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Eleftheriou G, Zandonella Callegher R, Butera R, De Santis M, Cavaliere AF, Vecchio S, Lanzi C, Davanzo R, Mangili G, Bondi E, Somaini L, Gallo M, Balestrieri M, Mannaioni G, Salvatori G, Albert U. Consensus Panel Recommendations for the Pharmacological Management of Breastfeeding Women with Postpartum Depression. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:551. [PMID: 38791766 PMCID: PMC11121006 DOI: 10.3390/ijerph21050551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024]
Abstract
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.
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Affiliation(s)
- Georgios Eleftheriou
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Riccardo Zandonella Callegher
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy;
- UCO Clinica Psichiatrica, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
| | - Raffaella Butera
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco De Santis
- Italian Society of Obstetrics and Gynecology (SIGO), Via di Porta Pinciana 6, 00187 Rome, Italy; (M.D.S.); (A.F.C.)
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Anna Franca Cavaliere
- Italian Society of Obstetrics and Gynecology (SIGO), Via di Porta Pinciana 6, 00187 Rome, Italy; (M.D.S.); (A.F.C.)
- Department of Gynecology and Obstetrics, Fatebenefratelli Gemelli, Isola Tiberina, 00186 Rome, Italy
| | - Sarah Vecchio
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Addiction Centre, Ser.D, Local Health Unit, 28100 Novara, Italy
| | - Cecilia Lanzi
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
| | - Riccardo Davanzo
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy; (R.D.); (G.M.)
- Maternal and Child Health Institute IRCCS “Burlo Garofolo”, 34137 Trieste, Italy
- Task Force on Breastfeeding, Ministry of Health, 00144 Rome, Italy
| | - Giovanna Mangili
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy; (R.D.); (G.M.)
- Department of Neonatology, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Emi Bondi
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- Department of Psychiatry, ASST Papa Giovanni XXIII, 24100 Bergamo, Italy
| | - Lorenzo Somaini
- Ser.D Biella, Drug Addiction Service, 13875 Biella, Italy;
- Italian Society of Addiction Diseases (S.I.Pa.D), Via Tagliamento 31, 00198 Rome, Italy
| | - Mariapina Gallo
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
- Italian Society for Drug Addiction (SITD), Via Roma 22, 12100 Cuneo, Italy
| | - Matteo Balestrieri
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy;
- Italian Society of Neuropsychopharmacology (SINPF), Via Cernaia 35, 00158 Rome, Italy
| | - Guido Mannaioni
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
- Italian Society of Pharmacology, Via Giovanni Pascoli, 3, 20129 Milan, Italy
| | - Guglielmo Salvatori
- Italian Society of Pediatrics, Via Gioberti 60, 00185 Rome, Italy;
- Department of Medical and Surgical Neonatology Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Umberto Albert
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- UCO Clinica Psichiatrica, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
- Italian Society of Neuropsychopharmacology (SINPF), Via Cernaia 35, 00158 Rome, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
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Verstegen RHJ, Anderson PO, Ito S. Infant drug exposure via breast milk. Br J Clin Pharmacol 2020; 88:4311-4327. [PMID: 32860456 DOI: 10.1111/bcp.14538] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/08/2020] [Accepted: 08/26/2020] [Indexed: 12/31/2022] Open
Abstract
More than half of women take medications during breastfeeding, predisposing their infants to medication exposure via breast milk. As a result, adverse drug reactions may emerge in the infant, although they are rarely reported. Disposition of maternal drugs in breast milk is described with several key parameters, which include relative infant dose (RID): infant drug intake via milk (weight- and time-adjusted) expressed as a percentage of the similarly adjusted mother's dose. Most drugs show RID values of <10%, indicating that drug concentrations in infant serum do not reach a level known to be therapeutic in adults unless drug clearance is markedly lower than the adult level on a weight basis. RID is a function of milk-to-(maternal) plasma drug concentration ratio (MP ratio) and maternal drug clearance. Therefore, MP ratio between drugs must be interpreted not by itself but with maternal drug clearance of each drug. This is why some drugs such as phenobarbital show an MP ratio of <1 but an RID as high as 50-70%, while morphine shows an MP ratio of 2 but an RID in the range of 5%. Using RID, we interpreted case reports of infant adverse outcomes, and we observed cases with relatively low infant serum concentrations of drug, consistent with low RID, as well as those with near- or above-adult therapeutic serum concentrations, with or without increased drug intake (i.e. high RID). It is important to consider both pharmacokinetic and pharmacodynamic factors in interpreting adverse outcomes in infants breastfed by a mother taking medications.
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Affiliation(s)
- Ruud H J Verstegen
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Philip O Anderson
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California, USA
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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Zaccarelli-Magalhães J, Amato Santoro M, de Abreu GR, Lopes Ricci E, Rinaldi Fukushima A, Kirsten TB, Faria Waziry PA, de Souza Spinosa H. Exposure of dams to fluoxetine during lactation disturbs maternal behavior but had no effect on the offspring behavior. Behav Brain Res 2019; 377:112246. [PMID: 31539576 DOI: 10.1016/j.bbr.2019.112246] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/09/2019] [Accepted: 09/16/2019] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Julia Zaccarelli-Magalhães
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of São Paulo, Av. Prof. Dr. Orlando Marques de Paiva, 87, 05508-270, São Paulo, Brazil.
| | - Maysa Amato Santoro
- Health Science Institute, Presbiterian Mackenzie University, Rua da Consolação, 930, 01302-907, São Paulo, Brazil.
| | - Gabriel Ramos de Abreu
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of São Paulo, Av. Prof. Dr. Orlando Marques de Paiva, 87, 05508-270, São Paulo, Brazil.
| | - Esther Lopes Ricci
- Health Science Institute, Presbiterian Mackenzie University, Rua da Consolação, 930, 01302-907, São Paulo, Brazil.
| | - André Rinaldi Fukushima
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of São Paulo, Av. Prof. Dr. Orlando Marques de Paiva, 87, 05508-270, São Paulo, Brazil.
| | - Thiago Berti Kirsten
- Environmental and Experimental Pathology, Universidade Paulista, Rua Dr. Bacelar, 1212, 04026-002, São Paulo, Brazil.
| | - Paula A Faria Waziry
- Dr. Kiran C. Patel College of Osteopathic Medicine, Tampa Bay Regional Campus, Nova Southeastern University, 98-148 Damascus Rd, Clearwater, FL, 33759, United States.
| | - Helenice de Souza Spinosa
- Department of Pathology, School of Veterinary Medicine and Animal Science, University of São Paulo, Av. Prof. Dr. Orlando Marques de Paiva, 87, 05508-270, São Paulo, Brazil.
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Datta P, Baker T, Hale TW. Balancing the Use of Medications While Maintaining Breastfeeding. Clin Perinatol 2019; 46:367-382. [PMID: 31010565 DOI: 10.1016/j.clp.2019.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Breast milk is the most beneficial nutrition a mother can give her infant. Fortunately, the dose of most drugs transferred into milk is small and does not lead to clinically significant effects on the infant. In almost all instances, the mother should be advised to continue breastfeeding. Certain medications are absolutely contraindicated, including anticancer agents, radioactive drugs, and those that inhibit milk production. However, most medications can be used safely. An improved understanding of the relationship between maternal and infant exposure to medications would provide a more enlightened understanding of the risk and benefit analysis for individual drugs.
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Affiliation(s)
- Palika Datta
- Department of Pediatrics, Texas Tech University Health Sciences Center, 1400 Wallace Boulevard, Amarillo, TX 79106, USA
| | - Teresa Baker
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, 1400 Coulter Street, Amarillo, TX 79106, USA
| | - Thomas W Hale
- Department of Pediatrics, Texas Tech University Health Sciences Center, 1400 Wallace Boulevard, Amarillo, TX 79106, USA.
