Ep. 107- PPD/PPA Medications and Breastfeeding

Transcript:

This is Maureen Farrell and Heather ONeal. And this is The Milk Minute. We’re midwives and lactation professionals bringing you the most up-to-date evidence for all things lactation. So you can feel more confident about feeding your baby, body positivity, relationships, and mental health. Plus, we laugh a little or a lot along the way.

So join us for another episode. We’re live on The Milk Minute Podcast. We’re not live at all. We’re recording. We’re recording The Milk Minute Podcast now. So sorry to bother you. We were just going to talk to you about depression and medication and breastfeeding. Yeah. It’s a, it’s, it’s an important topic.

And, you know, for whatever reason, we’ve just had a couple of downer episodes recently, but we’re going to try, we’re trying to like spice them up with not downer ones in between. It’s going to be okay though. We’re going to get through it. These are important things to talk about. Yeah. They are important things.

And first of all, if you are currently struggling with postpartum depression or anxiety and you even push play, I’d like to congratulate you because that is really hard to do. And it’s okay if you’re already crying and we haven’t even started talking about anything because crying is therapeutic and it’s fine.

And we promise we’re going to make this as painless as possible. And also just spoiler alert, there’s going to be timestamps in the show notes if you’d like to skip to the medication that you and your provider are currently discussing so you don’t have to listen to the whole episode. And if you feel like that medication is not for you, or this current medication that you’re taking is not working for you, you can skip to some of the other ones and see if that sounds like it’s more your speed. Yeah. And I hope that we cover the basics today. There are a lot of medications that can possibly be used for depression and anxiety.

And we are not going to cover every single one today, but just the most common. Yes. But first I want to hear about your life, Maureen. Cause I haven’t seen you in a long time. So, okay. Lyra is one. That’s insane. Just wild. I don’t know, but we’re there and she’s climbing stairs. Anxiety.

She’s not very good at it. Like, so I dug back through my videos and found ones of Griffin at the same age where he’s like climbing a ladder with zero assistance. But he, I guess, had he like his problem with how he did things and hers are very different and now I don’t know how to help her because he used to come down the right way and not go up the right way.

And she’s going up correctly and not down correctly. So there’s like this little two-step thing in our house and she’ll go up it. And then she’ll like fumble down the first step and fall on her butt onto the next one. And then like fall and hit her head on the floor. Does she cry or is she like meh? She usually cries for a minute and then she’s like, I would like to try that again.

And I can’t stand that phase to be honest with you. So I actually, with Griffin was really good about like low anxiety and the risky behavior, like the beginnings of risky behavior, because it has not stopped. I have a lot more anxiety with her and I think it’s because she’s just like a lot less supervised because I have other shit to do all the time and like a whole other child who needs my help.

So it’s always, when he’s like, I need help with this. I’m like, sure. And then I turn around and she’s like up on some new thing she’s never been up on before, like looking over her shoulder at me with that look where you’re like, could you do nothing? Just pause. It does mostly give me anxiety because I just, like I said, bigger house than I have experience with managing babies in.

And there’s just like places that I didn’t know, she could get hurt that she has. Fun. Yeah. I really hated that phase. When Theo was little, we lived in an apartment that had two flights of stairs in a row with a landing. And on the landing, there was a cutout in the wall. Like, I don’t understand how that was safe, but it was like a four-by-four cutout, right at the floor level of the landing with a six-foot drop on the other side to concrete in the foyer.

I was like, what the hell? So basically on the way up, he’d crawl up the first flight of stairs, look to the left, to try to escape thinking there was stairs down there or something. And there wasn’t. And then also if he was coming down the top, I would be worried that he would roll down the stairs to his death straight out of the creepy landing window.

And I was like, why, why is this happening? I should have just put a, you know, here’s the difference between 25-year-old, Heather and 34-year-old Heather. Then I just stressed about it all day long and constantly had anxiety. Now I would have just got a piece of plywood and nailed it to the wall. And it would have not been an issue anymore, right?

Like why didn’t I solve for the actual problem? I don’t know. I have to decide right now how much baby proofing I actually want to do, like where it’s necessary and where it’s actually going to be easier and not harder. So you’re tall, I’m not. And baby gates, even the short ones are above my hips. And so it means, first of all, they’re all pretty freaking narrow.

So I have to go like sideways through them or if I’m carrying Lyra and I forget what I’m doing, her legs get caught in it because she’s on my hip. And then I end up hurting her unless I like raise her up and go through the baby gate. So they’re actually a problem for me because I’m not very tall. I’m sorry.

I never thought about it. Yeah. And so we have one baby gate in our house just at the top of the stairs to keep her from falling down so I can poop because the bathroom is upstairs. That’s funny. Yeah. And that’s it right now. Cause I’m, and it is a, I hate that baby gate already. It’s been there for like a month.

I am just now recalling and I will find a picture of this and put it on Instagram. Please don’t report me to CPS. When Theo was little, at the bottom of the stairs, I made my own baby gate because there was no way, none of the baby gates available worked for the area for some reason. So I made one that was almost like a barn door with a hinge on it, but I made it out of pallets because I was poor.

And also I had no idea what I was doing. So there were a couple areas where nails were like definitely sticking out and it wasn’t the most sturdy and I guess it did the job and he didn’t get tetanus, but it didn’t, it, I do recall people coming to my house and like, you know, opening and closing it clearly thinking about the safety of it and the efficacy.

And I was like, oh, don’t worry about it. If he hurts himself, he’ll never do it again. Well, I, on that topic, we, so we have a wood stove in our house. Oh yes. I’ve seen it. And it’s how we heat the house and we’re moving out of like heating season. But and most of the winter Lyra couldn’t crawl so I really didn’t bother teaching her about it, but we’ve had like a month where we used it on and off and she’s been super mobile and super-fast.

And so I like finally started trying to teach her about it. She definitely touched it once when nobody was looking. And I don’t know when, but Ivan and I both looked at her and we were like, is that a burn? Like what, where did that come from? She must’ve done it. I have no idea when. She didn’t cry. So I don’t know.

