General considerations

It is important to complete an individual risk assessment for your patient and to apply the principles of prescribing in breastfeeding when looking at the available information and making treatment decisions.

This article includes some commonly prescribed antidepressants which are not classed as selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs). Many other antidepressant medicines are also available, and may need to be added in various combinations for more specialist situations. Contact our specialist service for further advice.

Recommendations

Duloxetine, mirtazapine, trazodone and venlafaxine can be used with caution and infant monitoring during breastfeeding, but SSRIs or TCAs are preferred.

Published evidence shows that milk levels with duloxetine, mirtazapine, trazodone, and venlafaxine are generally very small to negligible. However, there have been a few case reports of higher milk levels with venlafaxine.

These antidepressants, or their active metabolites, have relatively long half-lives, which could result in accumulation and increased risk of side effects in the infant due to their underdeveloped clearance capacity, particularly in the neonatal period. However, in the majority of cases, no infant side effects were reported.

The National Institute for Healthcare Excellence (NICE) advises avoiding sharing a bed with the infant when sedating medication has been used, due to the increased risk of sudden unexpected death in infancy.

Some of these medicines are used for other therapeutic indications. Recommendations apply to any indication the medicine is being used for.

Clinical considerations

Untreated or inadequately treated depression can have adverse effects on the mother and infant and it is important that the mother receives effective treatment and does not stop taking the antidepressant suddenly.

Treatment choice should primarily focus on controlling symptoms with suitability in breastfeeding a secondary consideration.

If duloxetine, mirtazapine, trazodone or venlafaxine have been used successfully during pregnancy, there is no need to switch to a preferred choice in breastfeeding, as long as the infant has been born full term and healthy.

Discontinuation syndrome

These antidepressants can cause discontinuation symptoms if stopped abruptly, particularly venlafaxine and duloxetine. This may make it more difficult to stop treatment, and should be considered when making medicine choices.

Neonatal withdrawal syndrome

Infants exposed to duloxetine, mirtazapine, trazodone or venlafaxine during pregnancy should be monitored for withdrawal symptoms. Symptoms may be more severe when exposed to more than one centrally acting medicine.

Symptoms may vary but could include poor adaptation, jitteriness, irritability, poor gaze, agitation, hypotonia, hypoglycaemia, gastro-intestinal disturbances, respiratory problems and convulsions. Hypoglycaemia may also manifest as jitteriness/tremors, sweating, irritability, fast breathing, looking pale, and unusual cry. Symptoms typically last for a few days (although symptoms could be delayed or prolonged with mirtazapine due to its extended half-life), but usually resolve without intervention. Continuing breastfeeding may help relieve withdrawal effects.

It may be difficult to distinguish between neonatal withdrawal symptoms and potential side effects from antidepressant exposure through breast milk. If symptoms do not resolve a few days after birth (or longer for mirtazapine), consider that side effects from exposure through breast milk may be a potential cause.

Effect on breastfeeding

Those taking an antidepressant may have more difficulty breastfeeding, particularly with establishing breastfeeding. The underlying condition may contribute to this and additional breastfeeding support may be required.

Specific recommendations

Patient Information

The NHS website provides advice for patients on the use of specific medicines in breastfeeding.

Contact us

Get in touch with the UK Drugs In Lactation Advisory Service (UKDILAS), our specialist breastfeeding medicines advice service if you need support in the following situations:

• you need further advice
• the medicine in question is not included in our advice
• the infant is unwell or premature
• multiple medicines are being taken

About our recommendations

Recommendations are based on published evidence where available. However, evidence is generally very poor and limited, and can require professional interpretation. Assessments are often based on reviewing case reports which can be conflicting and lack detail.

If there is no published clinical evidence, assessments are based on: pharmacodynamic and pharmacokinetic principles, extrapolation from similar drugs, risk assessment of normal clinical use, expert advice, and unpublished data. Simulated data are now increasingly being used due to the ethical difficulties around gathering good quality evidence in this area.

Bibliography

Full referencing is available on request.

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