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den Besten-Bertholee D, van der Meer DH, Ter Horst PGJ. Quality of Lactation Studies Investigating Antidepressants. Breastfeed Med 2019; 14:359-365. [PMID: 31013435 DOI: 10.1089/bfm.2019.0021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: The aim of this study was to determine the quality of lactation studies investigating antidepressants in breast milk according to the Food and Drug Administration (FDA) draft guidelines and the article by Begg et al., 2002, published in the official journal of the International Lactation Consultant Association (ILCA). Materials and Methods: We used PubMed and LactMed® for the literature search. Furthermore, cross references were searched for additional studies. Results: A total number of 60 articles were included for review. For selective serotonin reuptake inhibitors and venlafaxine, only two studies correctly assessed the absolute infant dose and milk to plasma ratio; one sertraline and one fluoxetine study. Of all tricyclic antidepressants, one study for amitriptyline and one for nortriptyline assessed these endpoints correctly. We found a lack of information on breast milk sampling methods in many studies. Concentrations needed for the calculations were based on single measurements instead of at least five measurements during one dose interval, and the relative infant dose was not normalized by maternal weight, or an average maternal weight of 70 kg was used as a standard. Discussion: We conclude that the quality of the current literature on this topic does not meet the standards of the FDA. Studies of higher quality are needed to determine the extent of drug transfer to breast milk for antidepressants, so an adequate recommendation about use of these drugs during lactation can be given.
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Kronenfeld N, Berlin M, Shaniv D, Berkovitch M. Use of Psychotropic Medications in Breastfeeding Women. Birth Defects Res 2018; 109:957-997. [PMID: 28714610 DOI: 10.1002/bdr2.1077] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/02/2017] [Accepted: 06/06/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Breastfeeding women who are prescribed with psychotropic medications on a regular basis are often concerned, regarding the possible implications of such treatment on the breastfed infant. A mother's well-being has a direct influence on the well-being of the baby. However, the notorious reputation of psychotropic medications may lead to suboptimal prescribing by the physician and poor adherence by the mother. METHODS A PubMed search (from 1976 through February 2017) was conducted for commonly used psychotropic drug classes, as well as individual medications commonly prescribed in these classes, along with the MeSH terms "breastfeeding"/"lactation". In each case, we chose studies that describe the pharmacokinetics of passage into breast milk and/or adverse effects in breastfed infants. RESULTS No large-scale controlled studies regarding the safety of psychotropic medications in breastfeeding mothers were reported. Based on case reports and small studies, most psychotropic medications produce low milk levels and low plasma levels in the infant, while serious adverse effects in the breastfed infant are rarely reported. Safety data for some psychotropic medications are still unavailable. CONCLUSION According to the data available in the literature to date, most psychotropic medications are expected to produce low levels in breast milk with no clinical importance. Nevertheless, an individual risk-benefit assessment of a proposed treatment should always be performed, as inter-individual differences may have a substantial effect on the breastfeeding infant's response to the treatment. Further studies and additional objective data are needed to consolidate and improve our current knowledge of psychopharmacotherapy in breastfeeding women. Birth Defects Research 109:957-997, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Nirit Kronenfeld
- School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem.,Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Maya Berlin
- Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dotan Shaniv
- Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology Unit, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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7
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Abstract
Adverse effects of psychotropic medication on breast-fed infants have not been studied in controlled and systematic research. Existing information comes from small case series and single case reports. These limited data confirm that psychotropics are excreted into breast milk and that the infant is exposed to them. In recent decades sufficient data have accumulated to allow psychiatrists to prescribe tricyclic antidepressants, selective serotonin reuptake inhibitors, conventional antipsychotics, carbamazepine and sodium valproate to breast-feeding mothers with safety. There are not sufficient data on atypical antipsychotics to allow women to breast-feed safely. Mothers on clozapine or lithium should not breast-feed. It is good practice to recommend that breast-feeding mothers requiring psychotropic medication be on a low dose of one single drug. Future research taking account of maternal mental health, psychopharmacological factors, infant physiological environment and individualised risk/benefit assessment will yield clearer responses to this complex issue.
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Nice FJ, DeEugenio D, DiMino TA, Freeny IC, Rovnack MB, Gromelski JS. Medications and Breast-Feeding: A Guide for Pharmacists, Pharmacy Technicians, and other Healthcare Professionals Part III. J Pharm Technol 2016. [DOI: 10.1177/875512250402000304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective:To provide a guide for practicing pharmacists, pharmacy technicians, and other healthcare professionals so that they are able to counsel and advise breast-feeding mothers and fellow healthcare professionals on the safety and use of antiinfectives, vaccines, antiepileptics, benzodiazepines, psychotherapeutic drugs, and radiopharmaceuticals during breast-feeding.Data Sources:Primary texts used by the breast-feeding community ( Medications and Mothers' Milk, Drugs in Pregnancy and Lactation, Drugs and Human Lactation) were searched, as well as Micromedex, MEDLINE, PubMed, EMBASE, and EMBASE2 (1984–February 2004).Study Selection/Data Extraction:Multiple sources were used wherever available to validate the data, and primary articles were used to verify all tertiary source information. Search terms included breast-feeding, lactation, nursing, and medications, as well as specific drug names.Data Synthesis:Concerns regarding medication use during breast-feeding have caused mothers to either discontinue nursing or not take necessary medications. Complete avoidance of medications or cessation of breast-feeding is often unnecessary. Although there are drugs that can be harmful to nursing infants, breast-milk concentrations of most drugs are insufficient to cause any harm.Conclusions:Having objective and reliable information on medications enables pharmacists, pharmacy technicians, other healthcare providers, and mothers to make educated decisions regarding drug therapy and breast-feeding.
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Affiliation(s)
- Frank J Nice
- FRANK J NICE MS MPA DPA CPHP, Assistant Director, Clinical Neurosciences Program (CNP), National Institutes of Health (NIH), Bethesda, MD
| | - Deborah DeEugenio
- DEBORAH DeEUGENIO PharmD, at time of writing, Pharmacy Student (USP), CNP, NIH; now, Assistant Professor, School of Pharmacy, Temple University, Philadelphia, PA; Clinical Pharmacist, Jefferson Antithrombotics Therapy Service, Jefferson Heart Institute, Philadelphia
| | - Traci A DiMino
- TRACI A DiMINO PharmD, at time of writing, Pharmacy Student (USP), CNP, NIH; now, Adverse Event Specialist, Global Safety Surveillance & Epidemiology, Wyeth, Collegeville, PA
| | - Ingrid C Freeny
- INGRID C FREENY PharmD, at time of writing, Pharmacy Student (USP), CNP, NIH; now, Medical Student, Drexel University College of Medicine, Philadelphia
| | - Marissa B Rovnack
- MARISSA B ROVNACK PharmD, at time of writing, Pharmacy Student (Wilkes University), CNP, NIH; now, Clinical Staff Pharmacist, Lehigh Valley Hospital and Health Network, Allentown, PA
| | - Joseph S Gromelski
- JOSEPH S GROMELSKI PharmD, at time of writing, Pharmacy Student (Wilkes University), CNP, NIH; now, Pharmacist, Walmart, Baltimore, MD; Law Student, University of Maryland, Baltimore
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Abstract
Depression is a common complication of pregnancy and the postpartum period. There are multiple risk factors for peripartum mood disorders, most important of which is a prior history of depression. Both depression and antidepressant medications confer risk upon the infant. Maternal depression has been associated with preterm birth, low birth weight, fetal growth restriction, and postnatal cognitive and emotional complications. Antidepressant exposure has been associated with preterm birth, reductions in birth weight, persistent pulmonary hypertension, and postnatal adaptation syndrome (PNAS) as well as a possible connection with autism spectrum disorder. Paroxetine has been associated with cardiac malformations. Most antidepressant medications are excreted in low levels in breast milk and are generally compatible with breastfeeding. The use of antidepressants during pregnancy and postpartum must be weighed against the risk of untreated depression in the mother.
