Antidepressants, Antipsychotics, Benzodiazepines, and the Breastfeeding Dyad

Perspectives in Psychiatric Care, Apr-Jun 2004 by Malone, Kirsten J, Papagni, Karla, Ramini, Sasha, Keltner, Norman L

Fluoxetine is the most extensively studied of all the SSRIs in the breastfeeding context. Collectively, there have been 11 published reports of fluoxetine use by breastfeeding mothers, which included 190 infants (Burt et al., 2001). In a study of 11 mother-infant pairs, infant plasma concentration of fluoxetine was

In a study of 10 women receiving 0.9 39 mg/kg/day of fluoxetine, average age levels of fluoxetine and norfluoxetine found in breast milk ranged from 24.4-181.1 ?g/L and 37.4-199.1 ?g/L, respectively. No adverse effects were noted in the infants (Taddio, Ito, & Koren, 1996).

One case report of a mother taking 20 mg/day fluoxetine noted severe colic, crying, and fussiness in her infant. Concentrations of fluoxetine and norfluoxetine in her breast milk were 9 69 ?g/L and 90 ?g/L, respectively. Infant plasma levels of both drug and metabolite were almost double normal maternal ranges 0 (0 340 ng/mL and 208 ng/mL). These levels were unusually high, and would be expected in a mother taking fluoxetine 40 mg/day, not 20 mg/day. The infant's symptoms resolved on maternal discontinuation of fluoxetine (Lester, Cucca, Andreozzi, Flanagan, & Oh, 1993).

One infant exposed to fluoxetine both in utero and by breast milk had nondetectable plasma fluoxetine levels at day 13, but increased to 61 ng/mL at day 21. The infant in this case report exhibited slight seizure activity at 3 weeks, 4 months, and 5 months (Brent & Wisener, 1998).

There is some evidence that infants exposed to fluoxetine via breast milk had growth curves significantly below infants who received breast milk free of fluoxetine. Mean body weight deficit was 392 g. No infants in this study were reported to exhibit behavioral changes (Chambers et al., 1999).

Hale (2002) states in his review of fluoxetine: "Infants born of mothers receiving fluoxetine are born with full steady state plasma levels of the medication, and each time they are breastfed, the level in the infant is likely to rise further. While perhaps controversial, I believe it is advisable to discontinue the use of fluoxetine prior to or following delivery in these infants (those exposed both in utero and via breast milk), and if possible, switch to an alternate SSRI immediately following birth" (p. 298).

Paroxetine (Paxil). Paroxetine is well absorbed (50%-100%) in the mother and is 95% protein bound (Deglin & Vallerand, 2003). Paroxetine has a half-life of -21 hours. The metabolites of paroxetine are not active (Hale, 2002). The general conclusions of studies of paroxetine and breastfeeding are that paroxetine can be considered relatively safe because the amount of drug transferred to the infant is quite low, and no adverse effects have been reported (Burt et al., 2001). In one case study, the maximum daily dose to the infant was 0.34% of the maternal dose (Hale, 2002).

In one study (Stowe et al, 2000) of 16 mother-infant pairs, levels of paroxetine in breast milk were low and varied according to maternal dose. Drug levels tended to be higher in the fattier "hind milk" (produced at the end of a feed) than in the less fatty "foremilk." Excretion of paroxetine into breast milk did not show predictable time course patterns. Paroxetine levels in infant serum were