I am currently back on LACTNET between jobs at the NIH and the FDA.

Until I am at the FDA, I can be contacted at: [log in to unmask]

My updated three-part series on medication use in breastfeeding will be
published in the January, March, and May issues of the "journal of Pharmacy
Technology."

I have completed my first draft of my textbook which will be a practical
guide for mothers and their healthcare professionals on the use of all types
of medications and herbals during breastfeeding.

SSRIs are similar to the tricyclic antidepressants, but usually have less
side effects for the mother.
Tricyclics are still a possible choice for breastfeeding mothers.There are
no repots of adverse effects in infants with mothers' use of desipramine,
amitriptyline, nortriptyline, or imipramine.  These would appear to be the
drugs of choice for tricyclic antiderpressants.

Of the SSRIs, the drugs of choice appear to be sertraline (as it does not
appear to significantly change infant plasma serum serotonin levels, it has
high protein binding, and infant doses are 2 to 3% of mothers' doses),
paroxetine (it is minimally excreted into breast milk at 1% of mothers'
doses with no detectable levels in infants' plasma with no adverse effects
noted, which may make it the best choice of all SSRIs), fluvoxamine (drug
minimally gets into breast milk at 0.5% with no adverse effects reported in
infants; it also has a short half-life, no active metabolite, and infant
plasma levels too low to detect), and bupropion (very little appears in
infants' plasma, and no adverse effects have been noted).

Most mothers are on antidepressants during pregnancy.  If the drug has been
effective during pregnancy, it should be continued during breastfeeding
(this includes fluoxetine).  Since the infant drug load may be highest right
after birth, mother and infant plasma levels may be advisable at this time
to establish a baseline.  If adverse reactions occur in the infant, it is
then that the drug use should be reevaluated and another antidepressant
chosen if necessary.  The mother should be weaned off the the initial
antidepressant while being titrated with the new antidepressant.

If the mother wishes to begin an antidepressant while breastfeeding, the
drug choices listed above should be utilized.

Useful guidelines are: review risks and benefits of treatment versus
nontreatment (taking into account also the benefits of breastfeeding),
choose drugs based upon (if not already on drug during pregnancy, or if
adverse effects occur on drug during breastfeeding) clinical status of the
mother and prior treatment response, use the lowest effective dose, do not
use multiple drugs, watch the mother and infant for adverse symptoms and
take plasma levels if necessary, and inform mothers of potential side
effects to look for in their children.  Each case must be evaluated
individually and carefully.

Finally, a  live mother taking an antidepressant who is breastfeeding in
better than a dead mother who has committed suicide and cannot breastfeed.

Frank J. Nice, DPA, CPHP

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