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Affiliation(s)
- Madeleine Becker
- Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, 1020 Sansom Street, Thompson Bldg, Suite 1652, Philadelphia, PA, 19107, USA.
| | - Tal Weinberger
- Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, 833 Chestnut St. 2nd floor, Suite 210, Philadelphia, PA, 19107, USA
| | - Ann Chandy
- Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, 1020 Sansom Street, Thompson Bldg, Suite 1652, Philadelphia, PA, 19107, USA
| | - Sarah Schmukler
- Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, 1020 Sansom Street, Thompson Bldg, Suite 1652, Philadelphia, PA, 19107, USA
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Kiryanova V, Meunier SJ, Vecchiarelli HA, Hill MN, Dyck RH. Effects of maternal stress and perinatal fluoxetine exposure on behavioral outcomes of adult male offspring. Neuroscience 2016; 320:281-96. [PMID: 26872999 DOI: 10.1016/j.neuroscience.2016.01.064] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/20/2016] [Accepted: 01/29/2016] [Indexed: 12/25/2022]
Abstract
UNLABELLED Women of child-bearing age are the population group at highest risk for depression. In pregnant women, fluoxetine (Flx) is the most widely prescribed selective serotonin reuptake inhibitor (SSRI) used for the treatment of depression. While maternal stress, depression, and Flx exposure have been shown to effect neurodevelopment of the offspring, separately, combined effects of maternal stress and Flx exposure have not been extensively examined. The present study investigated the effects of prenatal maternal stress and perinatal exposure to the SSRI Flx on the behavior of male mice as adults. METHODS C57BL/6 dams exposed to chronic unpredictable stress from embryonic (E) day 4 to E18 and non-stressed dams were administered Flx (25 mg/kg/d) in the drinking water from E15 to postnatal day 12. A separate control group consisted of animals that were not exposed to stress or Flx. At 12 days of age, brain levels of serotonin were assessed in the male offspring. At two months of age, the male offspring of mothers exposed to prenatal stress (PS), perinatal Flx, PS and Flx, or neither PS or Flx, went through a comprehensive behavioral test battery. At the end of testing brain-derived neurotropic factor (BDNF) levels were assessed in the frontal cortex of the offspring. RESULTS Maternal behavior was not altered by either stress or Flx treatment. Treatment of the mother with Flx led to detectible Flx and NorFlx levels and lead to a decrease in serotonin levels in pup brains. In the adult male offspring, while perinatal exposure to Flx increased aggressive behavior, prenatal maternal stress decreased aggressive behavior. Interestingly, the combined effects of stress and Flx normalized aggressive behavior. Furthermore, perinatal Flx treatment led to a decrease in anxiety-like behavior in male offspring. PS led to hyperactivity and a decrease in BDNF levels in the frontal cortex regardless of Flx exposure. Neither maternal stress or Flx altered offspring performance in tests of cognitive abilities, memory, sensorimotor information processing, or risk assessment behaviors. These results demonstrate that maternal exposure to stress and Flx have a number of sustained effects on the male offspring.
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Affiliation(s)
- V Kiryanova
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - S J Meunier
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - H A Vecchiarelli
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - M N Hill
- Department of Cell Biology and Anatomy, University of Calgary, Calgary, Alberta, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - R H Dyck
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada; Department of Cell Biology and Anatomy, University of Calgary, Calgary, Alberta, Canada; Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
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Abstract
AIMS Untreated perinatal depression and anxiety disorders are known to have significant negative impact on both maternal and fetal health. Dilemmas still remain regarding the use and safety of psychotropics in pregnant and lactating women suffering from perinatal depression and anxiety disorders. The aim of the current paper was to review the existing evidence base on the exposure and consequences of antidepressants, anxiolytics, and hypnotics in women during pregnancy and lactation and to make recommendations for clinical decision making in management of these cases. MATERIALS AND METHODS We undertook a bibliographic search of Medline/PubMed (1972 through 2014), Science Direct (1972 through 2014), Archives of Indian Journal of Psychiatry databases was done. References of retrieved articles, reference books, and dedicated websites were also checked. RESULTS AND CONCLUSIONS The existing evidence base is extensive in studying multiple outcomes of the antidepressant or anxiolytic exposure in neonates, and some of the findings appear conflicting. Selective serotonin reuptake inhibitors are the most researched antidepressants in pregnancy and lactation. The available literature is criticized mostly on the lack of rigorous well designed controlled studies as well as lacunae in the methodologies, interpretation of statistical information, knowledge transfer, and translation of information. Research in this area in the Indian context is strikingly scarce. Appropriate risk-benefit analysis of untreated mental illness versus medication exposure, tailor-made to each patient's past response and preference within in the context of the available evidence should guide clinical decision making.
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Affiliation(s)
- Daya Ram
- Director, Central Institute of Psychiatry, Ranchi, Jharkhand, India
| | - S. Gandotra
- Department of Psychiatry, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
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Sriraman NK, Melvin K, Meltzer-Brody S. ABM Clinical Protocol #18: Use of Antidepressants in Breastfeeding Mothers. Breastfeed Med 2015. [PMID: 26204124 PMCID: PMC4523038 DOI: 10.1089/bfm.2015.29002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.
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Affiliation(s)
- Natasha K Sriraman
- 1 Department of Pediatrics, Children's Hospital of The King's Daughters/Eastern Virginia Medical School , Norfolk, Virginia
| | - Kathryn Melvin
- 2 Department of Psychiatry, University of North Carolina Chapel Hill School of Medicine , Chapel Hill, North Carolina
| | - Samantha Meltzer-Brody
- 2 Department of Psychiatry, University of North Carolina Chapel Hill School of Medicine , Chapel Hill, North Carolina.,3 Perinatal Psychiatry Program, University of North Carolina Chapel Hill Center for Women's Mood Disorders , Chapel Hill, North Carolina
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Abstract
This article reviews the necessary skills required for clinicians to make informed decisions about the use of medications in breastfeeding women. Even without specific data on certain medications, this review of kinetic principles, mechanisms of medication entry into breast milk, and important infant factors can aid in clinical decision making. In addition, the article reviews common medical conditions (eg, depression, hypertension, infections) in breastfeeding women and their appropriate treatment.
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Affiliation(s)
- Hilary Rowe
- Department of Pharmacy, Fraser Health Authority, Surrey, British Columbia, Canada
| | - Teresa Baker
- Texas Tech University School of Medicine, 1400 Coulter Street, Amarillo, Texas 79106, USA
| | - Thomas W Hale
- Texas Tech University School of Medicine, 1400 Coulter Street, Amarillo, Texas 79106, USA.