Anyway, it’s one of those burns where they don’t cry. I have no idea. It wasn’t bad. It was just like a little red spot, but it was obviously the way it was scabbing. I was like, Ooh, that’s a, that was a hot thing. Weird. But now she, this, we went through this with Griffin too. They learn really quickly what hot is because they can feel it.

Yeah. So now when we go by the stove, she throws her hands up and goes, ha ha ha ha! Oh, smarty. Yeah. Or she’ll point to it and go, ha ha ha. And the funny, like sequala of events with that was I, we have one of those bottom drawer freezers in the fridge and I opened it and she was right next to it and she touched it and whipped her hand back.

And she was like, ha ha. You know, when you touch something so cold, it burns? And I was like, yeah, let’s go with that. Yes. It’s hot. Everything’s hot. Yeah. And watch you’re straightening irons. Oh, I don’t own one, but those things are like 450 degrees. I haven’t used one in years cause I’m doing the curly girl method by the way.

I finally realized that I’ve been doing the pineapple all wrong. Oh, those curly girls out there know what I’m talking about, where you wash your hair at night and then you put it in a ponytail literally right at the top of your head. I mean right where your forehead meets your hairline. I don’t have long enough hair to be able to do that.

What about people with shorter hair? You can do a unicorn. So there’s different methods where you do like half up, half down. There’s like a whole YouTube video about it that I finally took the time to watch and it has improved my life. Okay, so that’s good. Also I noticed in my car that is now a year old.

I drive a Ford Explorer. I was really looking the other day. I don’t know how to use a third of the buttons and I don’t know what they’re for. And I realized that I’ve been driving with my seat, not adjusted to my body for a year. And I’m like, why am I like this as a person? You know, some people get a new car and they’re like, I want to learn about all the buttons and I want to make my life easier and I’m going to adjust it to my seat and save my seat settings.

So it’s a fancy car. It’s because you have kids. Okay. The first time you got in the car, you were like, we gotta put these car seats in. Probably. And also, this is how I was with pumping. You know, like, it’ll be over soon. This is how I think of me driving. I’m just driving 10 minutes. Like, why do I need to make it comfortable?

You know, I’m just going to get there. And then I got to do my shit. Pumping is the same way. Like, oh, I’m just getting through it. So the here’s your public service announcement. Don’t be like me. Take an extra 10 minutes. Listen to the pump review episode, phone a friend. How can you make your life easier using your particular pump?

Maybe it will be better for you. I don’t know. Anyway, Heidi pooped on the potty. Yes, Heidi. I’m not proud of how it happened for myself, but I am proud of her. So I tried everything. Just so you know, I, I even bought the poop tent for her to poop in with privacy that is still set up in my living room. We have tried multiple different potties.

I took the class, we read the book, I did all of the things and we are now at the point where none of those worked and I knew she had to poop and she withholds for like 36 hours at a time. And so I held her down on the toilet nonconsensually by her little hips. And I said, you’re not getting up. And she freaked out.

Of course. Cause I would too if someone did that to me. Did she scream the poop out? Cause Griffin has done that. She screamed the poop out and it came out like a truck stop poop, like everywhere. And it was all liquid because she’d been holding it for 36 hours. And then I was like, you did it! And she was like, yeah, I did it.

And then started the manipulation where I was like, and you sat there the whole time. And she’s like, yeah. And I didn’t even get up. And I’m like, I know I’m so proud of you. You didn’t even get up. And I’m like, Heather, you’re so messed up. You know what? There, there will be plenty of things you do she’s in therapy for. Probably it’s not that one.

Yeah, I hope not. But so today was day two. She pooped her pants today, but then Cash said that she did eventually poop a little bit on the potty. So we’re getting there. We are getting there. She’s very smart. She can name all the West Virginia state birds and animals and all of that. But pooping, for some reason on the potty is a very big deal.

So anyway, thank you for riding this journey with me and please don’t judge me for the nonconsensual imprisonment on the potty that I performed yesterday. Sometimes we do have to violate our children’s consent to keep them safe and healthy. And her pooping in her pants long-term is not safe and healthy. Okay, thank you for making me feel better about that. 

And to make it up to her we did ice cream at Sonic after that, even though it was nine o’clock at night. And I threw her a poop party in the morning, I even got a poop emoji pinata. We made brunch for all of our neighbors and friends. Did it look like poop? Well, no, I’m not. I only had like two hours to plan it. So I got whatever was available at Walmart.

I’m sure did a wonderful job. And I’m sure it was a lovely poop party. It was the best poop party. And we even got an ice cream cake with a poop dollop on top and we stuck candles in it and she blew them out and we sang happy poop day. And I will put that on Instagram for you to see it. I’m so excited to see.

Well, talking about shitty things, maybe we should get toward the episode? I guess, but first we do have a question, right? Yeah. Yes. Today’s question is from Alyssa W from Wilmington, Delaware, who is a patron of ours. Alyssa says this honestly might sound really silly, but do you always have to empty fully when pumping?

I get so, so impatient sometimes, especially if I’m on my third or last pump of the day, I haven’t really had issues with supply, but I guess it could cause other issues not emptying all the way. Sometimes I just kind of stop when I feel like it. Is that a problem? 

Doesn’t sound like a problem to me. Nope. I just watched Maureen do an incomplete emptying and she’s fine. And then an hour later she did another full pump and it all came out and it was great. Yeah. I mean, here’s the thing. If we are looking to increase supply, it’s really important to pump or feed until there’s nothing or not much left. Right.

But when we’re just doing maintenance pumps, like we’re just trying to get enough to feed baby and not lose our supply. It’s okay for it to vary. Your baby’s not going to empty every time they feed. Right? So some pumps can be full drainage. Some can be smaller pumps. As long as overall, you’re removing about the same amount of milk as baby is eating, then that should be enough to maintain your supply.

If not fully emptying is giving you clogs and mastitis, then that’s another reason you might want to at least like maybe change pumping positions and do some massage and just make sure you’re moving things out of different areas. Maybe fully emptying depending on what’s going on, but really it sounds like you’re doing fine.

