SSRIs during breastfeeding: spotlight on milk-to-plasma ratio

Consensus Panel Recommendations for the Pharmacological Management of Breastfeeding Women with Postpartum Depression

INTRODUCTION

Our consensus statement aims to clarify the use of antidepressants and anxiolytics during breastfeeding amidst clinical uncertainty. Despite recent studies, potential harm to breastfed newborns from these medications remains a concern, leading to abrupt discontinuation of necessary treatments or exclusive formula feeding, depriving newborns of benefits from mother's milk.

METHODS

A panel of 16 experts, representing eight scientific societies with a keen interest in postpartum depression, was convened. Utilizing the Nominal Group Technique and following a comprehensive literature review, a consensus statement on the pharmacological treatment of breastfeeding women with depressive disorders was achieved.

RESULTS

Four key research areas were delineated: (1) The imperative to address depressive and anxiety disorders during lactation, pinpointing the risks linked to untreated maternal depression during this period. (2) The evaluation of the cumulative risk of unfavorable infant outcomes associated with exposure to antidepressants or anxiolytics. (3) The long-term impact on infants' cognitive development or behavior due to exposure to these medications during breastfeeding. (4) The assessment of pharmacological interventions for opioid abuse in lactating women diagnosed with depressive disorders.

CONCLUSIONS

The ensuing recommendations were as follows: Recommendation 1: Depressive and anxiety disorders, as well as their pharmacological treatment, are not contraindications for breastfeeding. Recommendation 2: The Panel advocates for the continuation of medication that has demonstrated efficacy during pregnancy. If initiating an antidepressant during breastfeeding is necessary, drugs with a superior safety profile and substantial epidemiological data, such as SSRIs, should be favored and prescribed at the lowest effective dose. Recommendation 3: For the short-term alleviation of anxiety symptoms and sleep disturbances, the Panel determined that benzodiazepines can be administered during breastfeeding. Recommendation 4: The Panel advises against discontinuing opioid abuse treatment during breastfeeding. Recommendation 5: The Panel endorses collaboration among specialists (e.g., psychiatrists, pediatricians, toxicologists), promoting multidisciplinary care whenever feasible. Coordination with the general practitioner is also recommended.

Computational Approach to Drug Penetration across the Blood-Brain and Blood-Milk Barrier Using Chromatographic Descriptors

Drug penetration through biological barriers is an important aspect of pharmacokinetics. Although the structure of the blood-brain and blood-milk barriers is different, a connection can be found in the literature between drugs entering the central nervous system (CNS) and breast milk. This study was created to reveal such a relationship with the use of statistical modelling. The basic physicochemical properties of 37 active pharmaceutical compounds (APIs) and their chromatographic retention data (TLC and HPLC) were incorporated into calculations as molecular descriptors (MDs). Chromatography was performed in a thin layer format (TLC), where the plates were impregnated with bovine serum albumin to mimic plasma protein binding. Two columns were used in high performance liquid chromatography (HPLC): one with immobilized human serum albumin (HSA), and the other containing an immobilized artificial membrane (IAM). Statistical methods including multiple linear regression (MLR), cluster analysis (CA) and random forest regression (RF) were performed with satisfactory results: the MLR model explains 83% of the independent variable variability related to CNS bioavailability; while the RF model explains up to 87%. In both cases, the parameter related to breast milk penetration was included in the created models. A significant share of reversed-phase TLC retention values was also noticed in the RF model.

Comparison of statistical methods for predicting penetration capacity of drugs into human breast milk using physicochemical, pharmacokinetic and chromatographic descriptors

In silico methods are often used for predicting pharmacokinetic properties of drugs due to their simplicity and cost-effectiveness. This study evaluates the penetration of 83 active pharmaceutical ingredients into human breast milk with an experimental milk-to-plasma ratio (M/P) obtained from the literature. Multiple linear regression (MLR), partial least squares (PLS) and random forest (RF) regression methods were compared to uncover the relationship between physicochemical, pharmacokinetic and membrane crossing properties of active pharmaceutical ingredients (APIs) using their rapid reference measurement value (R_f values), thin-layer chromatography (TLC) data from albumin-impregnated plates. Molecular descriptors of APIs proven to be important for their crossing into breast milk, including protein binding, ionisation state and lipophilicity and TLC data, have been included in the development of the prediction models. The best regression results were achieved by MLR (r ² = 0.83 and r ² = 0.86, n = 28) and RF (r ² = 0.85, n = 58). In addition, the discriminant function analysis (DFA) was performed on acidic, basic and neutral drugs separately and showed a prediction accuracy of 93%, with M/P included as the discriminating variable.