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Orsolini L, Bellantuono C. Serotonin reuptake inhibitors and breastfeeding: a systematic review. Hum Psychopharmacol 2015; 30:4-20. [PMID: 25572308 DOI: 10.1002/hup.2451] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 10/15/2014] [Accepted: 10/30/2014] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Laura Orsolini
- Psychiatric Unit and DEGRA Center, United Hospital of Ancona and Academic Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
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15
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Kiryanova V, McAllister BB, Dyck RH. Long-term outcomes of developmental exposure to fluoxetine: a review of the animal literature. Dev Neurosci 2014; 35:437-9. [PMID: 24247012 DOI: 10.1159/000355709] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 09/17/2013] [Indexed: 11/19/2022] Open
Abstract
During and following pregnancy, women are at high risk of experiencing depression, for which fluoxetine (FLX; brand names Prozac, Sarafem, Rapiflux) is the most commonly prescribed treatment. An estimated 1.4-2.1% of pregnant women use this medication, which inhibits the reuptake of serotonin and thereby increases serotonergic activity at the synapse. Serotonin acts as a cue guiding numerous neurodevelopmental processes, and changes in the concentration of serotonin can disrupt normal in utero brain development and organization in humans and other animals, thus providing a mechanism by which maternal intake of FLX might alter neural development and ultimately behaviour. Despite this possibility, long-term alterations of behaviour and the brain have not been well studied in individuals exposed to FLX during pregnancy or soon after birth, perhaps because conducting such studies beyond infancy presents significant challenges. To remedy this problem, many researchers have turned to modelling the effects of developmental FLX exposure in non-human animals, primarily rodents. The body of literature on this topic has expanded considerably over the past several years, yet a comprehensive review is lacking. In order to fill this gap, we have summarized the findings of those studies describing the long-term behavioural and neurophysiological effects of FLX exposure in non-human animals in early development. We also discuss methodological considerations and common shortcomings of research in this area. The precise nature of the long-term effects of developmental FLX exposure remains difficult to specify, as these effects appear to be highly variable and dependent on numerous factors. Overall, however, it is clear that early FLX exposure in non-human animals can alter the development of the brain in ways that are relevant to behaviour in adulthood, decreasing exploration and social interaction, and in some cases altering anxiety- and depression-like behaviours..
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Kiryanova V, Dyck RH. Increased Aggression, Improved Spatial Memory, and Reduced Anxiety-Like Behaviour in Adult Male Mice Exposed to Fluoxetine Early in Life. Dev Neurosci 2014; 36:396-408. [DOI: 10.1159/000363102] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 04/22/2014] [Indexed: 11/19/2022] Open
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17
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Hutchinson S, Marmura MJ, Calhoun A, Lucas S, Silberstein S, Peterlin BL. Use of common migraine treatments in breast-feeding women: a summary of recommendations. Headache 2013; 53:614-27. [PMID: 23465038 PMCID: PMC3974500 DOI: 10.1111/head.12064] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2013] [Indexed: 01/16/2023]
Abstract
BACKGROUND Breast-feeding has important health and emotional benefits for both mother and infant, and should be encouraged. While there are some data to suggest migraine may improve during breast-feeding, more than half of women experience migraine recurrence with 1 month of delivery. Thus, a thorough knowledge base of the safety and recommended use of common acute and preventive migraine drugs during breast-feeding is vital to clinicians treating migraine sufferers. Choice of treatment should take into account the balance of benefit and risk of medication. For some of the medications commonly used during breast-feeding, there is not good evidence about benefits. METHODS A list of commonly used migraine medications was agreed upon by the 6 authors, who treat migraine and other headaches on a regular basis and are members of the Women's Special Interest Section of the American Headache Society. Each medication was researched by the first author utilizing widely accepted data sources, such as the American Academy of Pediatrics publication "The Transfer of Drugs and Other Chemicals Into Human Milk; Thomas Hale's manual Medications and Mothers Milk; Briggs, Freeman, and Yaffe's reference book Drugs in Pregnancy and Lactation; and the National Library of Medicine's Drugs and Lactation Database (LactMed) - a peer-reviewed and fully referenced database available online. RESULTS Many commonly used migraine medications may be compatible with breast-feeding based on expert recommendations. Ibuprofen, diclofenac, and eletriptan are among acute medications with low levels in breast milk, but studies of triptans are limited. Toxicity is a concern with aspirin due to an association with Reye's syndrome; sedation or apnea is a concern with opioids. Finally, preventive medications not recommended include zonisamide, atenolol, and tizanidine. CONCLUSIONS Several excellent resources are available for clinicians making treatment decisions in breast-feeding women. Clinicians treating migraine should discuss both acute and preventive treatment options shortly before and within a few months after delivery, keeping in mind the clinical features of the individual patient, and in consultation with their obstetrician and pediatrician. An awareness of the pharmacological data that are currently available and how to access that data may be helpful in making treatment decisions in this population.
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Affiliation(s)
- Susan Hutchinson
- Orange County Migraine and Headache Center, Irvine, CA 92604, USA
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18
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Abstract
This article reviews the necessary skills required for clinicians to make informed decisions about the use of medications in women who are breastfeeding. Even without specific data on certain medications, this review of kinetic principles, mechanisms of medication entry into breast milk, and important infant factors can aid in clinical decision making. In addition, common medical conditions and suitable treatments of depression, hypertension, infections and so forth for women who are breastfeeding are also reviewed.
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Affiliation(s)
- Hilary Rowe
- Maternal Fetal Medicine, Fraser Health, Surrey, British Columbia, Canada
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19
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Abstract
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.
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Affiliation(s)
- Jessica R Gorman
- Department of Pediatrics, University of California, San Diego, La Jolla, California 92093-0828, USA
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20
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Muzik M, Thelen K, Rosenblum KL. Perinatal depression: detection and treatment. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/npy.10.8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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21
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Davanzo R, Copertino M, De Cunto A, Minen F, Amaddeo A. Antidepressant drugs and breastfeeding: a review of the literature. Breastfeed Med 2011; 6:89-98. [PMID: 20958101 DOI: 10.1089/bfm.2010.0019] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Riccardo Davanzo
- Division of Neonatology, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy.
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22
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Abstract
Epidemiological studies suggest there are considerable differences in the prevalence and presentation of depression in men and women. Women are more than twice as likely to be diagnosed with depression and may also report more atypical and anxiety symptoms than men. Men and women also differ in the metabolism and distribution of antidepressants and the presence of oestrogen in women of childbearing age may interfere with the mechanism of action of a number of antidepressants. These differences have led many researchers to question whether antidepressants are equally effective and tolerated in men and women. While some reports suggest that selective serotonin re-uptake inhibitors (SSRIs) are more effective and result in fewer adverse drug reactions in women than tricyclic antidepressants (TCAs), gender differences in antidepressant response remains a controversial topic. The potential effects of antidepressant exposure in utero and in breast milk further complicate treatment options for antenatal and postnatal depression. While some research suggests the SSRI paroxetine is teratogenic, further carefully designed naturalistic studies are required to fully evaluate these effects. Finally, response to antidepressants and the occurrence of adverse drug reactions is marked by inter-individual variability which may be in part due to genetic differences. Future studies should therefore consider genotypes of the mother, foetus and infant in antidepressant response.
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Affiliation(s)
- Robert Keers
- MRC SGDP Centre, Institute of Psychiatry, King's College London, 16 De Crespigny Park, Denmark Hill, London, UK.
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Berle JØ, Spigset O. Antidepressant Use During Breastfeeding. CURRENT WOMENS HEALTH REVIEWS 2011; 7:28-34. [PMID: 22299006 PMCID: PMC3267169 DOI: 10.2174/157340411794474784] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 04/26/2010] [Accepted: 05/31/2010] [Indexed: 01/16/2023]
Abstract
Background: The treatment of breastfeeding mothers with depression raises several dilemmas, including the possible risk of drug exposure through breast milk for the infant. This article provides background information and presents practical advice and recommendations for the clinician dealing with the treatment of depression and related disorders in the postpartum period. Methods: An electronic search for relevant articles was performed. As the use of tricyclic antidepressants has considerably decreased during the last decade and no new information on breastfeeding has emerged for the tricyclics in this period, this review exclusively focuses on the newer, non-tricyclic compounds. Results: Most newer antidepressants produce very low or undetectable plasma concentrations in nursing infants. The highest infant plasma levels have been reported for fluoxetine, citalopram and venlafaxine. Suspected adverse effects have been reported in a few infants, particularly for fluoxetine and citalopram. Conclusions: Infant exposure of antidepressants through breast milk is generally low to very low. We consider that when antidepressant treatment is indicated in women with postpartum depression, they should not be advised to discontinue breastfeeding. Paroxetine and sertraline are most likely suitable first-line agents. Although some concern has been expressed for fluoxetine, citalopram and venlafaxine, we nevertheless consider that if the mother has been treated with one of these drugs during pregnancy, breast-feeding could also be allowed during continued treatment with these drugs in the postpartum period. However, an individual risk-benefit assessment should always be performed.
