Objective: We conducted the first statistical meta-analysis of all available antidepressant levels in nursing mother/infant pairs, in order to identify the antidepressants that lead to minimal infant exposure.
Methods: Electronic and bibliographic searches identified 58 studies, of which 51 provided usable paired plasma and milk levels. We also collected unpublished data from 36 cases. Multiple measurements from the same subjects were deleted. Infant levels were standardized using the average maternal level.
Results: Symptomatic infants and infants with recent prenatal exposure were treated in separate analyses. Except for dothiepin, fluoxetine produces the highest mean standardized infant level and the highest proportion (29.4%) of infant levels that are elevated (> 10% of the average maternal level). Nortriptyline and paroxetine produce infant levels that are usually undetectable, but 7.6% of infant sertraline levels are elevated. Based on smaller numbers, 16.7% of infant citalopram levels are elevated. Prenatal exposure to fluoxetine results in persistently elevated levels that can last beyond six weeks of age.
Conclusions: Nortriptyline and paroxetine are unlikely to produce detectable or elevated infant levels and may be preferred choices in breastfeeding. Fluoxetine is more likely to produce elevated levels, especially following prenatal exposure. Research into effects of antidepressants on infants is needed.