Biological barriers, and the influence of protein binding on the passage of drugs across them

Drug-protein binding plays a key role in determining the pharmacokinetics of a drug. The distribution and protein binding ability of a drug changes over a lifetime, and are important considerations during pregnancy and lactation. Although proteins are a significant fraction in plasma composition, they also exist beyond the bloodstream and bind with drugs in the skin, tissues or organs. Protein binding influences the bioavailability and distribution of active compounds, and is a limiting factor in the passage of drugs across biological membranes and barriers: drugs are often unable to cross membranes mainly due to the high molecular mass of the drug-protein complex, thus resulting in the accumulation of the active compounds and a significant reduction of their pharmacological activity. This review describes the consequences of drug-protein binding on drug transport across physiological barriers, whose role is to allow the passage of essential substances-such as nutrients or oxygen, but not of xenobiotics. The placental barrier regulates passage of xenobiotics into a fetus and protects the unborn organism. The blood-brain barrier is the most important barrier in the entire organism and the skin separates the human body from the environment.

Exposure of dams to fluoxetine during lactation disturbs maternal behavior but had no effect on the offspring behavior

Fluoxetine is one of the most commonly prescribed drugs for treatment of depression during pregnancy as well as postpartum. Nevertheless, fluoxetine can cross the placental barrier and/or be secreted through breastmilk and questions remain unanswered regarding safety of the unborn and/or nursing infant. Passive administration of antidepressants to infants can cause neurological developmental delay and/or dysfunction. To date, there are limited studies on neurobehavioral effects due to passive administration of fluoxetine in nursing animals. Thus, the aim of the present study was to evaluate the effects of fluoxetine exposure on the behavior of lactating dams and their offspring. Dams received either 1, 10 or 20 mg/kg fluoxetine via oral gavage (controls received water alone) from lactating day (LD) 1 to 21. Maternal behavioral studies were conducted from LD5 to LD7 and offspring studies were conducted from LD2 to LD60. Results showed dysfunction in maternal behavior, both in direct and indirect behavior, but there were no differences and/or deficiencies observed in offspring behavior. These data suggest that the impairment of dams maternal behavior combined with the amount of fluoxetine that the offspring received through breast milk during lactation did not alter their social behavior in infancy and/or adulthood, suggesting no neurodevelopmental damage associated with maternal use of fluoxetine. This study contributes to the field of human psychiatric diseases by further elucidating the effects of antidepressant medications on the health of mothers as well as children who were passively exposed to drug treatment.

Extreme enhancement or depletion of serotonin transporter function and serotonin availability in autism spectrum disorder

A variety of human and animal studies support the hypothesis that serotonin (5-hydroxytryptamine or 5-HT) system dysfunction is a contributing factor to the development of autism in some patients. However, many questions remain about how developmental manipulation of various components that influence 5-HT signaling (5-HT synthesis, transport, metabolism) persistently impair social behaviors. This review will summarize key aspects of central 5-HT function important for normal brain development, and review evidence implicating perinatal disruptions in 5-HT signaling in the pathophysiology of autism spectrum disorder. We discuss the importance, and relative dearth, of studies that explore the possible correlation to autism in the interactions between important intrinsic and extrinsic factors that may disrupt 5-HT homeostasis during development. In particular, we focus on exposure to 5-HT transport altering mechanisms such as selective serotonin-reuptake inhibitors or genetic polymorphisms in primary or auxiliary transporters of 5-HT, and how they relate to neurological stores of serotonin and its precursors. A deeper understanding of the many mechanisms by which 5-HT signaling can be disrupted, alone and in concert, may contribute to an improved understanding of the etiologies and heterogeneous nature of this disorder. We postulate that extreme bidirectional perturbations of these factors during development likely compound or synergize to facilitate enduring neurochemical changes resulting in insufficient or excessive 5-HT signaling, that could underlie the persistent behavioral characteristics of autism spectrum disorder.