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Affiliation(s)
- Jan Øystein Berle
- Department of Psychiatry, Haukeland University Hospital, P.O. Box 23 Sandviken, N-5812 Bergen, Norway
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Kendall-Tackett K, Hale TW. The use of antidepressants in pregnant and breastfeeding women: a review of recent studies. J Hum Lact 2010; 26:187-95. [PMID: 19652194 DOI: 10.1177/0890334409342071] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antidepressants are one of the most commonly prescribed medications for pregnant and lactating women. However, there have been some recent concerns about their safety. This article summarizes recent research on the impact of untreated depression on the baby, the effects of antidepressants on the baby when prescribed during pregnancy, the short- and longer-term effects of prenatal exposure on infants and children, and the passage of medications into breast milk. Recommendations are made on providing mothers and their health care providers with information so they can make accurate risk/benefit analyses about using these medications while pregnant or breastfeeding.
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Fríguls B, Joya X, García-Algar O, Pallás CR, Vall O, Pichini S. A comprehensive review of assay methods to determine drugs in breast milk and the safety of breastfeeding when taking drugs. Anal Bioanal Chem 2010; 397:1157-79. [DOI: 10.1007/s00216-010-3681-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 03/17/2010] [Accepted: 03/22/2010] [Indexed: 11/24/2022]
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Tripathi BM, Majumder P. Lactating mother and psychotropic drugs. Mens Sana Monogr 2010; 8:83-95. [PMID: 21327172 PMCID: PMC3031938 DOI: 10.4103/0973-1229.58821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 12/20/2009] [Accepted: 12/21/2009] [Indexed: 11/06/2022] Open
Abstract
Usage of psychotropics during pregnancy and lactation has always been a topic of debate and controversy. The debate stems from the potential adverse effects on the growing fetus or infants due to the transfer of psychotropic drugs through placenta or breast milk of mothers receiving them; and the problem of discontinuing psychotropics in lactating mother considering chances of relapse. However, most of the psychotropics are found to be relatively safe when used cautiously during the lactation phase. This article describes available data on the use of psychotropics in lactating mothers, in particular, in relation to the safety profile of infants.
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Affiliation(s)
- B. M. Tripathi
- Professor, Department of Psychiatry and National Drug Dependence and Treatment center, All India Institute of Medical Sciences, New Delhi, India
| | - Pradipta Majumder
- Resident, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110029, India
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Muzik M, Marcus SM, Heringhausen JE, Flynn H. When depression complicates childbearing: guidelines for screening and treatment during antenatal and postpartum obstetric care. Obstet Gynecol Clin North Am 2009; 36:771-88, ix-x. [PMID: 19944300 PMCID: PMC4327901 DOI: 10.1016/j.ogc.2009.10.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Prevalence studies show that 1 in 5 women experience an episode of major depressive disorder during their lifetime. The peripartum period is a prime time for symptom exacerbation and relapse of depressive episodes. Health care providers, specifically those in obstetric care, should be aware of: (1) the frequency of depression in pregnant and postpartum women; (2) signs, symptoms, and appropriate screening methods; and (3) the health risks for the mother and growing fetus if depression is undetected or untreated. Because management of depressed peripartum women also includes care of a growing fetus or breastfeeding infant, treatment may be complex and requires input from a multidisciplinary team, including an obstetrician, psychiatrist, and pediatrician, to provide optimal care.
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Affiliation(s)
- Maria Muzik
- Department of Psychiatry, University of Michigan, Rachel Upjohn Building, Ann Arbor, MI 48109, USA.
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28
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Abstract
Prevalence studies show that one in five women experience an episode of major depressive disorder during their lifetime. It is important for health care providers to be aware of (1) the frequency of depression in this population; (2) signs, symptoms, and appropriate screening methods; and (3) health risks for the mother and growing fetus if depression is undetected or untreated. Because management of depressed pregnant women also includes care of a growing fetus, treatment may be complicated and primary care providers should consider a multidisciplinary approach, including an obstetrician, psychiatrist, and pediatrician, to provide optimal care.
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Affiliation(s)
- Sheila M Marcus
- Department of Psychiatry, University of Michigan, Rachel Upjohn Building, Ann Arbor, MI 48109, USA.
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Abstract
AIM: To assess the incidence of infantile colic and its association with variable predictors in infants born in a community maternity hospital, Tehran, Iran.
METHODS: In this prospective cohort study, mothers who gave birth to live newborns between February 21 and March 20, 2003 at the hospital were invited to join to the study. For every infant-mother dyad data were collected on infant gender, type of delivery, gestational age at birth, birth weight, birth order, and mother’s reproductive history. Then mothers were given a diary to document the duration of crying/fussiness behaviors of their infants for the next 12 wk. We scheduled home visits at the time the infants were 3 mo of age to collect the completed diaries and obtain additional information on infants’ nutritional sources and identify if medications were used for colic relief. Cases of colic were identified by applying Wessel criteria to recorded data. Chi-square and Mann-whitney U tests were used to compare proportions for non-parametric and parametric variables, respectively.
RESULTS: From 413 infants, follow-up was completed for 321 infants. In total, 65 infants (20.24%) satisfied the Wessel criteria for infantile colic. No statistical significance was found between colicky and non-colicky infants according to gender, gestational age at birth, birth weight, type of delivery, and, infant’s feeding pattern. However, firstborn infants had higher rate for developing colic (P = 0.03).
CONCLUSION: Colic incidence was 20% in this population of Iranian infants. Except for birth order status, no other variable was significantly associated with infantile colic.
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31
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Misri S, Kendrick K. Treatment of perinatal mood and anxiety disorders: a review. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2007; 52:489-98. [PMID: 17955910 DOI: 10.1177/070674370705200803] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To review the nonpharmacologic and pharmacologic treatment modalities for perinatal mood and anxiety disorders and to discuss the importance of weighing the risks and the benefits of exposing the fetus or baby to maternal mental illness as opposed to exposure to antidepressant medications. METHODS We conducted a literature search of the PubMed and MEDLINE databases. Key words included the following: perinatal, pregnancy, postpartum, depression, anxiety, pharmacologic, nonpharmacologic, psychotherapy, and treatment. RESULTS Recent literature reflects that both pharmacologic and nonpharmacologic treatments for perinatal women are associated with positive and negative outcomes. No treatment decision was found to be risk-free. The detrimental effects of untreated mental illness on the mother, as well as on the baby, highlight the need for treatment intervention. The long-term effects of exposure to either medications or maternal mental illness are unknown, as yet. CONCLUSION Women with perinatal depression and anxiety disorders require timely and efficient management with a goal of providing symptom relief for the suffering mother while simultaneously ensuring the baby's safety. Although knowledge in the area of appropriate intervention is constantly evolving, rigorous and scientifically sound research in the future is critical.