I agree. Couldn’t agree more. And you know what? We’re pumping because we’re busy and if you’re too busy to finish a complete pumping session, that’s fine. Don’t beat yourself up. Just make up for it later. Try to pump maybe a little bit sooner than you would normally and go on. Just go on with your life.

And you know what? I do that all the time where I’m like first pump is great. Second pump’s great. Third pump, I’m seven minutes in I’m like, screw this. I’m done. Done. Done. Let’s go home. Screw you guys. I’m good. And it’s fine. And sometimes like when my work schedules kind of hectic, I will pump like every two hours, but then like 30 minutes later I’ll pump and then not pumped for four hours and then pump again, just cause I was like, oh, I don’t know stuff’s going on. I don’t have time to do it. I’m catching babies. So it’s totally okay. It does not have to look the same every day. Just do your best. Yep.

Hey everybody, Heather here with some good news for you. If you’ve been wanting a lactation consult with me, but you’re not really sure how to go about it, I finally can take some insurance. So if you have Blue Cross Blue Shield, Anthem, or Cigna PPO, there’s a very good chance that you can get your visits a hundred percent approved with me.

So if you fill out the short form, it’ll take less than two minutes in the show notes with your insurance information, we’ll know in as little as five hours, if you’re approved and then we’ll throw you right on my calendar. And then we get to hang out. And guess what? It’s not just one visit. I can see you prenatally.

I can see you before you go back to work. I can see you when you start solid foods. I can see you through weaning. I mean, we got this whole journey covered. So shout out to those insurance companies for valuing this as work and I’m here for you every step of the way. So click the link in the show notes, to learn more about my private consults and make sure that we can get you what you need. I look forward to working with you. Bye.

Okay. Well, today we’re talking about depression medication, right? There’s many of our listeners who are on the fence about whether or not to take medication, like they know that they have a problem, but they don’t know if they’re ready to take that next step to medication for mental health. And hopefully this episode helps to shed some light on your options so you can feel better about your choices.

Yeah. And I think a lot of people do wait to make that choice because they’re not sure if it’s safe. So we’re going to try to go through that today so it can be one less thing that you worry about. However, this is not a debate about whether or not you should take medications. You know, we just want to say that a lot of people are taking like Zoloft and Paxil. 

And you know, we’re supportive of that guys. But this, it might not be the right choice for you and we can’t make that decision. Right. And we just wanted to give that little spoiler up top to save you some time in case you do have anxiety right now, you don’t want to have to wait to get that answer.

So Zoloft and Paxil are the two most recommended antidepressant slash anti-anxiety medications for breastfeeding parents. Yes. However, they are not the only ones that are compatible with breastfeeding. These just have the most research behind them. 

As well as Prozac. Prozac, we have the time. So Prozac was like the OG drug. So we have a lot of data on that. So that’s why that one is often a third one that they rotate in and out. Yeah. And in the rest of the episode, we’re going to hit Prozac. We’re going to talk about Celexa, Lexapro, Wellbutrin, and Pamelor. Those are all the brand names. We’ll talk about the generic names too.

Yeah. So hop down into the timestamps if you are looking for information on a specific one. 

We do have some evidence that breastfeeding can decrease your risk for postpartum anxiety and postpartum depression, so we have to weigh the risks of taking an antidepressant while breastfeeding versus not breastfeeding at all. Because there are risks to not breastfeeding, which we like to remind people. We don’t want to rub it in your face. If you have to formula feed, that’s awesome. That’s what it’s there for if you’re not able to breastfeed. But not breastfeeding does come with risks. So weighing those risks versus weighing the risk of breastfeeding with an antidepressant possibly in your milk.

I do want to add, there are a couple of studies that conclude the opposite and say that breastfeeding increases your risk for those. I don’t want to go into them today. We’re going to have a follow-up episode where we talk more about that relationship and more about what postpartum depression, anxiety, mood disorders are, what they look like, et cetera.

But I just want to put it out there. People are studying the relationship between the two. We don’t have strong enough conclusions to really be making like medical recommendations like you should or should not breastfeed if you are at high risk for postpartum depression or anxiety. Right. And also medication is actually a second line defense for postpartum depression and anxiety.

The first line is psychotherapy. So seeing a therapist who’s actually qualified and available for you, which of course is not accessible to everybody. So we just want to acknowledge that even though it’s the first recommendation is to get therapy, it’s not available for everyone. And that’s unfortunate.

And we would love to see some change in that. Like, maybe you can get a therapist, but you actually don’t jive with them. And they don’t specialize in postpartum depression, you know? Like, is that better? I’m going to go with maybe not because you also don’t have time. Like maybe it will be fine, but really I’m looking for someone who’s like specialized in what you’re going through.

That understands what it is to be a postpartum mom. Knows that you might be 10 to 15 minutes late for your appointment every time and not make you feel bad about it. You know, things like that. And also that you can afford and has availability on their schedule. So those are a lot of ifs and this is why we have medication because you have to be able to function to care for your tiny human.

And sometimes you need both, right? I, I talked to a lot of patients about this. I do not prescribe these, but everybody comes to me first to ask about it. And you know, when people are hesitant about it, my response is always like, this is not forever. You’re not signing a contract to take a medication for the rest of your life.

And you can view this as a tool. So if your goal is to be off medication, you can say, well, I’m going to take it for a certain amount of time. That medication is going to allow me to make lifestyle changes, see a therapist, get on a regular schedule, wake up and get out of bed in the morning. And then when I have all those ducks in a row, maybe I can get off the medication.

Like there are so many possibilities here, but there is no denying that these medications are lifesaving. And a lot of people take these medications preconception, prenatally, and if we found something that works while you’re pregnant, we don’t usually recommend changing it unless it’s very incompatible with breastfeeding, right?