Mindful with Your Baby: Feasibility, Acceptability, and Effects of a Mindful Parenting Group Training for Mothers and Their Babies in a Mental Health Context

Many mothers experience difficulties after the birth of a baby. Mindful parenting may have benefits for mothers and babies, because it can help mothers regulate stress, and be more attentive towards themselves and their babies, which may have positive effects on their responsivity. This study examined the effectiveness of Mindful with your baby, an 8-week mindful parenting group training for mothers with their babies. The presence of the babies provides on-the-spot practicing opportunities and facilitates generalization of what is learned. Forty-four mothers with their babies (0-18 months), who were referred to a mental health clinic because of elevated stress or mental health problems of the mother, infant (regulation) problems, or mother-infant interaction problems, participated in 10 groups, each comprising of three to six mother-baby dyads. Questionnaires were administered at pretest, posttest, 8-week follow-up, and 1-year follow-up. Dropout rate was 7%. At posttest, 8-week follow-up, and 1-year follow-up, a significant improvement was seen in mindfulness, self-compassion, mindful parenting, (medium to large effects), as well as in well-being, psychopathology, parental confidence, responsivity, and hostility (small to large effects). Parental stress and parental affection only improved at the first and second follow-ups, respectively (small to medium effects), and maternal attention and rejection did not change. The infants improved in their positive affectivity (medium effect) but not in other aspects of their temperament. Mindful with your baby is a promising intervention for mothers with babies who are referred to mental health care because of elevated stress or mental health problems, infant (regulation) problems, or mother-infant interaction problems.

Developmental fluoxetine exposure increases behavioral despair and alters epigenetic regulation of the hippocampal BDNF gene in adult female offspring

A growing number of infants are exposed to selective serotonin reuptake inhibitor (SSRI) medications during the perinatal period. Perinatal exposure to SSRI medications alter neuroplasticity and increase depressive- and anxiety-related behaviors, particularly in male offspring as little work has been done in female offspring to date. The long-term effects of SSRI on development can also differ with previous exposure to prenatal stress, a model of maternal depression. Because of the limited work done on the role of developmental SSRI exposure on neurobehavioral outcomes in female offspring, the aim of the present study was to investigate how developmental fluoxetine exposure affects anxiety and depression-like behavior, as well as the regulation of hippocampal brain-derived neurotrophic factor (BDNF) signaling in the hippocampus of adult female offspring. To do this female Sprague-Dawley rat offspring were exposed to prenatal stress and fluoxetine via the dam, for a total of four groups of female offspring: 1) No Stress+Vehicle, 2) No Stress+Fluoxetine, 3) Prenatal Stress+Vehicle, and 4) Prenatal Stress+Fluoxetine. Primary results show that, in adult female offspring, developmental SSRI exposure significantly increases behavioral despair measures on the forced swim test, decreases hippocampal BDNF exon IV mRNA levels, and increases levels of the repressive histone 3 lysine 27 tri-methylated mark at the corresponding promoter. There was also a significant negative correlation between hippocampal BDNF exon IV mRNA levels and immobility in the forced swim test. No effects of prenatal stress or developmental fluoxetine exposure were seen on tests of anxiety-like behavior. This research provides important evidence for the long-term programming effects of early-life exposure to SSRIs on female offspring, particularily with regard to affect-related behaviors and their underlying molecular mechanisms.

Prenatal stress and early-life exposure to fluoxetine have enduring effects on anxiety and hippocampal BDNF gene expression in adult male offspring

With the growing use of selective serotonin reuptake inhibitor medications (SSRIs) for the treatment of depression during the perinatal period, questions have been raised about the longterm impact of these medications on development. We aimed to investigate how developmental SSRI exposure may alter affect-related behaviors and associated molecular processes in offspring using a rodent model of maternal stress and depression. For this purpose, prenatally stressed or non-stressed male offspring were exposed to fluoxetine (5 mg/kg/day) or vehicle, via lactation, until weaning. Primary results show that postnatal fluoxetine exposure differentially altered anxiety-like behavior by increasing anxiety in non-stressed offspring and decreasing anxiety in prenatally stressed offspring. In the hippocampus, developmental fluoxetine exposure decreased BDNF IV and TrkB mRNA expression. Prenatal stress alone also decreased escape behaviors and decreased hippocampal BDNF IV mRNA expression. These data provide important evidence for the long-term programming effects of early-life exposure to SSRIs on brain and behavior.

