This will ensure that your milk flow does not diminish, just in case you decide to breastfeed again. Once you discontinue medications, you can ask your doctor if you can restart breastfeeding. It is always best to get treatment for depression.
Studies show that babies with depressed mothers who go untreated tend to have poor brain development. Mother-baby bonding is usually poor and they usually have less attachment. Developmental delays also occur. It is therefore advisable to take a safe medication than to go untreated while taking care of a baby.
Copyright WWW. Last Updated 26 October, Can Antidepressants and Breastfeeding Go Together? Never Leave the Depression Untreated It is always best to get treatment for depression. Other Ways to Manage Postnatal Depression 1. Some Self-Help Tips Get lots of sleep and rest. Ask your partner or someone to help you care for the baby. Relax and take a warm drink. Put on some music and take a nap while the baby is asleep.
Try to reduce your work load. Eat a healthy diet. Have balanced meals to get enough fuel and support your immune system. Human milk represents the ideal primary source of nutrients, immunological defenses, and growth-promoting factors for the term and preterm newborn, and provides the mother-infant dyad with major short and long-term health benefits.
Breastfed infants have less risk of mortality and morbidity i. Breastfeeding continues to offer health benefits into and after early childhood.
These include decreased risk for asthma, inflammatory bowel disease, diabetes mellitus and hematological cancers during infancy, as well as lower rate of obesity and asthma in adolescence. It has been associated with reduced risk of ovarian cancer and breast cancer, as well as post partum weight retention and bleeding 1 2.
Moreover, the intimate bodily contact during breastfeeding comprises the initial interpersonal communication and facilitates mother —infant attachment.
Both the American Academy of Pediatrics and the World Health Organization recommended the use of exclusive breast milk for 6 months for all infants with the option of adequate substitutes only for infants who cannot be breast fed 2 3. The prevalence of postpartum depression PPD has been estimated as high as Depressed mothers may prefer to avoid pharmacological treatment because of concerns about adverse effects in the nursing infants 5 6. Women with postpartum depression who are breastfeeding receive fewer prescriptions for psychotropic medications compared to non-breastfeeding women and are more likely to choose a non-pharmacological treatment 5.
Although psychotherapy has been demonstrated to be efficacious in treating PPD 6 , it is not widely available in public settings. The high prevalence of untreated PPD is a major health issue due to its association with functional impairment in the mother, elevated risk of psychopathology in the children as well as impacts on the mother-infant relationship 7 8.
Considering the use of antidepressants during lactation is a common clinical conundrum due to the frequency with which PPD occurs. Antidepressant medications are also appropriate for the treatment of other disorders common in women of childbearing age, such as panic disorder, generalized anxiety disorder, obsessive-compulsive disorder and bulimia 9.
Therefore, physicians will frequently encounter challenging questions such as: 1 What are the risks of untreated maternal illness? The available evidence on the effects of antidepressants during lactation largely consists of case reports and studies of small samples.
A detailed review and pooled analysis of antidepressant levels in lactating mothers, breast milk and nursing infants was published in the American Journal of Psychiatry in June, Results of the pooled analyses indicated that breastfed infants exposed to paroxetine and sertraline were unlikely to develop detectable serum drug levels.
Infants exposed to fluoxetine through breast milk were more likely to develop elevated levels of the drug especially if the mothers started the treatment during pregnancy due to prenatal loading.
The data on citalopram were limited compared the other SSRIs, but suggested that some infants developed quantifiable serum levels of the drug which may be associated with adverse effects. Weissman et al. The authors concluded that breastfeeding women may reasonably choose to use antidepressants and that routine laboratory measurement of infant serum drug levels for clinical purposes was not warranted.
The authors suggested the evaluation of serum infant levels as a direct measure of infant exposure in future research, since infant exposure to drugs is influenced not only by the amount ingested through breastfeeding but also by capacity to metabolize the drug. The goals of this paper are to: 1 Provide the results of a literature search with the same databases as in Weissman et al.
The tricyclic and heterocyclic antidepressants exhibit their therapeutic effect through blocking reuptake of norepinephrine, dopamine and serotonin, with the level of blockade dependent upon the specific agent. Tricyclic antidepressants are associated with cardiac toxicity in overdose as well as a variety of adverse effects due to their multiple receptor impacts. As a consequence, the use of tricyclics has decreased in clinical practice. However, a double blind randomizated clinical trial of nortriptyline TCA vs.
The rate of side effects or impairment due to side effects did not differ in the nortriptyline compared to the sertraline treated women. Breastfeeding women were included in this randomized clinical trial. Sixteen women in the NTP group were breastfeeding and provided mother-infant samples. The mean age of the nursing infants was 5.