There’s no worst time to change somebody SSRI then postpartum when all the hormones are flying and things are shifting around. So if you’re currently taking Prozac, for example, in pregnancy, and we just said that Zoloft or Paxil is the, are the number two most recommended, don’t be switching, you know, talk with your provider and make sure they know like, Hey, I’m stable right now on Prozac.

Should I switch to a more compatible medication with breastfeeding? The answer is probably going to be no, if you are stable and it’s not completely incompatible with breastfeeding cause stable moms are better at being parents. Yeah. I mean, it’s just like we talked about with Kelly Lemon, right. Where she actually differs people weaning off of their medications when they’re treating substance use disorder.

Because like the first year or two postpartum is like the most unstable time of your life. Yeah. Your quality of life decreases significantly and all these other coping mechanisms that maybe you used to have like exercising aren’t as available to you. So that’s not the time to be changing things around.

Yeah. So consistency is key and we’re going to support that. Okay. If you’re listening to this and you’re wondering, do I have postpartum depression? Do I have postpartum anxiety? We will link the Edinburgh Postpartum Depression Scale in the show notes, and you can take it. And if you score significantly high on that, you might want to talk to your provider.

They’re supposed to do this really at every postpartum visit for you, but sometimes they don’t or things fall through the cracks, but this is the screening tool that’s validated that we use to determine people that are at risk for postpartum depression and anxiety. 

Other things that put you at risk, that we’re just going to say straight out of the gate. And by the way, if you’re like, oh, all of those are me, you are at very high risk for having this. And that’s okay. Just because you’re at risk for it doesn’t mean you’re going to have it. It doesn’t mean that you aren’t strong. Like, oh my gosh, I moved and I had all these risk factors. And so did Sally down the street and she’s doing fine.

First of all, you don’t know that. Sally might be on Zoloft. Yeah Sally’s fine because she’s been on Zoloft for 10 years and has never come off of it. And that’s okay too. But here are some things I just wanted to put out there that will put you at a higher risk that we have found through research.

So prenatal depression. So if you’re currently pregnant and you are struggling with depression, then obviously you are going to be at a much higher risk for postpartum depression. Prenatal anxiety, same thing. So if you’re anxious during pregnancy, you’re probably going to be more at risk for being anxious, postpartum. 

History of previous depression. So not as strong a predictor as a depressive episode during pregnancy, you know, for example, if you were, you had a depressive episode in high school and that was 10 years ago, it still puts you at risk, but not as much as the most recent depression in pregnancy. Maternity blues. So baby blues is another word for that, especially when severe, can actually be a precursor to postpartum depression. 

Recent, stressful life events. And there’s a whole list of those. Moving, job changes, marriage, divorce, moving in with a partner. So many, so many things in your personal life, a death, that you might be thinking about for more than a few days, that could be one. Also inadequate social support, poor marital relationship, and one of the most consistent findings is that among women who report marital dissatisfaction and or inadequate social supports, postpartum depressive illness is much more common.

So not shocking there. Low self-esteem, childcare stress, which for sure childcare stress. Are you kidding? That’s like everyone in America, everybody. Yeah. Everybody in this country. Ah, yes, Maureen. It does. And that’s why we have really high rates of postpartum depression and anxiety. Shocker, by the way, we’re just going to say PPD and PPA.

So I don’t have to repeat that 1,000,001 times. A single marital status. So single moms, for sure, single parents. Unplanned or unwanted pregnancy, which by the way, 50% of pregnancies in the United States are unplanned. And lower socioeconomic status. So if you’re worried about where your next meal is going to come from, that is very stressful.

And that’s going to lead to more PPD and PPA. So if you have any or all of those risk factors, please know that you should probably listen to the rest of this episode, take the Edinburgh, talk to your provider and start getting some support for yourself.

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I’m going to tell you a little story about me, cause this is my podcast. And I think maybe it will help you feel more normal. So I had a surprise pregnancy that led to a shotgun wedding and we moved in together. So we got three right there. I started nursing school when I was eight weeks pregnant so you’re ticking off all those stressful life events.

I also hadn’t known my partner for very long. We’d only known each other for a few months. Oh God. Yep. So, that was a whole situation and we were trying to do the right thing. I will say we were trying to do the right thing by getting married and moving in together and there was also some religious stress to go along with that, which was not on the list, but I feel like it should be. Oh yeah.

That counts as major stuff. Like why is that not on the list? I don’t know. Anyway, we’ll talk about that another time, religion. Oh my God. So anyway, there was a point in time, I was seeing a midwife, and there was a point in time I was probably around 20 weeks pregnant that I was just sobbing uncontrollably on the couch by myself.

Lucky for me, I had my midwives’ cell phone number, which is irregular. And I understand not everybody has access to that. And I texted her and I said, I cannot get off the couch and I cannot stop crying. And she said, great, no problem. I’m calling in some Lexapro for you. It’s time. Because I had been talking with her about this and we had already been in discussion about it and I had been putting it off and putting it off.

And she was like, it’s time, that’s not healthy or okay. And you have a lot of pregnancy left and you’ve got a lot of shit to do because you’re trying to like build a marriage and build a life and all of these things. And she had a great point and she was absolutely right. So I started Lexapro and that did help me get through the day-to-day. 

Like, I literally had stuff to do to get ready for this baby, to go through school. And I was very happy for that. So it did get me off the couch. After my son was born, anxiety was an all-time high. He was a 36 weeker. He was very difficult as a kid and had one of those cries that was like. Oh, is it the high pitch? Yes. 

And whenever you leave the hospital and the nurses go, good luck with that one. And you’re like, thank you. You’re like, that makes me want to throw this baby back at you right now. This is not what I ordered. And so, and he just didn’t sleep and, and things got worse with my partner as they often do when you have the baby. That is the prime time for marital issues is in the postpartum and no wonder cause nobody’s sleeping.

Right. Well, well, anyway, so yes, things were not great. And I took my son to his pediatric appointment and it was my pediatrician actually from when I was a kid. So he knew me very well and I couldn’t make it through the appointment without crying. And it just, I was sobbing like an actual crazy person at my son’s appointment.