Developmental exposure to SSRIs, in addition to maternal stress, has long-term sex-dependent effects on hippocampal plasticity

RATIONALE

During pregnancy and postpartum period, 20 % of women are affected by depression, which is a growing health concern. Selective serotonin reuptake inhibitor (SSRI) medications are popular treatments for maternal depression; however, the effect of maternal depression and perinatal SSRI exposure on offspring's neural development needs further investigation.

OBJECTIVES

This study aims to determine the role of developmental fluoxetine exposure on hippocampal plasticity in the adult offspring.

METHODS

Sprague-Dawley rat offspring were exposed to fluoxetine beginning on postnatal day 1. Offspring were also exposed to prenatal maternal stress. Four groups of male and female offspring were used: (1) prenatal stress + fluoxetine, (2) prenatal stress + vehicle, (3) fluoxetine alone, and (4) vehicle alone. Hippocampi were analyzed for levels of cell proliferation, immature neurons, and new cell survival (3 weeks after 5-bromo-2-deoxyuridine injection) in the granule cell layer, as well as synaptophysin density in the CA3 region and granule cell layer. TPH staining was assessed in the dorsal raphe nucleus.

RESULTS

Developmental fluoxetine exposure to prenatally stressed offspring reversed the effect of prenatal stress or fluoxetine exposure alone on the number of immature neurons. Prenatal stress alone, regardless of developmental exposure to fluoxetine, markedly decreased hippocampal cell proliferation and tended to decrease new cell survival. Furthermore, in adult female offspring, developmental fluoxetine exposure greatly increased new cell survival and significantly decreased synaptophysin density in the granule cell layer.

CONCLUSIONS

There are long-term effects of developmental SSRI exposure on hippocampal plasticity that is differentially affected by expose to maternal adversity and offspring sex.

Serotonin reuptake inhibitors and breastfeeding: a systematic review

OBJECTIVE

The postnatal period represents a critical phase for mothers because of physiological hormonal changes, the increase of emotional reactions and a greater susceptibility for the onset/recrudescence of psychiatric disorders. Despite the evidence of an increasing utilization of antidepressant drugs during breastfeeding, there is still few reliable information on the neonatal safety of the selective serotonin reuptake inhibitors (SSRIs) and selective noradrenergic reuptake inhibitors (SNRIs) [serotonin reuptake inhibitors (SRIs)] in nursing mothers. The aim of this study is to provide a systematic review on the neonatal safety profile of these drugs during breastfeeding, also assessing the limits of available tools.

METHODS

MEDLINE and PubMed databases were searched without any language restrictions by using the following set of keywords: ((SSRIs OR selective serotonin inhibitor reuptake OR SNRIs OR selective serotonin noradrenaline inhibitor reuptake) AND (breastfeeding OR lactation OR breast milk)). A separate search was also performed for each SSRIs (paroxetine, fluvoxamine, fluoxetine, sertraline, citalopram and escitalopram) and SNRIs (venlafaxine and duloxetine).

RESULTS

Sertraline and paroxetine show a better neonatal safety profile during breastfeeding as compared with other SRIs. Less data are available for fluvoxamine, escitalopram and duloxetine. Few studies followed up infants breastfeed for assessing the neurodevelopmental outcomes.

CONCLUSIONS

Literature review clearly indicates paroxetine and sertraline as the drugs that should be preferred as first line choice in nursing women who need an antidepressant treatment.

Tricyclic antidepressants in pregnancy and puerperium

INTRODUCTION

Several concerns have been raised regarding the reproductive safety of the antidepressants most frequently used in clinical practice, such as selective serotonin reuptake inhibitors (SSRIs).

AREAS COVERED

This article aims to assess the risk/benefit ratio of the use of alternative pharmacological options, specifically tricyclic antidepressants (TCAs) in pregnancy and puerperium.