No adverse events were noted in the infants. The majority of the available infant serum level data for TCAs includes NTP and imipramine, which in most cases are not detectable and have not been associated with adverse clinical events.
Doxepin which is very sedating and has a metabolite with a long half-life has been associated with sedation and respiratory depression and has been widely considered contraindicated 12 TCAs can be considered first choice treatments for women with PPD when the mother has been treated successfully for past episodes and there are no current contraindications for their use, such as suicidality.
Beyond the primary activity of selective inhibition of serotonergic reuptake, different SSRIs display noradrenergic and dopaminergic reuptake inhibition, serotonin 2C, muscarinic and sigma 1 receptor antagonism, as well as inhibition of nitric oxide synthesis and of various cytocrome P enzymes. During the first days of treatment there may be adverse events due to rapidly increased serotonin levels in discrete regions of the body.
These effects are usually mild and resolve due to desensitization of post-synaptic receptors. However, Wisner et al 11 recommended starting with half the usual SSRI dose in women with PPD due to increased initial sensitivity, which resulted in severe headache in several subjects in a randomized trial.
Because of their relative safety in overdose, SSRIs are widely prescribed and are often first choice antidepressants. Four controlled studies and one case report on citalopram have been published since June, Heikkinen et al.
Outcome measures were infant weight and neurological development through 1 year. The weights of infants of citalopram-treated mothers did not differ from the weights of infant with drug-free mothers. The neurological development of all infants was judged as normal by pediatricians and physiotherapists. The authors monitored plasma and breast milk levels of citalopram and its active metabolites didesmethylcitalopram and desmethylcitalopram during pregnancy and for up to 2 months after delivery.
The mean estimated infant citalopram dose was 0. In line with the Weissman et al. These results suggested minimal exposure of the infant to citalopram and no evidence of clinical impact at 1 year of age. Hendrick et al 15 compared 78 nursing infants with mothers taking a variety of SSRIs and 6 month old breastfed infants from normative population.
The outcome was weight at 6 months of age, and no difference was found between groups. Only 3 infants were exposed to citalopram and no data on infant exposure level was provided. Berle et al 16 compared 26 breastfed infants whose mothers were treated with a variety of SSRIs in monotherapy mean age 19 weeks with 68 nursing infants whose mothers were drug-free mean age 16 weeks.
Ten infants mean age 18 weeks were in the citalopram-treated group. The short-term adverse events did not differ between the two groups. The authors found detactable but low serum levels of citalopram in 6 of the 10 infants mean level 1.
The authors also measured the cytochrome P genotypes of CYP2C19 to identify poor metabolizers who are likely to develop drug-specific adverse events.
Lee et al 17 compared the frequency of signs in 31 infants with depressed citalopram-treated mothers, 12 infants with depressed mothers treated with a variety of SSRIs, and 31 infants with healthy drug-free mothers.
There were no significant differences between the groups in the frequency of infant signs as reported by the mothers and physicians. Among the infants of citalopram-treated mothers, 9. No measures of infant exposure were provided.
Franssen et al. The infant had irregular breathing, hypotonia, sleep disruption through 3 weeks after delivery that gradually resolved Consistent with Heikkenen et al 14 , the relative dose at 25 days and 53 days after delivery were respectively 0. Escitalopram is the therapeutically active S-stereoisomer enantiomer of the SSRI citalopram and is noted for its highly selective serotonin reuptake inhibition.
Since June , one study with small sample and four case reports have been published. Rampono et al 19 evaluated the exposure to escitalopram and its active metabolite in 8 infants of mother taking a median dose of 10 mg daily of the drug. Neither short-term adverse events nor developmental abnormalities were noted by a neonatologist. Gentile 20 reported a case of a depressed mother who took escitalopram 20 mg daily at week 24 of gestation and discontinued the therapy gradually over the 2 month period before the delivery.
The mother restarted escitalopram at the same dosage post-birth. The infant had no adverse events, as evaluated by a pediatrician through 3 months of age, but no measures of infant exposure were provided.
Potts et al l 21 reported an case of necrotizing enterocolities NEC on the fifth postnatal day in a term neonate exposed to escitalopram 20 mg daily in utero and during breastfeeding. The mother continued taking escitalopram and discontinued breastfeeding.
The authors commented on the possible mechanisms that may increase the risk of NEC, including a hypercoagulable state resulting from SSRI withdrawal, as well as vasoconstriction due to the inhibition of nitric oxide production by SSRIs. It is important to note that causality cannot be inferred from a single case report; however, cases of NEC have been previously reported in 2 term neonates whose mothers took paroxetine during pregnancy in association with other agents desipramine and buspirone respectively The interesting aspect of the cases above is that NEC is unusual in full term infants.
