 40 percent liquor, depending on your body weight.

The American Academy of Pediatrics Section on Breastfeeding notes: “ingestion of alcoholic beverages should be minimized and limited to an occasional intake but no more than 0.5 g alcohol per kg body weight, which for a 60 kg mother is approximately 2 oz liquor, 8 oz wine, or 2 beers. Nursing should take place 2 hours or longer after the alcohol intake to minimize its concentration in the ingested milk.”

Factors that influence alcohol metabolism and its concentration in the milk are:

• Your baby's age
• A newborn has an immature liver, and will be more affected by alcohol
• Up until around 3 months of age, infants metabolize alcohol at about half the rate of adults
• An older baby can metabolize alcohol more quickly than a young infant
• Your weight
• A person's size has an impact on how quickly they metabolize alcohol
• A heavier person can metabolize alcohol more quickly than a lighter person
• Amount of alcohol
• The effect of alcohol on the baby is directly related to the amount of alcohol that is consumed
• The more alcohol consumed, the longer it takes to clear the mother's body
• Will you be eating
• An alcoholic drink consumed with food decreases absorption

(source: http://www.llli.org/faq/alcohol.html)

Note that we’re talking about the occasional social drinker (i.e., 1-2 drinks on special occasions). Chronic and heavy consumption of alcohol has been shown to cause impairment on motor and cognitive development, weight gain/failure to thrive and sleep patterns. References here. 

Substantial consume may cause drowsiness, sleep irregularities, weakness and decreased growth in the infant. Very importantly, the effects of alcohol may impair judgement and affect the ability of the mother care for her child and to be aware of her baby’s needs, whether she is breastfeeding or not. If you drink heavily, it is safest to arrange for extra supervision for your baby and it may be best not to breastfeed.

Also, the popular idea that alcohol improves milk production is a myth. Studies show that alcohol actually decreases milk production and that the presence of alcohol in breast milk causes babies to drink about 20 percent less breast milk (Mennella & Beauchamp 1991, 1993; Mennella 1997, 1999) or inhibit let-down (Coiro et al 1992; Cobo 1974). 

(For a complete of the amount of drugs that are transferred into human milk please read: http://pediatrics.aappublications.org/content/pediatrics/108/3/776.full.pdf)

Dr. Jack Newman, member of the LLLI Health Advisory Council, says this in his handout "More Breastfeeding Myths":

“Reasonable alcohol intake should not be discouraged at all. As is the case with most drugs, very little alcohol comes out in the milk. The mother can take some alcohol and continue breastfeeding as she normally does. Prohibiting alcohol is another way we make life unnecessarily restrictive for nursing mothers.”

In summary: "As alcohol leaves the bloodstream, it leaves the breast milk. Pumping and dumping will not remove it. Pumping and dumping, drinking a lot of water, resting, or drinking coffee will not speed up the rate of the elimination of alcohol from your body".

Mothers who are intoxicated should not breastfeed until they are completely sober, at which time most of the alcohol will have left the mother's blood (which may take up to three hours). Drinking to the point of intoxication,binge drinking, or drinking daily has not been adequately studied and is not advised in concurrence with breast feeding.