EXPERT OPINION

Although TCAs have been prescribed for several decades, their own teratogenic potential to cause structural defects remains undetermined. However, some signals seem to exist suggesting that prenatal clomipramine exposure may increase the risk of cardiac defects. Moreover, TCAs have been associated with the risk of prenatal antidepressant exposure syndrome. Among TCAs, clomipramine seems to be associated with more severe and prolonged neonatal symptoms. However, some findings of this syndrome reported with SSRI use, such as persistent pulmonary hypertension of the newborn, necrotizing enterocolitis and QT prolongation, have not been described after TCA exposure. Hence, current evidence suggests that, as a group, a preference of TCAs over SSRIs in early pregnancy is not justified. In contrast, there appears to be a small gain in safety if TCAs (with the exception of clomipramine) are used in late pregnancy. Among this class of antidepressants, nortriptyline seems to be safest medication for use during breastfeeding.

Developmental fluoxetine exposure facilitates sexual behavior in female offspring

RATIONALE

A growing number of infants are being exposed to selective serotonin reuptake inhibitor (SSRI) medications during the perinatal period. SSRIs target the serotoninergic system and are a popular treatment for maternal mood disorders. Serotonin itself plays a key role in the sexual differentiation through its role in the development of the hypothalamic-pituitary-gonadal axis, and previous research has shown that developmental SSRI exposure has an effect on sexual behavior in male offspring.

OBJECTIVES

Our aim was to determine the role of developmental exposure to a popular SSRI medication, fluoxetine, on sexual differentiation of the brain and behavior in female offspring using a rodent model of maternal adversity.

METHODS

Stressed and non-stressed Sprague-Dawley rat dams were chronically treated with either fluoxetine (5 mg/kg/day) or vehicle beginning on postnatal day 1. Four groups of female offspring were used: (1) control + vehicle, (2) control + fluoxetine, (3) prenatal stress + vehicle, and (4) prenatal stress + fluoxetine.

RESULTS

Primary results show that in adult female offspring, developmental fluoxetine exposure facilitates proceptive and receptive behaviors with a significant increase in the number of proceptive behaviors, a significant increase in the lordosis quotient, and a significant decrease in the rejection quotient.

CONCLUSIONS

This research contributes in the understanding of the long-term impact developmental fluoxetine exposure on the hypothalamus-pituitary-gonadal (HPG) system in adult female offspring.

Developmental fluoxetine exposure and prenatal stress alter sexual differentiation of the brain and reproductive behavior in male rat offspring

Depression during pregnancy and postpartum is a significant health problem and affects up to 20% of women. While selective serotonin reuptake inhibitor (SSRI) medications are the drug of choice for treatment of maternal depression, the combined effect of maternal depression and perinatal SSRI exposure on offspring development is poorly investigated. Our aim was to determine the role of exposure to fluoxetine during development on sexual behavior and sexually dimorphic brain structures in male offspring using a rodent model of maternal adversity. Sprague-Dawley rat dams were stressed during gestation and were chronically treated throughout lactation with either fluoxetine or vehicle beginning on postnatal day 1. Four groups of offspring were used: (1) Control+Vehicle, (2) Control+Fluoxetine, (3) Prenatal Stress+Vehicle, and (4) Prenatal Stress+Fluoxetine. We show here that developmental fluoxetine treatment decreases the anogenital distance in juvenile male offspring. In adult male offspring, maternal fluoxetine treatment results in a decrease in the number of intromissions, a longer latency to the first intromission, and a longer latency to the first ejaculation. Furthermore, developmental fluoxetine and/or prenatal stress decrease the area of the sexually dimorphic nucleus of the preoptic area (SDN-POA). Prenatal stress, but not exposure to developmental fluoxetine, decreases the number of tyrosine hydroxylase (TH)-positive cells in anteroventral periventricular nucleus (AVPv) and the volume of the posterior bed nucleus of the stria terminalis (pBST) in male offspring. These results provide important evidence for the long-term impact of maternal adversity and maternal fluoxetine use on the development of primary endocrinology systems in juvenile and adult male offspring.

Postpartum depression: diagnostic and treatment issues

Postpartum depression is the most common psychiatric complication of child-bearing. Despite the potentially deleterious effects of postpartum depression on the mother and her infant, the disorder is often unrecognized and untreated. Women may be reluctant to seek professional help because of the stigma of mental illness, or they may be unwilling to try medication because of concerns about safety during lactation. In this review of postpartum depression, we discuss its clinical presentation, diagnosis, differential diagnosis, and treatment.