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Abstract
Despite the well known severe repercussions of maternal depression on infants' well being, women are often reluctant to seek pharmacological treatment for postnatal depression. The fear of adverse events for the suckling infant plays an important role in such maternal considerations. However, the pharmacological approach to mood disorders at postpartum onset often represents one of the most realistic options in a number of clinical conditions. Therefore, the necessity exists to establish the safety of antidepressant treatment in the breastfed infant. For this reason, the aim of this article is to propose a specific safety index that assesses the frequency and degree of severity of adverse events in infants associated with maternal treatment with second-generation antidepressants during puerperium. The index is derived from a simple formula that uses the number of reports of adverse events in infants exposed to antidepressants as the numerator and the combined total of reports of healthy outcomes and reports of adverse events as the denominator. The sum is then multiplied by 100. A value of < or =2 indicates that the drug should be relatively safe for use during breastfeeding, a value of 2.1-10 indicates that the drug should be used with great caution and a value >10 indicates that the drug should be contraindicated in breastfeeding mothers. In addition to the figure created by this calculation, each drug will also be assigned a letter or the combination of a letter and a subscripted number to symbolise, respectively, the type and clinical management of the most serious recorded event. At this early developmental stage of the index, a complete classification of contemporary antidepressants regarding their safety in infants nursed to the breast is unfeasible. Indeed, because of the lack of suitable published data, so far the index has been limited to the evaluation of four antidepressants. In accordance with the index classification for these four antidepressants, sertraline and paroxetine should be considered as first-line medications in women who need to start antidepressant treatment during the postpartum period and wish to continue breastfeeding. The utilisation of fluoxetine and citalopram seems conversely to be associated with a relatively higher risk of adverse events (with a low degree of severity, however). For the other newer antidepressant drugs, the index is still of no assistance to the patient or physician in deciding on the safety of their use in lactation.
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Affiliation(s)
- Salvatore Gentile
- Department of Mental Health ASL Salerno 1, Mental Health Center n. 4, Cava de' Tirreni, Salerno, Italy.
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33
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Eberhard-Gran M, Eskild A, Opjordsmoen S. Use of psychotropic medications in treating mood disorders during lactation : practical recommendations. CNS Drugs 2006; 20:187-98. [PMID: 16529525 DOI: 10.2165/00023210-200620030-00002] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Many new mothers who need antidepressant or mood-stabilising drug treatment may wish to breastfeed their infants, but are hesitant to do so because of possible harmful effects of the medication on the infant. This article reviews current data on drug excretion into breast milk and the effects on the breast-fed child, and provides recommendations for the use of the different psychotropic drugs in lactating women. Relevant literature was identified through systematic searches of MEDLINE, EMBASE and the Science Citation Index Expanded (ISI) from 1966 to February 2005. The present knowledge is based on the accumulation of case studies. No randomised controlled trials in breast-fed infants have been performed and there is a lack of long-term follow-up studies. Use of SSRIs and TCAs (except doxepin) is compatible with breastfeeding. However, if treatment with an SSRI is started in the postpartum period, fluoxetine and citalopram may not be drugs of first choice. With regard to other antidepressants, such as venlafaxine, trazodone, mirtazapine, reboxetine, moclobemide and other MAOIs, very little knowledge exists. Breastfeeding should be avoided while using lithium. Carbamazepine and sodium valproate (valproic acid) are generally better tolerated by the breast-fed infant than lithium. Data on lamotrigine are still sparse. Knowledge is also scarce on the novel antipsychotics and thus recommendations in lactating women cannot be made for these agents. It is unwise to expose infants unnecessarily to drugs that may have severe adverse effects. As such, clozapine should probably be avoided because of the risk of agranulocytosis. Our knowledge of the impact of drug exposure through breast milk is still limited. Infant drug exposure is, however, generally higher during pregnancy through placental passage than through breast milk. Despite the low dosage transferred to the infant through breast milk, premature infants and infants with neonatal diseases or inherited disturbances in metabolism may be vulnerable to such exposure.
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Affiliation(s)
- Malin Eberhard-Gran
- Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.
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Abstract
Postpartum depression is a crippling mood disorder, historically neglected in health care, leaving mothers to suffer in fear, confusion, and silence. Undiagnosed it can adversely affect the mother-infant relationship and lead to long-term emotional problems for the child. This article differentiates postpartum depression from other postpartum mood and anxiety disorders and addresses these aspects of postpartum depression: symptoms, prevalence, risk factors, interventions, and the effects on relationships and child development. Instruments available to screen for postpartum depression are also reviewed.
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&NA;. Use of selective serotonin reuptake inhibitors during pregnancy and breastfeeding has both benefits and risks. DRUGS & THERAPY PERSPECTIVES 2006. [DOI: 10.2165/00042310-200622030-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Kwok B, Yamauchi A, Rajesan R, Chan L, Dhillon U, Gao W, Xu H, Wang B, Takahashi S, Semple J, Tamai I, Nezu JI, Tsuji A, Harper P, Ito S. Carnitine/xenobiotics transporters in the human mammary gland epithelia, MCF12A. Am J Physiol Regul Integr Comp Physiol 2006; 290:R793-802. [PMID: 16195500 DOI: 10.1152/ajpregu.00087.2005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The barrier function of the human mammary gland collapses if challenged with cationic drugs, causing their accumulation in milk. However, underlying molecular mechanisms are not well understood. To gain insight into the mechanism, we characterized transport of organic cations in the MCF12A human mammary gland epithelial cells, using carnitine and tetraethylammonium (TEA) as representative nutrient and xenobiotics probes, respectively. Our results show that the mammary gland cells express mRNA and proteins of human (h) novel organic cation transporters (OCTN) 1 and hOCTN2 (a Na+-dependent carnitine carrier with Na+-independent xenobiotics transport function), which belong to the solute carrier superfamily (SLC) of transporters. Other SLC OCTs such as hOCT1 and extraneuronal monoamine transporter (EMT)/hOCT3 are also expressed at mRNA levels, but hOCT2 was undetectable. We further showed mRNA expression of ATB0+ (an amino acid transporter with a Na+/Cl−-dependent carnitine transport activity), and Fly-like putative transporter 2/OCT6 (a splice variant of carnitine transporter 2: a testis-specific Na+-dependent carnitine transporter). TEA uptake was pH dependent. Carnitine uptake was dependent on Na+, and partly on Cl−, compatible with hOCTN2 and ATB0+ function. Modeling analyses predicted multiplicity of the uptake mechanisms with the high-affinity systems characterized by Km of 5.1 μM for carnitine and 1.6 mM for TEA, apparently similar to the reported hOCTN2 parameter for carnitine, and that of EMT/hOCT3 for TEA. Verapamil, cimetidine, carbamazepine, quinidine, and desipramine inhibited the carnitine uptake but required supratherapeutic concentrations, suggesting robustness of the carnitine uptake systems against xenobiotic challenge. Our findings suggest functional roles of a network of multiple SLC organic cation/nutrient transporters in human mammary gland drug transfer.
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Affiliation(s)
- Bruce Kwok
- Division of Clinical Pharmacology and Toxicology, Department of Pediatrics, Research Institute, Hospital for Sick Children, 555 Univ. Ave., Toronto, Ontario, Canada M5G 1X8
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Abstract
The aim of this review was to assess existing information about the long-term neurocognitive development of children whose mothers took SSRIs during pregnancy and/or breastfeeding. The available literature consists of 11 studies (examining a total of 306 children) that demonstrate no impairment of infant neurodevelopment following prenatal and/or postnatal exposure to SSRIs, and two studies (examining 81 children) that suggest possible unwanted effects of fetal SSRI exposure. These unwanted effects included subtle effects on motor development and motor control. Thus, the available data are not unanimous in excluding possible long-term detrimental neurodevelopmental sequelae of intrauterine exposure to SSRIs. However, it is clear that the research suggesting a lack of adverse events on infants' neurocognitive development is much more numerous and methodologically better conducted than the studies showing possible unwanted effects. Nevertheless, all reviewed studies had procedural inadequacies, and the screening instruments used have limitations, especially in the evaluation of infants. Furthermore, it is not advisable to extend the generalisations emerging from the findings of a few trials to every infant. Some infants may experience difficulties in metabolising the drugs and/or their metabolites, so the benign outcome described for most infants may not occur. Thus, the findings emerging from the reports are inconclusive and are not able to fully clarify the repercussions of maternal SSRI treatment on infants' long-term neurocognitive development. Further large, simple and well designed, randomised, prospective studies will be required for this purpose. These should also be of adequate length and performed using reproducible neurophysiological parameters in order to firmly establish the safety of these medications.