It was not my appointment. And I was like, oh my God, I’m sorry. I just can’t pull it together. Things are awful. And he’s a terrible baby. And he hates me. And, and so my doctor said, what are you taking? And I said, I’m taking Lexapro. And he said, I’m switching you to Celexa, it’s better for anxiety. And he put me on the highest dose possible, which I did not know.

So he flip-flop meds and he gave me the highest, just out of nowhere, out of nowhere. And so it helped with my anxiety, but I was a little bit, it was maybe a bit much for me or maybe it was just enough. I’m not sure, but I do know that when my ex and I would fight, I would just stand there and it did not affect me that much.

I was a bit dead inside. It sounds like it was maybe a slightly too high of a dose. Maybe, slightly, too high of a dose for me. It was, nothing was getting in. The receivers were not receiving. So I did realize that that was probably a bit much and I worked with my midwife to like, kind of back that down a little bit.

And I’m sure it’s very annoying for providers when many providers start prescribing SSRIs. That’s probably dangerous. Like, don’t do what I did as usual. Don’t be like me. Do it the right way, work with one provider. And I did want relief and I got it, you know, except my son did not sleep. And now I do know that Celexa, especially in high doses, can lead to sleeplessness in infants. 

So that wasn’t helping me either. It was like it was shutting me down emotionally, which was kind of good at the time. Cause it was a bit much for me to deal with. Not a good long-term strategy, but I see how it helped you survive. Yes, full survival mode, but my son wasn’t sleeping.

So lack of sleep does not help either. So we got to find a middle ground there. So what I’m basically saying is any of these medications that might have side effects, you’re trying to weigh the side effects with the benefits and hopefully find a happy medium for you, no matter what medication you choose.

So I was prepared for this next pregnancy, and I knew with Heidi that I was at risk. So I went ahead and talked to my midwife about it, and she knew me very well. Knows that I’m a pretty anxious person. And I went on Zoloft in the first trimester and I was like, we’re not gonna wait to hit rock bottom this time.

We are going to fix this from the gate and thank God. Thank God, because I was already going way up that rollercoaster of high emotions and not just like I’m feeling things, but like I’m feeling things that I shouldn’t be feeling. Like this is not rational when I was well beyond rational thought and everything was bothering me.

And that was not a fun way to live. And you should be able to enjoy your pregnancy. And I did, after I was medicated and I am off of it now. I use it when I need to use it, and then I come off of it. And if I need it again, I will go on it again. So that’s my story. It’s not going to be everyone’s story, but I’m very happy that I did that.

So I know you guys are probably having a lot of the same thoughts Heather did right now. And frankly, the same thoughts I’m having right now, because I just had a discussion with my PCP about starting Wellbutrin. You know, you have to wonder, is, is this going to cause side effects in me? Is it worth it to wait however many weeks you have to wait to see if it’s working to, you know, through whatever side effects baby’s going to have and your dosage?

And it is hard work to find the right medication and the right dosage. But you will know when it is the right time for you. And this is a discussion to have with your partner, with your friends, with your family, with your doctor, talk to everybody about it. Talk about it until you’re ready. Right. And also like, if you start on Zoloft and it’s not working for you just know that Zoloft is a great place to start.

Like a lot of, I think the research says that most people try six different SSRIs before they find one that works for them the best. I’m just going to say that is terrifying to me. I know. I’m sitting here right now being like, is it time to call back my doctor and be like, sure, we can start Wellbutrin? No, I don’t want to, because I don’t want to try six different medications before I find what works.

Yeah. I know. So start somewhere and work with one provider. Don’t bring too many cooks into the kitchen. Yeah. That’s my best advice for you. And I have no regrets about treating my mental health and I’m sure my children would say the same. Yeah. 

And for the most part, when we are talking about taking these medications in pregnancy or breastfeeding, the benefits of having a healthy parent outweigh the risks, in general. Yes. A hundred percent. We are here for the healthy parents. 

So let’s take a minute to talk about how medications are transferred in the breast milk. It’s actually pretty fascinating. And we could do a whole episode on it, but we’re just going to hit the highlights for now. So medications the mothers take are transferred to their infants differently, depending on whether they take these medications while pregnant or breastfeeding.

So we know now that SSRIs do cross the placenta into the fetus, and that is different than how the baby will receive it via breast milk. Two different filters. Okay. One, you’re sharing a blood supply and the other you are not. So that makes a huge difference for exposure. 

How much of this medication gets into the milk depends on the size of the molecule in the medication and its ability to get through the semi-permeable lipid membrane in the breast, otherwise known as your boob filter. So the first three days of life, when you’re working on getting your milk to come in, there’s a lot more space between the mammary epithelial cells, which allows a larger molecules to pass through.

However, the volume of milk being transferred at that time is relatively small because your milk isn’t in. It’s your colostrum. So although the molecules may be transferred a lot more, the bigger molecules, they’re less available to the baby because there’s less milk. And also a little fun fact, when you have active mastitis, and the mastitis actually interrupts those epithelial cells, it can once again, disrupt that barrier and allow larger molecules to spill through. Which is very interesting but makes total sense that I never thought about before we did research for this. 

Yeah. And some things that affect it are like is this molecule lipid soluble? What’s the molecular weight? You know, there’s a lot of nuance to this. And one day I hope we can do an episode where we interview like Dr. Hale or somebody. Come on, who can explain like all of the things that we consider when we’re deciding if these medications are safe or not. 

So some other things that can affect how much has passed into the milk is its ability to bind to protein and the pH of the milk. So all of those things combined basically determines how much of that medication gets into the milk. One thing to note as healthcare providers and as breastfeeding people yourself, people who are taking antidepressants are probably going to have more trouble breastfeeding in general because they are depressed.

So we want to make sure those people get extra support breastfeeding, that they can see LCs that their partner’s on board, all of that stuff. 

Okay. So we actually have what I would consider like a very comfortable amount of evidence on most of these medications we’re going to talk about today. You know, like 67 studies where we actually look at like the levels of medicine and milk and all, like hundreds of research cases.

