Dear Lactnet associates,
   Any discussion of antidepressant use in the bf'ing mother has to be
tempered by the statement of the American Academy of Ped's Committee on
Drugs published in Pediatrics Vol 93 pp.137-50 (1/94).  In that article that
Committee lists ALL antidepressant drugs in the category of "Drugs whose
effect on nursing infants is unknown but may be of concern."  It goes on to
explain that "no case reports of adverse effects in bf'ing infants, these
drugs do appear in human milk and this could *conceivably* alter short-term
and long-term central nervous system funtion"
   Nontheless many physicians have successfully treated bf'ing mothers with
antidepressants without apparent adverse effects on the infant.  Certainly
the older class of drugs, the tricyclic antidepressants such as
nortriptyline (Pamelor and others) have the longest track record of apparent
safety for bf'ing moms and their infants.  (see also the input in this
regard from Cindy Smith.)  However this class of drugs has many side effects
which limit usefulness.
   Newer drugs such as the selective serotonin reuptake inhibitors (SSRI's)
such as Prozac (fluoxetine), Zoloft, Paxil and now others have been a great
advance in the field of psychopharmacology because of their tolerability
and perhaps more rapid onset of action.  Before I forget, let me comment on
some writers' concerns with messing with serotonin.  Realize that serotonin
is a neurotransmitter, BUT so is norepinephrine, dopamine, acetylcholine and
others.  All antidepressants affect one or another neurotransmitter.  That
is how they work!  I am not aware of any greater need for concern when it
comes to drugs that affect serotonin versus other neurotransmitters in the
bf'ing mother.
   I certainly agree with the concern expressed by many writers here that
with such a new drug class such as the SSRI's, we don't know the full
ramifications of using it on bf'ing moms with PP depression.  Nontheless
there is at least one encouraging report published in Pediatrics which is
worth quoting from.  In a 1992 article (pp676-7), Kelly Burch and Barbara
Wells, Pharm D's reviewed fluoxetine and norfluoxetine (the parent and major
breakdown product of Prozac) concentrations in human milk.  This study
involved only one patient treated for PP depression begun 10 weeks post
delivery.  They found levels in the milk of 120 ng/ml which if the baby
receives 150 ml/kg of milk per day produces a dose in the infant of 15-20
micrograms/kg per day.  In other words in a 10 kg. baby, this would amount
to ingesting 0.2 mg/day.  Compare this to the 60 kg mother who is taking 20
mg. daily.  Based on my calculations, this would lead to a dose in the
mother of >300 micrograms/kg/day.  In other words the baby is receiving less
than 0.5% of the therapeutic dose on a weight for weight basis.  Are you
still with me?  The authors go on to say that based on their measurements
and calculations, combined with their observations of no adverse behavioral
or developmental outcome in the baby, it may be reassuring to those who
consider using Prozac as an alternative to traditional agents in lactationg
mothers with PP depression.  They go on to say that further work is needed
before Prozac becomes a *preferred* agent in this situation.
   Let me clear up one other point.  One of our participants on Lactnet
state that Briggs 1994 edition describes Prozaac as contraindicated with
bf'ing.  MY 1994 volume of Briggs states no such thing (p. 375)!  The only
statement of concern in my volume of Briggs is that which I described in the
opening of this letter--that of the American Academy of Peds where Prozac
was lumped with all other antidepressants  whose effects are unknown but may
be of concern.
   As an internist, I have successfully ised nortriptyline for PP
depression.  I don't have any personal experience with prescribing Prozac
for the bf'ing mother.
   Regarding Melissa's question, certainly one would expect that the
exposure of a 3 year old to Prozac excreted in breastmilk would be much less
than the younger child due to the fact that a 3 year old would be consuming
a substantial amount of solid foods.  Also one would expect that neurological
 development
would be more advanced  than in the younger child.  Therefore there
should be less concern.
   I certainly look forward to others' experiences and research in this
area.
                       Harry Chaikin, M.D.