Is Sertraline safe while breastfeeding?

Effects on the breastfed infant

Benign neonatal sleep myoclonus occurred in one 4-month-old infant and agitation that spontaneously resolved whose mother was taking sertraline 75 mg daily.[ 23 ] None of 26 infants with an average age of 16.6 weeks (range 4 to 28 weeks) whose mothers were receiving an average of 124 mg sertraline daily had any detectable acute adverse reactions to sertraline in breastmilk. All had been breastfeeding for at least 3 weeks.[ 11 ] Whole blood serotonin levels were measured in 14 mothers and their breastfed infants after 6 to 16 weeks of sertraline therapy. Maternal dosages ranged from 25 to 200 mg daily. Although maternal serotonin levels were decreased from 159 mcg/L to 19 mcg/L by sertraline therapy, infant serotonin levels averaged 227 mcg/L before and 224 mcg/L after maternal therapy. The authors concluded that these findings indicate that the amount of sertraline ingested by the infants was not sufficient to affect platelet serotonin uptake in breastfed infants. Platelets and neurons both have the same serotonin transporter, so this lack of effect was seen as indirect evidence of safety of sertraline use during breastfeeding. None of the infants experienced any adverse effects from sertraline in breastmilk, including 6 exclusively breastfed infants under 3 months of age.[ 27 ] Twenty-five mothers who took an average sertraline dosage of 82.4 mg daily breastfed their infants exclusively for 4 months and breastfed at least 50% during months 5 and 6. Their infants had 6-month weight gains that were normal according to national growth standards and the mothers reported no abnormal effects in their infants.[ 28 ] In 6 infants aged 5 to 34 weeks whose mothers were taking sertraline 50 to 100 mg daily, no adverse reactions were noted clinically at the time of the study.[ 12 ] No adverse effects were seen in 7 infants who were 4 weeks old and whose mothers had been taking sertraline 50 mg daily since day 4 postpartum.[ 25 ] One study of side effects of SSRI antidepressant

Effects on milk supply

Sertraline has caused galactorrhea in nonpregnant, nonnursing patients, sometimes with normal serum prolactin.[ 45 - 51 ] However, in a study of cases of hyperprolactinemia and its symptoms (e.g., gynecomastia) reported to a French pharmacovigilance center, sertraline was not found to have an increased risk of causing hyperprolactinemia compared to other drugs.[ 52 ] The prolactin level in a mother with established lactation may not affect her ability to breastfeed. A midwife observed 6 patients who reported a decrease in milk supply after starting sertraline (dosages not reported). One of the mothers had been taking sertraline since the 6th month of pregnancy. She reported an increase in milk supply when she stopped sertraline for one week at 4 months postpartum. When she restarted sertraline, her milk supply reportedly decreased. In all of the women, the milk supply increased in 2 to 3 days after increasing fluid and the frequency of nursing.[ 53 ] In a small prospective study, 8 primiparous women who were taking a serotonin reuptake inhibitor (SRI; 3 taking fluoxetine and 1 each taking citalopram, duloxetine, escitalopram, paroxetine or sertraline) were compared to 423 mothers who were not taking an SRI. Mothers taking an SRI had an onset of milk secretory activation (lactogenesis II) that was delayed by an average of 16.7 hours compared to controls (85.8 hours postpartum in the SRI-treated mothers and 69.1 h in the untreated mothers), which doubled the risk of delayed feeding behavior in the untreated group. However, the delay in lactogenesis II may not be clinically important, since there was no statistically significant difference between the groups in the percentage of mothers experiencing feeding difficulties after day 4 postpartum.[ 54 ] A case control study compared the rate of predominant breastfeeding at 2 weeks postpartum in mothers who took an SSRI antidepressant throughout pregnancy and at delivery (n = 167) or an SSRI during pregnancy only (n = 117)

Levels in milk

Sertraline is metabolized to norsertraline (desmethylsertraline), which has antidepressant activity of about 10% that of sertraline. Maternal Levels. In a pooled analysis of serum levels from published studies and 4 unpublished cases, the authors found that 15 mothers taking an average daily dosage of 83 mg (range 25 to 200 mg) had an average breastmilk sertraline level of 45 mcg/L (range 7 to 207 mcg/L).[ 1 ] Using the average dosage and milk level data from this paper, an exclusively breastfed infant would receive an estimated 0.5% of the maternal weight-adjusted dosage of sertraline. Twenty-six women who were an average of 15.8 weeks postpartum (range 5 to 36 weeks) and receiving an average of 124 mg sertraline daily for at least 14 days for severe depression were studied while breastfeeding with extensive milk and serum sampling over a 24-hour period. All milk samples had detectable sertraline (average 129 mcg/L; range 11 to 938 mcg/L) and norsertraline (average 258 mcg/L; range 20 to 1498 mcg/L). Drug concentrations were higher in the hindmilk than the foremilk. Analysis of milk sertraline data from 15 mothers who submitted complete sets of milk samples indicated that the peak concentration of the drug and metabolite occurred 8 to 9 hours after a dose. In these women, the concentration in milk correlated with serum concentration, but not daily dosage. The authors estimated that an exclusively breastfed infant would receive an average of 0.54% of the maternal weight-adjusted dosage and that pumping and discarding milk 8 to 9 hours after the mother's dose would decrease the infant's daily dosage by 17%.[ 11 ] From data in 6 mothers who were 5 to 34 weeks postpartum and taking sertraline in an average daily dosage of 64 mg (range 50 to 100 mg), the authors estimated that an exclusively breastfed infant would receive 0.9% of the maternal weight-adjusted dosage.[ 12 ] At 2 months postpartum, 4 mothers taking an average of 87.5 mg of sertraline daily had average milk

Alternatives LactMed lists

• Nortriptyline
• Paroxetine