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Date: Sat, 23 Sep 1995 00:10:36 -0700
From: rlam@unixg.ubc.ca (Dr. Raymond W. Lam)
Subject: Sertraline during breast feeding
At 11:26 PM 9/21/95 -0400, Dr. Allan Gold wrote:
I have heard speculation by a few neuroscientists at scientific meetings that a possible effect on the structuring of the brain might occur if neurotransmitters are affected in the developing brain as these molecules are used in concentration gradients to guide the migrating neurons and neuronal projections.I just attended a session yesterday at our Canadian Psychiatric Association Annual Meeting in beautiful, sunny Victoria, B.C., where Dr. Lee Cohen from the Mass. General discussed this very issue. The limited data show no effects of antidepressants in breast-fed babies. They had initially tried to measure levels in breast milk, but found it to be too variable to be useful (it depended on how the milk was expressed, whether it was excreted from "low" or "high" lobes, etc.). Instead, their practice is to measure the serum levels in the babies at about 2 weeks. In their rather extensive experience, they have not been able to find any measurable antidepressant levels, despite an assay with a sensitivity of 5 ug/ml. They also say that a 1 ug/ml-sensitive blood assay is also available. This seems like a sensible approach to me -- whatever is excreted in breast milk, it would be serum levels in the baby that would be important, and testing at 2 weeks would likely prove definitive and comforting to parents and clinician alike.
Date: Thu, 05 Oct 1995 18:56:11 EDT
From: LHSQ76A@prodigy.com (Dr Valerie D Raskin)
Subject: Antidepressants during breast feeding
Zach Stowe, M.D., at Emory, is the expert on this. He has obtained multiple breast milk samples, generally indiciating that sertraline is found in very small doses in milk. He and his colleagues presented data at the APA in 5/95 on a small group of infants nursed by mothers taking sertraline -- compared to non-breast fed babies they were superior developmentally.
Many women with OCD are having serious symptoms revolving around horrifying images of their infants. At the same time, obsessional thinking makes it hard for them to consider weaning, since breast milk is well known to be superior to formula and they have a strong urge to be the best possible mothers. The images may cause them to withdraw from their infants for fear of harming them. In many cases, I believe that medication is superior to months of this situation, which often progresses to depression as well as OCD.
In breast feeding women with OCD, the agents of choice are those with the shortest half life. See Katherine Wisner's 1995 article on clomipramine in lactation. Also consider fluvoxamine, venlafaxine, and sertraline.
From: LHSQ76A@prodigy.com (Dr Valerie D Raskin)
Date: Fri, 21 Jun 1996 11:14:05, -0500
Subject: Antidepressants during breast feeding
I am treating a pregnant woman for depression who wishes to remain on Prozac and and also breast-feed. She was on Prozac prior to the current pregnancy and also during the second and third trimester. Does anyone have any experience, comments, etc., regarding the pros and cons of the use of the medication for this patient? She is aware that Prozac is excreted in breast milk.I treat many breast feeding patients, and have a chapter in an upcoming APA book edited by Laura Miller, M.D., on pharmacologic issues in postpartum patients.
Prozac, in my opinion, is the worst possible choice for nursing because it's been documented to accumulate in nursing babies, due to its much longer half life. But I use it a lot in pregnancy because of the JAMA study indicating no increased risk of morphologic malformations.
What I do is this: stop if possible at 36-38 weeks gestation, then begin a shorter acting SSRI (I usually use sertraline or venlafaxine) immediately upon delivery. I prefer TCAs to SSRIs if clinically reasonable. I don't stop the fluoxetine early if she's sure to crash, but a wash out is especially optimal in lactation.
Some of my colleagues who work with lactating patients a lot would disagree; this is not the revealed word. They would say that since you've already exposed the infant to fluoxetine, why change, just monitor the baby by a blood test and/or observation (harder to do if this is this mom's first baby, every whimper is worrisome the first time around). I would possibly consider fluoxetine if it were uniquely beneficial to her. Talk to the pediatrician in advance so that you aren't giving the patient mixed signals.
Lester BM, Cucca J, Andreozzi L, Flanagan P, Oh W. Possible association between fluoxetine hydrochloride and colic in an infant. Journal of the American Academy of Child & Adolescent Psychiatry. 32 (6): 1253-5, 1993 Nov.
Gelenberg AJ. Fluoxetine labelling revised. Biological Therapies in Psychiatry, 18: 9, 1995. (This is truly an excellent, brief summary of these issues.)
Date: Thu, 18 Jul 1996 07:19:59 -0400
From: "Andrea M. Hessel, MD" <hessel@is3.nyu.edu>
Subject: Fluoxetine during breast feeding
I went to a paper session about this at the APA this year. As I remember, they could hardly measure levels of most antidepressants, including Prozac, in the blood of babies during nursing by mothers who were taking them. They concluded that it was too soon to determine the long-term effects although there did not seem to be any early ones.
Wisner KL, Perel JM: Serum nortriptyline levels in nursing mothers and their infants. Am J Psych 148: 1234-1236, 1991.
From: "Michael Block" <mblock@ibm.net>
Date: Sat, 16 Nov 96 15:18:21 +1000
Subject: Dothiepin during breast feeding
In my perinatal psychiatry programme I use dothiepin more than anything else because it is effective, is well tolerated in ante and postpartum depression, has a low misuse rate in these women and is shown to be (pretty) safe both in pregnancy and breastfeeding.
