postnatal depression and lactation

Last edited 03/2021 and last reviewed 07/2021

Post-natal depression has the dilemma of frequent improvement with anti-depressant drugs, so improving maternal-infant bonding, but passage of the same drugs to infant in breast milk.

  • antidepressant therapy is indicated for women who have severe depression or who fail to respond to appropriate counselling
  • tricyclic antidepressants (TCA) are relatively safe but most manufacturers advise avoid. The accumulation of doxepin metabolite may cause respiratory depression and sedation (1)
  • the majority of SSRIs are not licensed for use in breast feeding and manufacturers recommend that they are not used during lactation. Summary points re: SSRIs (2)
    • fluoxetine - licensed for use in pregnancy - excessive sleepiness in the baby may occur if continued during breast feeding
    • sertraline - published studies on more than 30 infants have demonstrated no untoward effects and levels in plasma at the limitis of detection; has a shorter half-life than fluoxetine and an inactive metabolite
    • paroxetine - "there are reports of withdrawal with jitteriness, vomiting, irratibility and hypoglycaemia"; half-life of 21 hours
    • citalopram - 2 reports of poor weight gain, decreased feeding and excessive somnolence; half-life is 36 hours; inactive metabolite enters breast milk in low levels
  • the current evidence does not seem to warrant a recommendation that the mother stops breast feeding whilst taking a serotonin selective re-uptake inhibitor (SSRI) (though there is less available data than for TCAs) or a TCA (3)
  • the mother should be alerted to watch for signs of poor handling, drowsiness and poor feeding in the child
  • if a woman is receiving a high dose or a combination of antidepressant drugs then there is a stronger argument, in light of the lack of data, for stopping breast feeding

NICE state (4):

  • when choosing an antidepressant for pregnant or breastfeeding women, prescribers should, while bearing in mind that the safety of these drugs is not well understood, take into account that:
    • tricyclic antidepressants, such as amitriptyline, imipramine and nortriptyline, have lower known risks during pregnancy than other antidepressants · most tricyclic antidepressants have a higher fatal toxicity index than SSRIs
    • fluoxetine is the SSRI with the lowest known risk during pregnancy
    • imipramine, nortriptyline and sertraline are present in breast milk at relatively low levels
    • citalopram and fluoxetine are present in breast milk at relatively high levels
    • SSRIs taken after 20 weeks' gestation may be associated with an increased risk of persistent pulmonary hypertension in the neonate · paroxetine taken in the first trimester may be associated with fetal heart defects
    • venlafaxine may be associated with increased risk of high blood pressure at high doses, higher toxicity in overdose than SSRIs and some tricyclic antidepressants, and increased difficulty in withdrawal
    • all antidepressants carry the risk of withdrawal or toxicity in neonates; in most cases the effects are mild and self-limiting

SIGN (5) state with respect to breast feeding and antidepressants:

  • avoid doxepin for treatment of depression in women who are breast feeding
  • if initiating selective serotonin reuptake inhibitor treatment in breast feeding, then fluoxetine, citalopram and escitalopram should be avoided if possible
  • when initiating antidepressant use in women who are breastfeeding, both the absolute dose and the half life should be considered
  1. BNF (Appendix 5: Breast Feeding)
  2. Pulse 2002; 62(29): 60.
  3. Drug and Therapeutics Bulletin 2000; 38 (5): 33-37.
  4. NICE (February 2007). Antenatal and postnatal mental health.
  5. SIGN (March 2012). Management of perinatal mood disorders.