There are numerous factors to consider when assessing the safety of drugs in lactating women. Drug properties facilitating transfer into milk as well as the pharmacokinetic properties of the drug in the mother and infant must be evaluated. Drug properties which promote low milk concentrations are: large volume of distribution, high protein binding, low lipid solubility, ionization at physiologic pH and large molecular weight. Following transfer into breast milk, drugs with low bioavailability and short elimination half-lives in neonates have improved safety.
Women who suffer from postpartum depression require treatment. Caution must be exercised if any antidepressant is used. These agents concentrate in the central nervous system; therefore, serum concentrations and breastmilk: plasma ratios may not accurately predict infant drug exposure. Since there is no absolute contraindication to breastfeeding during antidepressant use, recommendations should be made on a case-by-case basis limited to healthy term infants. When possible plasma antidepressant concentrations, including metabolites, should be measured in the infant. Frequent developmental follow-up, not only during the treatment period but throughout childhood, should be performed on these infants.
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