Breastfeeding among women exposed to antidepressants during pregnancy

This prospective cohort study compares the breastfeeding outcomes of women exposed to selective serotonin reuptake inhibitor (SSRI) antidepressants at the time of delivery, those who discontinued use prior to delivery, and those not exposed. Participants include 466 pregnant women who enrolled in the California Teratogen Information Service Clinical Research Program (CTIS) over 10 years. In bivariate analyses, breastfeeding rates were significantly different across SSRI exposure groups, with unexposed women having the highest rates. We used logistic regression to examine the relationship between SSRI exposure and breastfeeding outcomes. After adjustment for potential confounders, those exposed to an SSRI both prior to delivery (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.20-0.94) and at the time of delivery (OR, 0.34; 95% CI, 0.16-0.72) were significantly less likely to initiate breastfeeding as compared to unexposed women. Women exposed to an SSRI during pregnancy appear to be at risk for poorer breastfeeding outcomes and may benefit from additional education and support.

Perinatal pharmacology: applications for neonatal neurology

The principles of clinical pharmacology also apply to neonates, but their characteristics warrant a tailored approach. We focus on aspects of both developmental pharmacokinetics (concentration/time relationship) and developmental pharmacodynamics (concentration/effect relationship) in neonates. We hereby aimed to link concepts used in clinical pharmacology with compound-specific observations (anti-epileptics, analgosedatives) in the field of neonatal neurology. Although in part anecdotal, we subsequently illustrate the relevance of developmental pharmacology in the field of neonatal neurology by a specific intervention (e.g. whole body cooling), specific clinical presentations (e.g. short and long term outcome following fetal exposure to antidepressive agents, the development of new biomarkers for fetal alcohol syndrome) and specific clinical needs (e.g. analgosedation in neonates, excitocytosis versus neuro-apoptosis/impaired synaptogenesis).

Fluoxetine during development reverses the effects of prenatal stress on depressive-like behavior and hippocampal neurogenesis in adolescence

Depression during pregnancy and the postpartum period is a growing health problem, which affects up to 20% of women. Currently, selective serotonin reuptake inhibitor (SSRIs) medications are commonly used for treatment of maternal depression. Unfortunately, there is very little research on the long-term effect of maternal depression and perinatal SSRI exposure on offspring development. Therefore, the aim of this study was to determine the role of exposure to fluoxetine during development on affective-like behaviors and hippocampal neurogenesis in adolescent offspring in a rodent model of maternal depression. To do this, gestationally stressed and non-stressed Sprague-Dawley rat dams were treated with either fluoxetine (5 mg/kg/day) or vehicle beginning on postnatal day 1 (P1). Adolescent male and female offspring were divided into 4 groups: 1) prenatal stress+fluoxetine exposure, 2) prenatal stress+vehicle, 3) fluoxetine exposure alone, and 4) vehicle alone. Adolescent offspring were assessed for anxiety-like behavior using the Open Field Test and depressive-like behavior using the Forced Swim Test. Brains were analyzed for endogenous markers of hippocampal neurogenesis via immunohistochemistry. Results demonstrate that maternal fluoxetine exposure reverses the reduction in immobility evident in prenatally stressed adolescent offspring. In addition, maternal fluoxetine exposure reverses the decrease in hippocampal cell proliferation and neurogenesis in maternally stressed adolescent offspring. This research provides important evidence on the long-term effect of fluoxetine exposure during development in a model of maternal adversity.

Antidepressant drugs and breastfeeding: a review of the literature

The use of antidepressants in breastfeeding mothers is controversial: Manufacters often routinely discourage breastfeeding for the nursing mother despite the well-known positive impact that breastfeeding carries on the health of the nursing infant and on his or her family and society. We conducted a systematic review of drugs commonly used in the treatment of postpartum depression. For every single drug two sets of data were provided: (1) selected pharmacokinetic characteristics such as half-life, milk-to-plasma ratio, protein binding, and oral bioavailability and (2) information about lactational risk, according to some authoritative sources of the literature: Drugs in Pregnancy and Lactation edited by Briggs et al. (Lippincott Williams, Philadelphia, 2008), Medications and Mothers' Milk by Hale (Hale Publishing, Amarillo, TX, 2010), and the LactMed database of TOXNET ( www.pubmed.gov ; accessed June 2010). Notwithstanding a certain variability of advice, we found that (1) knowledge of pharmacokinetic characteristics are scarcely useful to assess safety and (2) the majority of antidepressants are not usually contraindicated: (a) Selective serotinin reuptake inhibitors and nortryptiline have a better safety profile during lactation, (b) fluoxetine must be used carefully, (c) the tricyclic doxepine and the atypical nefazodone should better be avoided, and (d) lithium, usually considered as contraindicated, has been recently rehabilitated.

