11 - Antidepressants in breastfeeding

Antidepressants in breastfeeding

Prescribing in pregnancy and breastfeeding CHAPTER 7 ■ ■Where a mother has taken a particular psychotropic during pregnancy and until delivery, continuation with the drug while breastfeeding will usually be appropriate (but see notable exceptions later), as this may minimise withdrawal symptoms in the infant. ■ ■In each case the benefits of breastfeeding to the mother and infant must be weighed against the risk of drug exposure in the infant. Consider the infant’s general health and gestational age at birth.3 ■ ■It is usually inappropriate to stop breastfeeding unless the currently prescribed drug is absolutely contraindicated in breastfeeding. As treatment of maternal mental illness is the priority, in such cases treatment should not be withheld but the mother should be advised to bottle feed with formula milk. ■ ■When initiating a drug postpartum it is: ■ ■important to consider the mother’s previous response to treatment ■ ■best to avoid a psychotropic with high reported infant plasma levels or a high RID ■ ■important to consider the half-­lives of the drugs: drugs with a long half-­life can accumulate in breast milk and the infant. ■ ■Neonates and infants do not have the same capacity for drug clearance as adults. Premature infants and infants with renal, hepatic, cardiac or neurological impairment are at a greater risk from exposure to drugs. ■ ■Infants should be monitored for any specific adverse effects of the drugs as well as for abnormalities in feeding patterns and growth and development. ■ ■Infant plasma levels should be monitored if adverse effects are noted or toxicity is suspected. ■ ■Women receiving sedating medication should be strongly advised to not breastfeed in bed as they may fall asleep and roll onto the baby, with a potential risk of hypoxia to the baby. ■ ■Sedation may affect women’s ability to interact with their children. Women receiving sedating drugs should be monitored for this effect. ■ ■Wherever possible: ■ ■use the lowest effective dose ■ ■avoid polypharmacy ■ ■continue the regimen prescribed during pregnancy. Table  7.1 outlines recommendations for treatment with psychotropics in breastfeeding. Antidepressants in breastfeeding Table 7.2 provides information on individual drugs in breastfeeding based on available published data in late 2023. Manufacturers’ formal advice on drugs in breastfeeding is available in the formal product literature or European Public Assessment Report for individual drugs. Table 7.2 does not include this advice (which is often uninformative), but instead uses primary reference sources. It is worth repeating that it is usually advisable to continue the antidepressant prescribed during pregnancy. Switching drugs postpartum for the purpose of breastfeeding is usually not sensible. Table 7.2 should be used as a guide when initiating treatment postpartum. In each case previous response (and lack of response) to treatment must be considered.