It’s, it’s really nice. I feel like we don’t often have this many studies to work from. Well, and also that’s a testament to how many people are actually on these medications. And before you start becoming all Tom Cruisy on us and being like, well, if everybody’s on these medications and maybe it’s not really a problem, maybe everyone just needs to learn how to get over it.

And that might be possible if we didn’t have to work so freaking hard and we had more resources and our faces ever saw sunlight. I dare you Tom Cruise, to cram your little ass into a cubicle for 40 hours a week with a thankless manager, an unsupportive partner. Working nine to five. Working 9-5. 

Okay, but let’s, let’s jump into this with the SSRIs.

Yeah. Tell us what an S S R I is. I do. It’s a selective serotonin re-uptake inhibitor. So you got these little receptors in your brain, and you’ve got all of these little neurotransmitters that make you happy or sad or stressed, and sometimes you either have a lack of re-uptake. So your receptors aren’t able to suck those in and respond to them, or you have a lack of the actual neurotransmitter.

So there’s two, well, there’s more than two things going on there, but those are the two that I’m specifically talking about right now. So we’re going to talk about five of those today, I think. 

Anyway, we’re going to start with Zoloft, which is sertraline is the generic name. And this is considered the antidepressant of choice during lactation.

And it also does work a little bit on anxiety as well, which is why it’s also one of the number one most recommended because you could be depressed and then someone hands you a baby, and then now you’re anxious. Now what? But anyway, we know that this is excreted in really low levels into breast milk.

And the amounts ingested by the infant are typically not detectable in the infant serum. Okay. So that’s really good. It may not be compatible if you have a preterm infant. So something to consider, but limited study shows that the infant dosage is around 0.5% of the maternal adjusted dosage. Some studies place it a little bit higher, but it’s still very low.

And just as an aside, newborn’s hepatic function is not really completely kick-started until three months. So you have to take that into consideration too. So if your baby’s in the first three months, that’s much different than if you are, if you’re breastfeeding an eight-month-old, trying to determine if you should take medications or not. 

Your newborns are feeding very frequently. So that’s increased exposure and also their livers aren’t at peak function. However, you’re still putting a very small amount with Zoloft into the system. So even an immature liver won’t blink, you know, it’ll be fine. 

Okay. So I’m going to list some side effects that have been reported in case reports. This might sound scary altogether, but these are pretty rare. So we have a few cases of benign neonatal sleep myoclonus, which is just an increase of those jerks during sleep, those little body twitches. We have some infants who are a little bit more sedated, some agitation, some diarrhea, weight loss, but also in these case reports, we don’t have necessarily direct links to that medication.

It’s just, this was reported in these infants and the mom was taking that med, right? A lot of these have confounding variables and it’s hard to point directly at it. Whereas some of the medications that are absolutely contra-indicated for breastfeeding, we can point a finger directly at that medication and go, nope, it was you. Yes, you did this.

But the studies that we have that are a larger, show normal development, normal weight gain. We’ve got some mixed reports about milk supply, but nothing really significant one way or the other. But we do know that people who take this medication in pregnancy have an increased rate of breastfeeding initiation.

Okay. As opposed to people who get a general depression, anxiety, et cetera, diagnosis during pregnancy and do not take anything. Hmm. That’s interesting. Yeah. So those people who don’t get a prescription are less likely to be breastfeeding at discharge from the hospital. That’s significant to me. Yeah. That is, that is, absolutely. And it’s a good thing for you to know if you’re planning to breastfeed. 

Okay. Let’s move on to Paxil. You want to do this one? Paroxetine? There’s a lot of small studies on paroxetine, otherwise known as Paxil. Again, much like Zoloft, there are low levels excreted in breast milk. It’s definitely one of the preferred medications during breastfeeding and only about one to 2% of the maternal adjusted dosage, possibly up to 5%, in some limited studies enters into the neonate, through the breastmilk. 

The maternal dose or the amount that the mom is taking is not actually the best indicator for the infant dose, probably because of the varying hepatic function, like the liver function of the baby. Possibly the amount of breast milk that the infant is ingesting or the frequency, or also the timing of the dose.

And, and just also like, then we have the mother’s metabolism to consider. So there are a lot of factors there. I mean, sometimes we have medications where we’re like direct link, dosage, how much is in the milk? This is not exactly one of them. Right. And, well, it’s kind of a good thing. I mean, if it was more lipid-soluble, we’d able to see it much more clearly in the milk and it would stay in the milk and we’d be able to determine like A plus B equals C. But because it kind of floats in and out and varies widely, that’s actually not a bad thing. 

We do see some mild side effects in infants from time to time, including insomnia, restlessness, increased crying, agitation, and difficulty feeding. However, I would like to say that some of those effects in the infants, not something we can link to the meds and might be the cause of your anxiety and depression.

Yeah. And again, like when we see these lists of kind of generalized stuff that happens in most babies anyway, or like a certain subset of babies, we’re like, okay. Maybe, maybe not. Really hard to say, a chicken or the egg. We also might just have some developmental delays, some very small like motor delays, but they weren’t really, they’re not reported to be significant.

Right? Like your kid is just moving slower than they used to. Is that bad? I mean, I think it’s more like maybe not meeting all the milestones exactly on time. Yeah, well, the CDC doesn’t seem to be too phased by that either. I don’t know. And we did have a few case studies with slightly more concerning issues where we can’t be sure if the medication caused the issues.

Paxil has also been shown to possibly increase prolactin and hyper lactation and may have delayed onset of lactation, but not of clinical relevance. Some people experience a boost and milk supply with this drug. Some people experience a delay in their initial milk coming in with this drug. It’s not a lot of people. Right. Okay. So you’ll have to basically take it and see how your body reacts. 

Well, we’re going to move on to your favorite one next, Heather. Celexa. Celexa works for so many people. How do we say this one? Citalopram. Lovely. Anyway Celexa, again, this is excreted in low levels in breast milk, but it is detectable in infant serum sometimes. 