In a case of a mother taking escitalopram 20 mg daily in combination with reboxetine 4 mg daily , the relative dose of escitalopram was 4. Castberg et al 24 evaluated exposure levels and short term adverse events in a nursing infant with escitalopram-treated mother at 1 week and 7.
At 1 week, the mother was taking escitalopram 5 mg daily and at week 7. The relative doses of escitalopram at 1 and 7 weeks after delivery were 5. The infant did not have clinical abnormalities as reported by the mother and the general practitioner. The SSRI fluoxetine is characterized by its long half life, which ranges from 1 to 3 days after a single dose and from 4 to 6 days after a long term use.
Similarly, its active metabolite. Its pharmacokinetic characteristics explains why fluoxetine is more likely than other SSRIs to result in quantifiable levels in breast milk and infant serum. Additionally, in utero exposure may result in prenatal loading which contributes to post-birth infant serum levels. Since , five controlled and two uncontrolled studies have been published.
In Heikkinen et al 25 11 mothers taking fluoxetine mg daily during pregnancy and lactation and a control group of 10 medication-free mothers were recruited. Their infants were compared on weight and neurological development through 1 year. Infant weights were not significantly different between the two groups and the neurological development of all infants was judged as normal by pediatricians and physiotherapists.
The authors monitored plasma and breast levels of fluoxetine and its active metabolite norfluoxetine during pregnancy through to 2 months after delivery with a single breast milk and infant plasma sample at several time points.
The relative dose of fluoxetine plus norfluoxetine was 2. These results suggested minimal exposure of the infant to the drug. No evidence of short term adverse events or neurodevelopmental impact at 1 year of age was observed. In two controlled studies considering a variety of SSRIs, two lactating women were fluoxetine-treated. In the single case of breastfed infant of a fluoxetine-treated mother described by Lee et al 17 any adverse effects was noted. In another study 29 breastfed infants did not differ in weight at 6 months compared to a normative population In both studies any measure of infant exposure was provided.
Oberlander et al 26 found detectable serum levels of fluoxetine in 7 infants with prenatal and postnatal exposure to fluoxetine mean dose of Kim et al 27 evaluated 23 women taking fluoxetine mg daily and collected samples at a mean time point of 3. The relative dose of fluoxetine and norfluoxetine were 0. Epperson et al 28 studied the effect of serotonin uptake in platelets in 11 mother-infant pairs infant mean age at the start of the study before and after 4 to 12 weeks of maternal treatment with fluoxetine mg daily.
While the mothers showed the expected marked decline in platelet serotonin, only one infant had little or no decline in platelet serotonin. Moreover, no adverse events were noted in the nursing infants. Because platelets and neurons share the same serotonin transporter, this report suggested that fluoxetine delivered to the infant through breast milk had minimal impact on serotonin blockade in the infant brain. Fluvoxamine has no active metabolites and its mean half-life is Hendrick et al 15 reported that 3 infants exposed to fluvoxamine did not differ in weight compared to unexposed breast fed infants at 6 months.
The breastfed extent not stated infants of 11 women taking fluoxetine 20 to 40 mg daily during pregnancy and lactation had trough milk fluoxetine and norfluoxetine levels measured on day 4, week 2 and month 2 postpartum. At 2 weeks of age, fluoxetine was detectable in the serum of 2 of the infants in concentrations of 7. At 2 months of age, no infant had detectable fluoxetine levels; norfluoxetine was detectable in the serum of all infants in concentrations averaging 6. Thirty serum levels were obtained from 23 infants with an average age of 3.
Six of 7 infants had detectable serum levels in the first month, 6 of 8 in the second month and 2 of 14 thereafter. Infant serum levels of S-fluoxetine and S-norfluoxetine were about 3 times as high as the R-isomers during the first 2 months. Only norfluoxetine could be detected after this time and the S- to R-isomer ratio fell to about 1. Fluoxetine has caused increased prolactin levels and galactorrhea in nonpregnant, nonnursing patients.
In a small prospective study, 8 primiparous women who were taking a serotonin reuptake inhibitor SRI; 3 taking fluoxetine and 1 each taking citalopram, duloxetine, escitalopram, paroxetine or sertraline were compared to mothers who were not taking an SRI. Mothers taking an SRI had an onset of milk secretory activation lactogenesis II that was delayed by an average of However, the delay in lactogenesis II may not be clinically important, since there was no statistically significant difference between the groups in the percentage of mothers experiencing feeding difficulties after day 4 postpartum.
Among the two groups who had taken an SSRI, 33 took citalopram, 18 took escitalopram, 63 took fluoxetine, 2 took fluvoxamine, 78 took paroxetine, and 87 took sertraline.
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