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.
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