This is another one where the dosage is not related, where infant dosage is not related to maternal dosage. This is basically entirely reliant on the genetic metabolic activity of the mother and the infant. So whether or not we have higher levels in baby maybe isn’t because you took the highest dosage. Maybe. 

Also could be it was the first three months of his life and he was 36 weeks. So really adjusted, I mean, who knows how long it took his liver to fully mature. And also medication wise, I’ve always been kind of a lightweight, so I don’t know what my liver is up to. It could have been letting a lot more pass through than it needs to. But there are no real adverse effects in development reported up to a year postpartum.

We have some minor side effects like fussiness, disturbed sleep, general drowsiness. This isn’t one that doctors really recommend a lot, but it’s not a, it’s not a reason to discontinue breastfeeding and it should definitely be on the table if some of the ones we discussed previously are not working. And oddly enough, there’s a slightly higher risk of hyper lactation than other SSRIs.

So more milk. So I mean, you know, for most people are going to hear that and think, oh, great. But for your over suppliers are going to hear that and think this is not the medication for me. I also don’t see that for me. Yeah. Like what? That didn’t happen to me. And that’s not like, you know, for most of these, it’s like 10 people reported this, so now they have to put it in the listing.

Right. So for the most part, this is not the majority of people. This is just enough people that they can say it might be linked to the medication. 

Okay. Lexapro, I don’t know how to say this one either. Oh, I got it. Escitalopram. Is it Escitalopram? That’s what I was wondering. Okay. Anyway slightly more limited information here.

Yeah. Low levels excreted into your milk though. And generally we don’t really expect it to have adverse effects in the infant. However, we have a little bit of less information about this one than some of the others we talked about. I wonder why? I don’t know. The infant dose, in some studies, was anywhere between 1 and 8% of the maternal dosage.

Maternal metabolism plays a big role in the milk levels. Again, not dosage dependent, but as far as we can tell for the infant whose mothers took this, we have normal growth and development. Very limited reports, probably, that might literally be a handful of infants, of nausea, vomiting, fever, irritation, and eating problems.

And we have some reports of an increased serum, prolactin levels. So there you go, Lexapro. 

Now we’re going to talk about Prozac. Fluoxetine, the OG SSRI. So with Prozac, there is a higher amount in breast milk than most SSRIs, and it is detectable in the infant serum for the first two months postpartum.

However, no adverse effects on development were found up to a year postpartum. So adverse meaning like this kid isn’t meeting milestones, this kid isn’t okay. But we have seen some side effects, you know, colic, fussiness, drowsiness, vomiting, loose stool, decreased weight gain, et cetera, which could be from anything. Just being alive and being a baby is hard.

Again, it’s not directly linked to the medication. This is one of those where it’s like not on our number one list, but if you’re already taking it, you should continue taking it. If something else hasn’t worked, it’s, you could certainly try it. The maternal dose, again, cannot predict the infant dose than it’s getting.

And the infant dosage can be as high as 7% of the adjusted maternal dosage and Prozac produced the highest proportion of elevated infant levels and the highest average infant level. Right? So this is one that we’re noticing the dosage is higher in proportion to the maternal dosage then the other SSRIs we looked at.

So anyway, if you’re already on Prozac and you’re doing well, talk to your provider, they might not want you to switch, but just keep an eye on the baby a little bit more. Maybe they’ll schedule and additional pediatric visit, just to make sure everything’s good with the GI system and the colic and fussiness.

And there might be some other things that we can do on the infant side to support them in their symptoms, rather than change your SSRI and kind of mess you up. Yeah, certainly. 

The next one I want to talk about is not an SSRI. It’s, Wellbutrin. The S N R I. Serotonin and norepinephrine re-uptake inhibitors.

Yes. And what is that? Bupropion? Bupropion. Yes, Wellbutrin right. Bupropion. Anyway, so we have data that maternal doses up to 300 milligrams daily are producing really low levels in milk. So we generally want to stay under that dosage. We don’t really expect adverse effects in infants. Not a lot of them have been reported. Some general reports of, again that GI tract upset maybe sedation, a little irritation.

There were a few case reports of infants experiencing seizures, but they cannot necessarily be linked to that medication. Again, this is not one of the preferred meds, but absolutely not a reason to stop breastfeeding. So if you’re already on it, don’t worry about that. I was going to say this one, Wellbutrin, is great for people that have debilitating depression. People that really, really struggle to function in everyday life that need it to function. 

So if you need it to function and it’s not a reason to discontinue breastfeeding, please don’t think that you need to stop Wellbutrin. However, I will say, if you are a person that also struggles with intense anxiety, Wellbutrin can make your anxiety worse. It brings you so far up out of depression, it can send you into mania. Yay. Not great in that way. 

For example, my friend won’t mind me talking about this, I know. We were, we were at lunch a couple months back and she was like up, up, up a little bit, a little bit, a little bit, a little bit like talking 3000 miles a minute. She ate three bites of her food. She was like 90 pounds soaking wet. And I was like, hi, what are we doing? Are we on cocaine? What’s happening? Why are we like this now? She’s like, what do you mean? I don’t know. There’s something wrong with me. I just can’t eat. I can’t ever eat. I try, I try to eat. I try really hard to eat and I just can’t eat.

And I was like, whoa, what are you on right now? And she was like, I’m on 300 milligrams of Wellbutrin. And I was like, oh my God, please get off of that. I was like, buddy, she, she was depressed. Her depression resolved, situationally, her natural anxiety took over plus the Wellbutrin carried her, rocketed her, we’ll say into the fourth dimension of anxiety.

And so she called her provider. I was, you never want to stop it abruptly, by the way. You always want to. Pretty much all of these meds that we’re talking about for the most part, you want to wean down, especially if you’re in a high dose. Yes. So she weaned off of that and started Zoloft. Okay. And she’s doing great.

She’s eating complete meals. She is a little bummed that she doesn’t have the extra energy to vacuum her entire house at the end of a workday. Her life is much more balanced. So there you go. 