Date: 24 Jan 97 21:32:20 EST
From: Leslie Gise <76106.413@compuserve.com>
Subject: Bupropion during breast feeding
Bupropion is classified as B rather than C, ie, less bad for breastfeeding, but I still take a conservative view.
From: "Chris Verster" <chrisv@iafrica.com>
Date: Thu, 20 Feb 1997 10:43:17 +0200
Subject: Antidepressants during breast feeding
A recent paper reviewed the literature about antidepressants during breastfeeding:
Wisner KL, Perel JM, Findling RL. Antidepressant treatment during breast-feeding. American Journal of Psychiatry. 153 (9): 1132-7, 1996 Sep.
They concluded that amitriptyline, nortriptyline, desipramine, clomipramine, dothiepin and sertraline were not found in substantial concentrations in the serum of breastfed babies while their mothers were using the drugs. Adverse events were described in babies whose mothers were treated with doxepin and fluoxetine. All of the drugs were present in breastmilk, so once again one should weigh the consequences of a non depressed mother giving her baby the advantages of breastfeeding against the unknown (probably negligible?) effects of minute quantities of antidepressants absorbed by the baby.
From: "Michael Block" <mblock@ibm.net>
Date: Sun, 06 Apr 97 17:16:04 +1000
Subject: Antidepressants during breast feeding
On Fri, 4 Apr 1997 18:57:38 -0700 (MST), Alan Feiger MD wrote:
An ob-gyn colleague of mine asked which antidepressant would be the safest for a nursing mom.I would consider a tricyclic or sertraline. Check my page, Medication, Pregnancy and Lactation.
From: LJGROLD@aol.com (L. James Grold M.D)
Date: Tue, 8 Apr 1997 10:34:06 -0400 (EDT)
Subject: Antidepressants during breast feeding
There have been some similar small n studies with fluoxetine and it looks like perhaps using SSRIs may be relatively safe and better overall than forced weaning.It still scares me to have mothers giving even small amounts of antidepressants to infants when their babies' brains are in such a plastic formative state -- especially since we don't even know the long term effects in adults.The risks of untreated postpartum depression (there are some pretty decent studies showing having depressed mothers very adversely affects kids' growth and development) and the documented phenomena of postpartum type psychiatric illnesses occuring with weaning months after giving birth may outweigh the possible risks of low level exposure to SSRIs given the benefits of breastfeeding to relationship development in families who chose and value that.
I did a literature search on mood disturbance in the childbearing years a couple years ago. Sufffice it to say that nursing researchers and clinicians find that postpartum mood disturbances that last for up to a year are terribly common. Medications like SSRIs are probably amongst the best clinically for these conditions because they can be effective in fairly small doses sometimes and allow mothers not to feel so sedated or out of touch that they can't care for their kids, wake up to feed and so forth.
--Deb McMahon RN
Date: Wed, 30 Apr 1997 17:47:29 +1200
From: david.menkes@stonebow.otago.ac.nz (David Menkes)
Subject: Sertraline during breast feeding
IMHO sertraline is probably OK during breastfeeding, especially if it is taken nocturnally [eg, at 10 pm] and most feeds are more than 12 hours later (eg, between 10 am and 10 pm) -- see:
Altshuler LL, Burt VK, McMullen M, Hendrick V. Breastfeeding and sertraline: a 24-hour analysis. Journal of Clinical Psychiatry. 56 (6): 243-5, 1995 Jun. Analysis of sertraline levels was performed on eight samples of breast milk obtained over a 24-hour period ... from a lactating patient taking sertraline and nortriptyline. During this same 24-hour period, two serum samples ... were taken ... for analysis of sertraline and nortriptyline levels... Breast milk levels of sertraline were lowest 1 hour before the ingestion of sertraline and highest 5 to 9 hours after ingestion of the drug. The infant's serum sertraline and nortriptyline levels were nondetectable.
From: PMBrig@aol.com (Peter M. Brigham, MD)
Date: Fri, 2 May 1997 09:43:51 -0400 (EDT)
Subject: Sertraline during breast feeding
Isn't the breast secreting milk around the clock? So what collects over those 12 hours -- and ends up in the infant's stomach with the morning feeding -- includes the milk that was secreted during the peak level period. I would think that the way to minimize the amount of drug in the milk would be to use a breast pump 12 hours post-dosage and discard that. Then subsequent feedings would indeed have a lower drug content.
I have no idea if any of this matters, but I'm trying to puzzle it out, since occasionally a mother who wants to breast feed will ask me for every single way known to humankind of minimizing risk.
Date: 02 Jun 97 04:44:31 EDT
From: Stephen Bazire <101326.1546@compuserve.com>
Subject: Mianserin during breast feeding
Mianserin is rarely used in the UK these days, but I'm aware of one report of its use in breast-feeding:
Two women taking mianserin 60 and 40 mg/d were studied. Mianserin levels were 22 and 25 mcg/l in maternal plasma and 80 and 20 mcg/l in milk. These are low levels and the infants showed no untoward effects (Buist et al, Br J Clin Pharmacol 1993, 36, 133-4).
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Dr. Bob is Robert Hsiung, MD,
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URL: http://www.dr-bob.org/tips/split/Antidepressants-during-bre.html
Original tips copyright 1994-97 original authors.
Web page copyright 1995-97 Robert Hsiung.