Here is the letter I sent to the good doctors who wrote the letter to 
the New England Journal about sertraline (Zoloft).  For those of you 
wondering about any medication and breastfeeding, the approach, I think 
should be summed up as below:  

I found your letter to the New England Journal about sertraline very 
informative and fascinating.  I think the information you provide, plus 
the known pharmacokinetics of sertraline which suggest that very little 
indeed would get into the milk, will help move us away from the 
situation where every nursing mother is being told to discontinue 
breastfeeding when prescribed antidepressants.  

I would just like to suggest, however, that there is more to consider in 
prescribing a drug such as sertraline, or paroxetine, which would also, 
at least in theory, result in extremely low milk levels, than whether 
the drug results in ³physiologically meaningful² effects on the baby.  

If we decide that a mother cannot be treated pharmacologically for her 
depression without stopping breastfeeding, then what is the option?  The 
option, if the baby is young, is an industrially produced milk, which 
also has physiologically meaningful effects on the baby‹physiologically 
meaningful effects which are not only theoretical.  For example, 
epidermal growth factor, present in human milk, but absent from formula 
results in more rapid maturation of the gut, with more rapid sealing up 
of the ³leaky² mucosa of the newborn intestine.  This has been 
demonstrated conclusively in animals, and studies suggest it is true in 
humans as well.  The passage of foreign proteins through the mucosa may 
have serious long term effects on the child.  For the child at risk of 
developing juvenile diabetes, for example, exposure to cow milk protein 
may increase his risk considerably (1-4).  The presence of a host of 
immune factors present in human milk (and absent in formula), which not 
only protect the infant passively, but may also cause more rapid 
maturation of his immune system, needs to be also taken into account 
(5).  Indeed, there are hundreds of physiologically active factors known 
to be present in human milk which are not present in formula.  

Certainly, one needs to be prudent in the use of medication for nursing 
mothers, or anyone for that matter.  But this prudence should also 
extend to the replacement for the physiologic method of feeding.  It is 
rare for the risk of breastfeeding (with added sertraline, or whatever) 
to outweigh the risk of formula.

Finally, I am at the receiving end of many, sometimes desperate, calls 
from nursing mothers being told they must stop breastfeeding because 
they are to be put on sertraline, or amoxycillin, or propranalol or 
whatever.  The ones who are suffering from postpartum depression often, 
in surprisingly similar terms, express their dilemma‹³The only thing 
which is going well for me in the world is the breastfeeding, and they 
want me to stop that².  As if such a mother has not suffered enough 
loss. 

With so little evidence of harm of tiny amounts of most antidepressants 
in the milk, with some compelling evidence of the harm of artificial 
feeding, surely, in the final analysis too, it is the mother who should 
make an informed choice based on complete information of what we know 
and do not know.  Unfortunately, many physicians treating nursing 
mothers with antidepressants present them with an ultimatum:  ³Stop 
breastfeeding or I will not prescribe this medication².    

There is more to this issue than ³Will the baby get some drug in the 
milk².  I thank you for your attention.