There is limited information on the recommendation to stop breastfeeding for postpartum depression (PPD). But it is possible to find scientific articles on psychiatric treatment with antidepressants, indicating whether their use during breastfeeding may be harmful..
Postpartum depression (PPD) is the most common maternal psychiatric disorder that negatively affects the mother-infant dyad and infant development, with a prevalence of 15-20% and affects breastfeeding continuity.
The fifth edition of the Statistical Manual of Mental Disorders (DSM-5) characterizes PPD as a moderate to severe depressive episode beginning in the first month after delivery. A guide to diseases and health problems” (ICD-10) defines it as a mild mental and behavioral disorder in the sixth week after birth with a duration of six months.
PPD can cause family dysfunction, interfere with effective mother-child bonding, cause early cessation of breastfeeding, and adversely affect infant brain growth and development.
A common neuroendocrine mechanism between mood, oxytocin levels, and maternal affectivity has been demonstrated in breastfeeding. This supports the position that women with depression benefit from ongoing breastfeeding counseling and support.
Exclusive breastfeeding for the first six months of life provides optimal nutrition for newborns and infants, as endorsed by the World Health Organization and the American Academy of Pediatrics. Breastfeeding problems increase the risk of developing PPD; in addition, PPD negatively affects the duration of breastfeeding. Women with postpartum depression have a higher risk of stopping breastfeeding compared to women who have not experienced depression.
Breastfeeding support and counseling should be a fundamental part of PPD treatment. Timely intervention, encouragement, and promotion of breastfeeding has a potentially significant impact on maternal and infant health.
The physician can evaluate the physical and chemical characteristics of the drug and the patient’s characteristics to determine whether breastfeeding and taking the drug is appropriate.
Generally, only 1% to 2% of any drug dose is transmitted to the infant through breast milk. Although all antidepressants penetrate breast milk, this is not necessarily a contraindication to their use during breastfeeding.
However, if the infant shows negative symptoms, breastfeeding should be stopped. The effects of antidepressants show little evidence of dysmorphogenic harm from use during pregnancy or exposure during lactation. Selective serotonin reuptake inhibitors (SSRIs) (fluoxetine, sertraline, paroxetine) are thought to be compatible with breastfeeding, but there is little or no information about adverse effects on the baby.
Women with postpartum depression are less likely to breastfeed, or if they breastfeed, only briefly, or because of concerns about the possible effects of antidepressants on the baby’s development; therefore, the decision to prescribe an antidepressant to a nursing mother must be based on a careful risk/benefit assessment.
Breastfeeding has been described as a protective factor in first-born mothers; it stimulates some psychological benefits in the nervous and immune systems, reducing inflammatory activity by attenuating increases in cortisol, ACTH, adrenaline, and noradrenaline, reducing maternal reactivity to stress, favoring infant feeding.
The number of women who stop breastfeeding on the advice of health professionals is high. One of the main reasons for stopping breastfeeding is to resume medication due to lack of information.
The understanding of the pharmacokinetics of drugs in human milk has improved considerably over the past 20 years. Most of the physicochemical properties that contribute to drug penetration into breast milk, such as molecular weight, pharmacokinetics, affinity properties, and lipid solubility, have been extensively studied.
Most antidepressants are not contraindicated during lactation; however, some cause high levels in milk.
The risks of drug exposure in preterm infants and very low birth weight infants have not been studied, although these are the most vulnerable subgroup of infants. On the other hand, breastfed infants, who tend to be older, are at low risk of side effects from the drugs.
Sertraline penetrates minimally into breast milk, so it is preferred at the beginning of treatment, but switching to another SSRI is generally not recommended because it may increase the risk of relapse , and no side effects have been reported in infants exposed to this medication.
The benefits of breastfeeding outweigh concerns about SSRI exposure in most cases, but the risks to premature or sick infants should be determined by the pediatrician.
Sertraline is one of the safest antidepressants during breastfeeding. It is recommended to start with low doses and gradually increase them, closely monitoring the newborn for side effects such as irritability, poor feeding or insomnia, especially if the baby was premature or of low birth weight.
The effects of the drug on children can be reduced by not breastfeeding them during the period when drug concentrations are at their highest.
If the decision is made to switch to sertraline, treatment should be initiated after a rigorous assessment of the possible risks and benefits with careful monitoring of the baby.
International studies show that selective serotonin reuptake inhibitor-based antidepressants are among the most commonly used medications in breastfeeding, and that depressive disorders are one of the main reasons leading to medication use.
Sertraline is the drug of first choice for breastfeeding women because of its low level of exposure to infants and the very few side effects described in case reports.
Another article suggests that antidepressants such as sertraline and paroxetine are compatible with breastfeeding, but should be used with caution.
In another review, they noted that although other antidepressants were the treatment of choice several years ago, selective serotonin reuptake inhibitors are now preferred, reportedly for their "Superior safety profile”, Is the most prescribed antidepressant with no side effects.
In general, the benefits of breastfeeding and the low risk of sertraline during PPD treatment are supported; however, according to the aforementioned review, breastfeeding is less common among women with PPD, despite the benefits of breastfeeding.
In a study of breastfeeding mothers with PPD, infants benefited significantly: one-month-old infants who had a stable breastfeeding regimen had less risk of developing reactive personality traits, and at one month of age, they did not show abnormal asymmetry of the frontal EEG, commonly seen in children of mothers with postpartum depression.
In addition, the mother-child pair continued to interact better when the infants were three months old. Thus, breastfeeding benefited them, although it is unclear whether the mothers were taking antidepressants.
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Most studies have conflicting information about stopping breastfeeding during antidepressant treatment. The American Academy of Pediatrics and the World Health Organization advocate exclusive breastfeeding for the first six months because it is good for the mother and optimal infant nutrition.
Breastfeeding may be an alternative if breastfeeding difficulties are triggers or chronic factors in depression itself.
Although regulatory agencies have proposed a framework for breastfeeding clinical trials, data on drug absorption into breast milk are often lacking, and recommendations can be misleading, leading to confusion, leading to early discontinuation of breastfeeding or inadequate medical care, in which case the physician may evaluate the physical and chemical characteristics of the drug and patient characteristics to determine whether breastfeeding is appropriate. Despite this, most medications are considered safe during breastfeeding.
Scientific societies recommend that prescribing pharmacologic treatment during breastfeeding should be based on an individual assessment of each case, as well as providing information to parents to facilitate decision making and communication with the pediatrician to adequately monitor the infant’s clinical condition.
It is also recommended that you start with low doses, gradually adjust the dose, and prescribe treatment preferably in single doses.
The decision to use a medication should take into account factors that will allow the most appropriate choice in each case: pharmacokinetics (route of administration, dose, interval between doses); physical and chemical characteristics of the medication (solubility and protein binding); aspects of breastfeeding (infant age, frequency of feeding, time between drug intake and feedings).
The frequent use of medications during breastfeeding indicates a real need for a more thorough review of psychotropic medications used in this age group, very few medications require stopping breastfeeding, medications that need to be taken for a long time can be prescribed reasonably for the welfare of mother and child. Working together to support the woman and doctor in making the best decision about starting and continuing breastfeeding.