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Sertralina Postpartum
Sertralina Postpartum
Sertralina Postpartum
To cite this article: Alessandro Cuomo, Giuseppe Maina, Stephen M Neal, Graziella De Montis,
Gianluca Rosso, Simona Scheggi, Bruno Beccarini Crescenzi, Simone Bolognesi, Arianna Goracci,
Anna Coluccia, Fabio Ferretti & Andrea Fagiolini (2018) Using sertraline in postpartum and
breastfeeding: balancing risks and benefits, Expert Opinion on Drug Safety, 17:7, 719-725, DOI:
10.1080/14740338.2018.1491546
REVIEW
CONTACT Andrea Fagiolini andreafagiolini@gmail.com University of Siena, Department of Molecular and Developmental Medicine (AC, GDM, SS, BBC, SB, AG, AF)
© 2018 Informa UK Limited, trading as Taylor & Francis Group
720 A. CUOMO ET AL.
maternal sertraline levels. A significant relationship was exposed to sertraline. In this group (n = 30), signs of blunted
instead found between infant and maternal plasma concen- pain response were observed [47].
trations of desmethylsertraline. However, desmethylsertra- However, several studies reported no adverse events. For
line is not as active as sertraline. instance, Lee and colleagues [69] reported no adverse event
The authors concluded that their findings confirm the role in a control group that included two infants breastfed by a
of sertraline as first-line antidepressant and support the prac- mother who was treated with sertraline [63]. In addition, no
tice to target sertraline dose at the best level to completely adverse outcomes were observed in an infant breastfed by a
treat depression, as opposed to prescribing low doses out of mother receiving sertraline 50 mg daily and methylpheni-
fear of an excessive infant exposure. date 72 mg/day. The evaluations conducted at 6 and
12 months of age confirmed the absence of developmental
problems in the child [64].
3. Adverse impacts of sertraline during breastfeding
In addition, in a study of sertraline for postpartum depres-
Sertraline may affect the production of breast milk. Cases sion, no adverse even was reported for any of the six infants
of galactorrhea in non-expectant and non-nursing women who were breastfed [65].
treated with sertraline have been reported [60–62], despite Hale and colleagues [66] evaluated antidepressant discon-
the fact that most studies on the topic have concluded tinuation syndrome in the infants of 403 (188 on sertraline)
that sertraline is less likely than other SSRISs or than some women who received an antidepressant only during preg-
SNRIs to cause hyperprolactinemia [57]. nancy or during both pregnancy and breastfeeding (n = 527,
Holland reported to have observed a reduced milk supply 405 on sertraline).
in six nursing mothers treated with sertraline. Interestingly, Discontinuation syndrome was reported only for a small per-
one of the women experienced an increase in milk supply centage of infants exposed to antidepressants. Interestingly,
after stopping sertraline for 1 week, which reversed upon re- infants of women who took antidepressants during pregnancy
starting the medication. However, the author noted that the and breastfeeding were 2–8 times more likely to experience
reduction in milk supply was temporary in all six cases, and symptoms of discontinuation than infants that were exposed
that milk production improved within 2–3 days from an only during breastfeeding.
increase in the intake of fluids [58]. A telephone follow-up survey was conducted among 124
Another case study [59] evaluated the impact of SSRIs females who used benzodiazepines during breastfeeding to
(including sertraline) on human lactation in a cohort of 431 determine whether their newborns demonstrated any symptom
women and observed that women on SSRI were more likely to of sedation. One of the women was also taking sertraline 50 mg/
experience delayed secretory activation. day, along with 2.5 mg of zopiclone as needed, up to three times
A cohort study compared the breastfeeding outcomes of a day. Sedation was reported in the breastfed infant but it was
women treated with SSRI at the time of delivery with a group not possible to establish if sertraline contributed [67].
of women who discontinued the antidepressant before deliv- Muller and colleagues [68] reported of a 33-week preterm
ery, and a group of women who were never exposed to infant who was exposed to sertraline during both pregnancy
sertraline. Breastfeeding rates resulted significantly higher in and lactation. Signs of serotonergic overstimulation were
unexposed women. In addition, both women exposed to an observed until day 9 after birth, when breastfeeding was
SSRI prior to delivery and women who were still taking sertra- discontinued. The symptoms resembled an abstinence syn-
line at the time of delivery (total number of women exposed drome and included muscle tone dysregulation, high-pitched
to sertraline = 87) were less likely (respectively, 27% and 33%) crying, and hyperthermia. Interestingly, sertraline blood level
to breastfeed than unexposed women, despite the fact that in the infant was within the normal range estimated for adults.
there were not significant differences in lactation rates among However, the serotonergic overstimulation could be due to
the study groups. The authors concluded that women the infant’s reduced metabolic capacity and/or the immaturity
exposed to SSRIs during pregnancy may benefit from addi- of the blood–brain barrier.
tional education and support regarding breastfeeding and the In a study of 247 infants exposed to an antidepressant
risks of antidepressant exposure [60]. during the third trimester of pregnancy, a higher risk of devel-
Although several studies reported no adverse effects [61], oping poor neonatal adaptation was observed in infants who
isolated cases of adverse events potentially related to expo- received formula feeding compared to those infants who were
sure to sertraline during breastfeeding have been reported. breastfed or received mixed feeding. Of note, 68 of the total
For instance, Rohan described the history of a 5-month-old sample was exposed to sertraline during pregnancy and all
baby who became agitated after her mother took sertraline mothers continued the medication during breastfeeding [69].