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Abstract
Section 1 describes the benefits of breastfeeding to both mother and infant as well as the potential risks to the infant from maternal drug use. The extent of adverse drug-related events and the need for quality information on drug transfer is stated. Section 2 describes the physiology of lactation and the effects of drugs that stimulate or decrease milk production. Section 3 deals with transport mechanisms for drug passage into milk and factors that may modify the infant's exposure to drugs. The critical descriptors of 'absolute' and 'relative' infant dose are defined to give an objective measure of infant exposure to drugs in milk. Section 4 reviews new or commonly used drugs under the headings of analgesics and anti-inflammatory agents, neurological, endocrine, psychotropic and antihypertensive drugs. Section 5 concludes with an expert opinion of the drug industry and drug use in lactation, herbal preparations, the process of 'risk-benefit' analysis, minimising infant exposure, understanding drug-related adverse events and fostering good experimental design for drugs in lactation studies.
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Affiliation(s)
- Kenneth F Ilett
- University of Western Australia, School of Medicine and Pharmacology, Crawley, 6009, Australia.
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Abstract
There is continuing emphasis by many professionals and organizations on the importance of breastfeeding as optimal infant nutrition. Pediatricians are frequently asked about the safety of medications taken by the nursing mother and the risk to the infant. Most drugs and many chemicals will be transferred into milk. For a vast majority of these compounds, there is no risk to the infant. It is almost always possible for the mother to continue nursing while taking the necessary medication. This article presents an introduction to the pharmacology of the transfer of drugs into milk, discusses the importance of the infant's age in assessing safety and presents a number of maternal conditions for which drugs need to be used.
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Affiliation(s)
- Cheston M Berlin
- Penn State Children's Hospital, MS Hershey Medical Center, PO Box 850, 500 University Drive, Hershey, PA 17033-0850, USA.
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41
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Whitby DH, Smith KM. The Use of Tricyclic Antidepressants and Selective Serotonin Reuptake Inhibitors in Women Who Are Breastfeeding. Pharmacotherapy 2005; 25:411-25. [PMID: 15843288 DOI: 10.1592/phco.25.3.411.61597] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Postpartum depression is a well-recognized psychiatric condition that has gained increased attention over the past decade due to several nationally publicized tragedies. Medical management of this condition in women who are breastfeeding provides a unique challenge to health care professionals who may seek to maintain a fine balance between limiting the infant's exposure to hormone-altering drugs and maintaining the benefits of breastfeeding. No controlled trials have examined antidepressant therapy in nursing women; however, numerous case reports and case series have been published. Relatively few serious adverse effects have been reported. Although tricyclic antidepressants have been the treatment of choice in the past, selective serotonin reuptake inhibitors are gaining popularity due to their superior safety profiles. Of all the agents reviewed in the literature, sertraline was the most prescribed, and no adverse effects were reported. Therefore, this agent would be a good first choice for treatment-naive women. For treatment of postpartum depression in women with a history of successfully treated depression, the most practical approach may be to continue therapy with the previously effective agent. Treatment should be maintained at the lowest effective dosage to minimize infant exposure. Both mother and child should be closely monitored; in addition, collaboration between the prescribing physician and the child's pediatrician is essential.
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Affiliation(s)
- Dale H Whitby
- Department of Pharmacy Services, Shands Hospital at the University of Florida, Gainesville, Florida, USA
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42
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Hines RN, Adams J, Buck GM, Faber W, Holson JF, Jacobson SW, Keszler M, McMartin K, Segraves RT, Singer LT, Sipes IG, Williams PL. NTP-CERHR Expert Panel Report on the reproductive and developmental toxicity of fluoxetine. ACTA ACUST UNITED AC 2005; 71:193-280. [PMID: 15334524 DOI: 10.1002/bdrb.20014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Oberlander TF, Grunau RE, Fitzgerald C, Papsdorf M, Rurak D, Riggs W. Pain reactivity in 2-month-old infants after prenatal and postnatal serotonin reuptake inhibitor medication exposure. Pediatrics 2005; 115:411-25. [PMID: 15687451 DOI: 10.1542/peds.2004-0420] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In this prospective study, we examined biobehavioral responses to acute procedural pain at 2 months of age in infants with prenatal and postnatal selective serotonin reuptake inhibitor (SSRI) medication exposure. Based on previous findings showing reduced pain responses in newborns after prenatal exposure, we hypothesized that altered pain reactivity would also be found at 2 months of age. METHODS Facial action (Neonatal Facial Coding System) and cardiac autonomic reactivity derived from the respiratory activity and heart rate variability (HRV) responses to a painful event (heel-lance) were compared between 3 groups of infants: (1) infants with prenatal SSRI exposure alone (n = 11; fluoxetine, n = 2; paroxetine, n = 9); (2) infants with prenatal and postnatal SSRI (via breast milk) exposure (total n = 30; fluoxetine, n = 6; paroxetine, n = 20; sertraline, n = 4); and (3) control infants (n = 22; nonexposed) during baseline, lance, and recovery periods. Measures of maternal mood and drug levels were also obtained, and Bayley Scales of Infant Development-II were administered at ages 2 and 8 months. RESULTS Facial action increased in all groups immediately after the lance but was significantly lower in the pSE group during the lance period. HR among infants in the pSE and ppSE groups was significantly lower during recovery. Using measures of HRV and the transfer relationship between heart rate and respiration, exposed infants had a greater return of parasympathetic cardiac modulation in the recovery period, whereas a sustained sympathetic response continued in control infants. Although postnatal exposure via breast milk was extremely low when infant drug levels could be detected in ppSE infants, changes in HR and HRV from lance to recovery were greater compared among infants with levels too low to be quantified. Neither maternal mood nor the presence of clonazepam influenced pain responses. CONCLUSIONS Blunted facial-action responses were observed among infants with prenatal SSRI exposure alone, whereas both prenatal and postnatal exposure was associated with reduced parasympathetic withdrawal and increased parasympathetic cardiac modulation during recovery after an acute noxious event. These findings are consistent with patterns of pain reactivity observed in the newborn period in the same cohort. Given that postnatal exposure via breast milk was extremely low and altered biobehavioral pain reactivity was not associated with levels of maternal reports of depression, these data suggest possible sustained neurobehavioral outcomes beyond the newborn period. This is the first study of pain reactivity in infants with prenatal and postnatal SSRI exposure, and our findings were limited by the lack of a depressed nonmedicated control group, small sample size, and understanding of infant behaviors associated with pain reactivity that could have also have been influenced by prenatal SSRI exposure. The developmental and clinical implications of our findings remain unclear, and the mechanisms that may have altered 5-hydroxytryptamine-mediated pain modulation in infants after SSRI exposure remain to be studied. Treating maternal depression with antidepressants during and after pregnancy and promoting breastfeeding in this setting should remain a key goal for all clinicians. Additional study is needed to understand the long-term effects of prenatal and early postnatal SSRI exposure.
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Affiliation(s)
- Tim F Oberlander
- Department of Pediatrics, Biobehavioral Research Unit, Centre for Community Child Health Research, Room L408, 4480 Oak St, Vancouver, BC, Canada.