Prenatal exposure to serotonin reuptake inhibitors: a case report

Two premature twins (33 weeks gestation) were born to a woman who had used paroxetine during pregnancy for an anxiety-depression disorder. They were admitted to the NICU, where they showed prolonged RDS, cardiovascular malformations, and facial dysmorphisms. Soon after birth, they also presented abnormal neurobehavioral and motor signs, which partially disappeared during the following weeks, although alterations of tone persisted even at discharge.

Selective serotonin reuptake inhibitor (SSRI) antidepressants are considered the primary treatments for depression and anxiety in pregnancy. Since intrauterine exposure to these drugs has been associated with poor neonatal adaptation, low birth weight, RDS, neurobehavioural symptoms, and potential teratogenic effects, further studies are needed to assess risks and mechanism of action of SSRIs. Meanwhile, it is advisable to evaluate for each patient the real risk/benefit ratio of continuing or suspending treatment during pregnancy.

Serotonin transport and metabolism in the mammary gland modulates secretory activation and involution

CONTEXT

Serotonin [5-hydroxytryptamine (5-HT)] is an important local regulator of lactation homeostasis; however, the roles for the serotonin reuptake transporter and monoamine oxidase have not been known.

OBJECTIVE

The aim of the study was to determine whether drugs that impact 5-HT affect human lactation physiology.

DESIGN AND SETTING

We conducted laboratory studies of human and animal models and an observational study of the onset of copious milk secretion in postpartum women at a university medical center.

PARTICIPANTS

We studied women expecting their first live-born infant; exclusion criteria were: referred to the medical center for another medical condition, known contraindication to breastfeed, and less than 19 yr of age and unable to obtain parental consent.

INTERVENTION(S)

The mothers were interviewed. The cell and animal studies consisted of a variety of biochemical, pharmacological, and genetic interventions.

MAIN OUTCOME MEASURE(S)

The human subjects outcome was prevalence of delayed onset of copious milk secretion. The cell and animal outcomes were physiological and morphological.

RESULTS

Inhibiting serotonin reuptake in mammary epithelial cells altered barrier function, and the effects were amplified by coadministering a monoamine oxidase inhibitor. Direct delivery of fluoxetine by slow-release pellets caused localized involution. TPH1 knockout mice displayed precocious secretory activation. Among a cohort of 431 women, those taking SSRI were more likely (P = 0.02) to experience delayed secretory activation.

CONCLUSIONS

Medications that perturb serotonin balance dysregulate lactation, and the effects are consistent with those predicted by the physiological effects of intramammary 5-HT bioactivity. Mothers taking serotonergic drugs may need additional support to achieve their breastfeeding goals.

Postpartum depression

Postpartum depression (PPD) affects up to 15% of mothers. Recent research has identified several psychosocial and biologic risk factors for PPD. The negative short-term and long-term effects on child development are well-established. PPD is under recognized and under treated. The obstetrician and pediatrician can serve important roles in screening for and treating PPD. Treatment options include psychotherapy and antidepressant medication. Obstacles to compliance with treatment recommendations include access to psychotherapists and concerns of breastfeeding mothers about exposure of the infant to antidepressant medication. Further research is needed to examine systematically the short-term and long-term effect of medication exposure through breastmilk on infant and child development.

Fetal and neonatal effects of maternal drug treatment for depression

Depression has a female sex predilection with 2 to 3% of the pregnant women population presently requiring treatment with selective serotonin reuptake inhibitors (SSRI). Exposure to SSRIs in late gestation leads to clinical manifestations in as much as 30% of the neonates. These include neurobehavioral, respiratory, gastrointestinal, and somatic symptoms. Among the respiratory manifestations, persistent pulmonary hypertension syndrome is a newly recognized and concerning side effect of SSRI exposure in utero. This causal association has been reproduced in an animal model where fluoxetine administration to pregnant rats induces fetal pulmonary hypertension. The pharmacological effects of SSRI on the fetus and newborn, available treatment, and prevention strategies are discussed in this review.