and of an infant who was exposed to sertraline from 10 days Uguz and colleagues [70] retrospectively evaluated the
postpartum through the remaining of the first 3 months of life. tolerability of sertraline and paroxetine in 72 breastfed infants,
During this period, the infant was somnolent, had low muscle of whom 42 were exposed to paroxetine and 30 to sertraline.
tone, and hearing problems, which markedly improved when Sertraline dose was 25 mg in 3 mothers, 50 mg in 24 mothers,
the drug was discontinued [62]. and 100 mg in 3 mothers. Paroxetine dose was 10 mg in 10
Oberlander and colleagues evaluated biobehavioral mothers and 20 mg in 32 mothers.
responses to pain at 2 months of age in infants exposed to The prevalence of adverse events was 12.5%. Four infants
SSRI. The study group of 30 infants who were exposed to SSRIs in the sertraline group and five infants in the paroxetine group
both pre and post-natally, included four subjects who were experienced adverse events, and the most frequent symptoms
722 A. CUOMO ET AL.
were insomnia (88.9%), restlessness (55.6%), and excessive usually considered as first-line options in breastfeeding (e.g.
crying (22.2%). citalopram or fluoxetine) should be taken only after a thor-
All adverse events developed within 2 weeks of initiation of ough evaluation of the risks and benefits of switching versus
sertraline treatment and completely recovered within the continuing an ongoing effective medication while monitoring
3 days from treatment discontinuation. the infant carefully [33,90].
If sertraline is administered to a nursing mother after delivery,
it is recommended to begin at a low doses and then titrate the
4. Conclusion
dose up slowly, while monitoring the infant for adverse effects
A number of psychological interventions have been devel- (irritability, poor **feeding, or uneasy sleep, particularly if the
oped and tested for the treatment of mild postnatal infant is sick, premature or has a low weight) [17,22,35,40,91–
depression: interpersonal therapy (IPT) [71–77]; cognitive 94]. The target dose should be the lowest effective one, although
behavioral therapy (CBT) [78–80]; psychodynamic therapy care should be taken to ensure that such dose is high enough to
[79]; individual or support group counseling [81,82]. be effective [95].
Overall, psychological interventions for the treatment of Infant exposure to an antidepressant could be minimized
depression in the postpartum period have shown moder- by avoiding breastfeeding at the time of peak antidepressant
ate effect sizes [83]; antidepressant medications have concentration in the breast milk[96]. However, avoiding breast
shown larger effect sizes [84]. feeding when peak drug levels occur may not be practical [86].
Pharmacotherapy should be considered for women who are When adverse effects in the infant are noted, options to be
experiencing moderate to severe depression and do not respond considered include a dosage decrease, a change to partial or
to, or are not good candidates for, psychotherapy. When consider- full bottle-feeding, or a change in the prescribed medication.
ing an antidepressant a woman who needs to breastfeed, there is Although the ability to metabolize drugs is not usually fully
not a 100% safe option or an universally accepted treatment developed in neonates, routine breast milk and/or infant
algorithm option. It is noteworthy that many antidepressants in serum sampling for drug levels evaluation is generally not
general, and sertraline in particular, show minor concentrations in recommended [21,35,97]. However, in selected cases serum
breast milk and even lower – often undetectable – concentrations sampling may be helpful to reassure a mother who desires
in the infant serum. When an antidepressant therapy is indicated to continue breastfeeding but is worried about the drug con-
in females suffering from depression, it is not always necessary to centrations in her milk and/or in her infant circulation.
discontinue breastfeeding, especially when a relatively safe med- The literature on this topic is rapidly growing. Once a decision
ication, such as sertraline, is prescribed. has to be taken, we recommend to monitor current knowledge
through publications and websites that update and review pub-
lished information frequently (https://toxnet.nlm.nih.gov/new
5. Expert opinion
toxnet/lactmed.htm; www.mededppd.org, www.postpartum.
A personalized risk–benefit evaluation should be conducted net, www.womensmental-health.org, and www.motherrisk.org).
before a decision is made whether an antidepressant should
be started/continued in postpartum and whether breast feed-
Funding
ing should be suggested. A partnership between the mental
health professional and the pediatrician is paramount, as no none
clinical decision in the context of postpartum depression is
completely without risk.
Clinical variables that may inform treatment options Declaration of interest
include the mother’s clinical history, the current symptoms, A Fagiolini is/has been a consultant and/or a speaker and/or has received
the risks of untreated depression, the risks and benefits of research grants from Allergan, Angelini, Generici DOC, Lundbeck, Italfarmaco,
Janssen, Otsuka, Pfizer, Recordati, Roche, and Sanofi Aventis. G Maina is/has
breastfeeding, and the mother’s preferences [85].
been a consultant and/or a speaker and/or has received research grants from
In most cases, women who are already taking sertraline Janssen, Otsuka, Lundbeck, Fb Health, Angelini, and Sanofi Aventis. G Rosso
should be advised to continue for at least 6 months after is/has been a consultant and/or a speaker and/or has received research
recovery of the depressive episode. Important variables to grants from Otsuka, Lundbeck, and Angelini. The authors have no other
consider include the number of previous episodes and the relevant affiliations or financial involvement with any organization or entity
with a financial interest in or financial conflict with the subject matter or
risk of relapse if the treatment is discontinued [86,87].
materials discussed in the manuscript apart from those disclosed.
Moreover, continuing the antidepressants while breast-
feeding may reduce the risk of withdrawal symptoms for
the infant [88]. In fact, stopping an antidepressant abruptly ORCID
may lead to withdrawal effects[89]. Gianluca Rosso http://orcid.org/0000-0002-2308-9146
Sertraline is one of the safest and most studied medica-
tions to be used during breastfeeding, owing to its docu-
mented low levels of exposure in breastfed infants and to References
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