Funny enough. My doctor mentioned that as an option for helping to manage adult ADHD. And she was like, we’ve had really good success with this. So if you get an ADHD diagnosis, maybe we’ll think about that, but my insurance will not cover the assessment. So here we are trying to find something I don’t have to pay $1,800 for. Right. 

Also Wellbutrin does not have as many sexual side effects as the SSRIs. So if sex is a very big part of your life and orgasms are a thing that helped keep you stable, that might be something to consider.

And we’re not talking about maternal side effects at all here. Right? We’re just talking about safety for the infant in breastfeeding. So that is something you want to talk fully about with your provider before starting a new medication. Okay. We’re almost through it. 

So we’re going to talk about some other medications now. Let’s, let’s talk about Pamelor. This one is interesting. It’s nortriptyline. That sounds right. Nortriptyline. I like it. It is excreted in low levels in breast milk. There has been some limited study and follow up and they have not found significant adverse effects in infant growth or development.

Some people might consider this one of the preferred medications to use while lactating. Other sources recommend caution because we cannot agree. We just can’t agree. But low maternal doses do not produce detectable levels in milk, which is very encouraging. But of course, maternal dose is not always the best indicator of the infant dose.

Some studies show that infant doses were actually an average of like 10% of the plasma levels of the mothers. Some showed way less. This is a pretty variable thing. And also it’s a really good reminder that you shouldn’t not go up in your dosage if you need to, for fear that you’re going to expose your infant more because it just doesn’t work like that.

So you get the dose that you need. Absolutely. And then we will continue to triage and assess, right. And really when you’re talking to your doctor about this, and you’re thinking about using one of those medications, that’s “not recommended,” but not contra-indicated, you can always say, Hey, I’m taking this medication for anxiety.

I clearly have anxiety about what this is going to do to my infant. Can I follow up in two weeks with you to see baby? Can we do weekly visits for you to just look at my baby and tell me they’re fine? That’s okay. You’re allowed to do that. You know, you’re allowed to go see your doctor more often. And also, I just want to say I do have some patients who are so anxious about what’s going on in the breastfeeding relationship that they have said, I just think I might, I don’t know how much longer I can do this. I think I might have to discontinue breastfeeding. 

And that’s fine. But if breastfeeding is also, in the same breath you’re telling me that breastfeeding is a very important goal, then this might be the middle ground. Is going on some medication to get your anxiety a little bit down so we can troubleshoot the actual problem and then reevaluate the goal.

And if you’ve gone through it and you’ve tried the medication, it’s not working and you need to discontinue breastfeeding to maybe get on something that’s not compatible with breastfeeding, or you’re just not wanting to do any of the breastfeeding right now, that’s fine. Yeah. You don’t have to justify weaning to anybody.

That’s why we have formula and it’s amazing that we have it. Yep. I just want to say at the end of all this, antidepressant medications and other fun meds we can use for this are not the only option for treating depression and anxiety. But for some people they may be the best option or the most realistic and doable thing at that time. And the fastest, right?

So we have some risks associated with all of those medications we just talked about. But for most of you having this conversation with your doctor, you’re probably going to conclude that the risk of untreated depression is greater than the risk of one of those medications. We will absolutely follow up at another time to talk more deeply about what depression and anxiety are, what they look like and some non-pharmacological options for treatment and support.

And just to reiterate, the best combination is therapy with medication, as opposed to medication on its own. With a provider that follows up with you. With support systems at home. With realistic expectations for yourself. Yes. So I just want you guys to know all of the ones we listed today, I would be comfortable taking while breastfeeding. All of the ones we’ve listed today, not together, I’ve basically taken. Not together, but one at a time.

And I am actively considering taking some, one of those medications on the list right now. I support you a hundred percent. So if you’re there with me, we’re gonna get through this, whether we are on medication for the rest of our lives or whether it’s just for the next six months. Yes, we will get through it.

Email us of course, if you have a story to tell at MilkMinutePodcast@gmail.com. We hope this helps you all. And if you’re a provider listening and this helped you, please let us know. We love to hear from our providers around the world. Because it’s different other places, by the way. Yeah. And if there’s another med, you’re like, man, this should definitely be on that list.

Please let us know. I mean, there are so many medications I didn’t add, but I really just wanted to talk about the most commonly prescribed. Right? Okay. Well, best of luck, everyone. This is just a blip in your life. Take that next step, whatever it may be towards your peace. You deserve it..

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Well guess who deserves an award today? I know, I know. Sarah Kollment from Clermont, Florida, who is a patron of ours. Sarah says my son is 32 weeks old today and we’ve breastfed the whole time. Starting to get all the feelings though, since we started purees a few weeks ago and that technically means we’ve started to wean.

Oh, I know those feelings are sad happy. Yes. And Sarah, thank you for plugging that for weaning, because as you know, or you may not know, we did an episode on weaning that you are welcome to go look at and we will link it in the show notes. Okay, Sarah, I’m going to give you the Triumphant Transitions Award because you are just rocking it out, riding all those transitions from exclusive breastfeeding to introducing solids and you’re going to keep doing that. 

Also you’re aware of the fact that you are in the middle of a transition, which is half the battle. Absolutely. So congratulations on making it this far and being so incredibly successful. And we really hope that the rest of this journey for you is incredible. Yes. And if you would like to celebrate with Sarah, we will be putting her picture and her award on our Instagram highlights.

All right, everybody. Thanks for listening to this episode, even if it was kind of a downer. We’re trying to bring it up. The way we changed this big system, that’s not set up for lactating families is by educating ourselves, our loved ones, our children, our coworkers, all the people. And if you can spare a dollar a month, please support us on Patreon.

You will get all the cool stuff like merch. Patrons get access to behind-the-scenes videos, posts, pictures of our insanity, live Q and A’s all of that cool stuff. So check it out at Patreon.com/MilkMinutePodcast and patrons, if you guys are like, I want something different, just ask us. I’m pretty sure we’ll give it to you.

Yeah, we’ll probably just give it to you. We just love you so much. Yeah. Thank you everybody. All right. See you next week. Toodle-y do.