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Hallberg P, Sjöblom V. The use of selective serotonin reuptake inhibitors during pregnancy and breast-feeding: a review and clinical aspects. J Clin Psychopharmacol 2005; 25:59-73. [PMID: 15643101 DOI: 10.1097/01.jcp.0000150228.61501.e4] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Mood and anxiety disorders are common in women during their childbearing years. The prevalence of depression has been reported to be between 10% and 16% during pregnancy. The use of selective serotonin reuptake inhibitors during pregnancy or lactation is, to date, not promoted because of lack of safety documentation. However, the off-label use of these drugs has been common for several years. In the treatment of mood and anxiety disorders during pregnancy, the serotonin reuptake inhibitors are often preferred over tricyclic antidepressants because of their relatively few adverse effects and safety in overdose. This has created concern among women planning pregnancies and pregnant women, as well as among their families and physicians. Several studies and reports of the use of serotonin reuptake inhibitors during both pregnancy and lactation have been published and advanced our knowledge. We here review and discuss those studies which have been published so far on this subject.
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Affiliation(s)
- Pär Hallberg
- Department of Clinical Pharmacology, Uppsala University Hospital, Uppsala, Sweden.
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45
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Abstract
The pregnancy and postpartum periods are considered to be relatively high risk times for depressive episodes in women, particularly for those with pre-existing psychiatric illnesses. Therefore, it may be necessary to start or continue the pharmacological treatment of depression during these two timeframes. Hence, the aim of this review is to examine the effects on the fetus and infant of exposure, through the placenta and maternal milk, to the following drugs: fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram, mirtazapine, venlafaxine, reboxetine and bupropion. The teratogenic risks, perinatal toxicity and effects on the neurobehavioural development of newborns associated with exposure through the placenta or maternal milk to these medications need to be carefully assessed before starting psychopharmacological treatment in pregnant or lactating women. In spite of the limitations of some of the studies reviewed, the older selective serotonin-reuptake inhibitors (SSRIs) [as we await further data regarding escitalopram] and venlafaxine seem to be devoid of teratogenic risks. By contrast, the data concerning possible consequences related to exposure to SSRIs via the placenta and breastmilk on neonatal adaptation and long-term neurocognitive infant's development are still controversial. Nevertheless, a number of reports have shown that an association between placental exposure to SSRIs and adverse but self-limiting effects on neonatal adaptation may exist. In addition, the information on both teratogenic and functional teratogenic risks associated with exposure to bupropion, mirtazapine and reboxetine is incomplete or absent; at present, these compounds should not be used as first-line agents in the pharmacological treatment of depression in pregnancy and breastfeeding. Untreated depression is not without its own risks since mothers affected by depression have a negative impact on the emotional development of their children and major depression, especially when complicated by a delusional component, may lead to the mother attempting suicide and infanticide. Consequently, clinicians need to help mothers weigh the risks of prenatal exposure to drugs for their babies against the potential risks of untreated depression and abrupt discontinuation of pharmacological treatment. Given these situations, we suggest that choosing to administer psychopharmacological treatment in pregnant or breastfeeding women with depression will result primarily from a careful evaluation of their psychopathological condition; currently, the degree of severity of maternal disease appears to represent the most relevant parameter to take this clinical decision.
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Affiliation(s)
- Salvatore Gentile
- Department of Mental Health, ASL Salerno 1, District n. 4, Cava de' Tirreni (Salerno), Italy.
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46
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Affiliation(s)
- Thomas W Hale
- Department of Pediatrics, Texas Tech University School of Medicine, Amarillo, Texas 79106, USA.
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47
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Currie ML, Rademacher R. The pediatrician's role in recognizing and intervening in postpartum depression. Pediatr Clin North Am 2004; 51:785-801, xi. [PMID: 15157598 DOI: 10.1016/j.pcl.2004.01.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Increasing evidence of postpartum depression is encouraging pediatricians to include screening and intervention for postpartum depression in standard newborn and infant care. Pediatricians have the most frequent exposure to mothers and infants in the most high-risk time period and they have a vested interest in the well-being of the child and mother. Because the time required to achieve basic screening and referral services is minimal, there is enough evidence that postpartum screening and intervention are crucial components of comprehensive newborn and infant care. It is incumbent upon pediatricians to screen for and intervene in cases of postpartum depression to provide thorough care for infants and their families.
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Affiliation(s)
- Melissa L Currie
- Medical College of Wisconsin, Children's Hospital of Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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48
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Malone K, Papagni K, Ramini S, Keltner NL. Antidepressants, antipsychotics, benzodiazepines, and the breastfeeding dyad. Perspect Psychiatr Care 2004; 40:73-85. [PMID: 15323416 DOI: 10.1111/j.1744-6163.2004.00073.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Kirsten Malone
- Lactation Services, Children's Hospital of Alabama, Birmingham, USA
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49
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Abstract
Postpartum depression (PPD) occurs more commonly in U.S. women than most physicians realize. PPD is present in at least 10% and up to 20% of women in the United States within the first 6 months of delivery. The rate may be 25% or higher in women with a history of postpartum depression after a previous delivery. Over half of all women who develop postpartum depression still suffer symptoms a year later. This condition causes tremendous morbidity in terms of suffering and decreased quality of life. As with other psychiatric disorders, patients with PPD are more likely to seek help from their primary care doctors than from mental health professionals. Therefore, these providers should be equipped with the knowledge and tools necessary to properly care for women with PPD.
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Affiliation(s)
- Emily C Clay
- Department of Family Practice, Madigan Army Medical Center, Ft. Lewis, WA 98431, USA
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50
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Zeskind PS, Stephens LE. Maternal selective serotonin reuptake inhibitor use during pregnancy and newborn neurobehavior. Pediatrics 2004; 113:368-75. [PMID: 14754951 DOI: 10.1542/peds.113.2.368] [Citation(s) in RCA: 204] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This is a prospective study of the effects of maternal use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy on newborn neurobehavioral integrity, including systematic measures of behavioral state, sleep organization, motor activity, heart rate variability (HRV), tremulousness, and startles. METHODS The sample included 17 SSRI-exposed and 17 nonexposed, full-birth-weight newborn infants who had no obvious medical problems and were matched on maternal cigarette use, social class, and maternal age. SSRI exposure was determined by medical records and maternal self-report during a standard interview. Behavioral state, startles, and tremulousness were evaluated for 1 hour between feedings. Automated recordings of motor activity and HRV were also assessed during a 15-minute subset sleep period. HRV was subjected to spectral analysis to detect rhythms in autonomic regulation. Exposed and nonexposed infant groups were compared on measures of neurobehavioral development both before and after adjustment for gestational age as a covariate. RESULTS SSRI-exposed infants had a shorter mean gestational age; were more motorically active and tremulous; and showed fewer rhythms in HRV, fewer changes in behavioral state, fewer different behavioral states, and a lower peak behavioral state. SSRI-exposed infants also had significantly more rapid eye movement sleep, which was characterized by longer continuous bouts in that state and higher numbers of spontaneous startles or sudden arousals. After effects of gestational age were covaried, significant differences continued to be found in tremulousness and all measures of state and sleep organization, but effects on startles, motor activity, and rhythms in HRV were no longer significant. CONCLUSIONS Results provide the first systematic evidence that women who use SSRIs during pregnancy have healthy, full-birth-weight newborn infants who show disruptions in a wide range of neurobehavioral outcomes. Effects on motor activity, startles, and HRV may be mediated through the effects of SSRI exposure on gestational age. Future research can lead to a better understanding of the effects of SSRI use during pregnancy and an improved public health outcome.
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Affiliation(s)
- Philip Sanford Zeskind
- Department of Pediatrics, Carolinas Medical Center, Charlotte, North Carolina 28232, USA.
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