Mass General Hospital

Harvard Medical School

Withdrawal Symptoms in Newborns Exposed to SSRIs

A recent report suggests that newborns exposed to selective serotonin reuptake inhibitors (SSRI) antidepressants such as Prozac, Zoloft, Celexa and Paxil may be at risk for developing withdrawal symptoms after delivery (Levinson-Castiel 2005). However, the investigators also noted that the symptoms usually disappeared within 48 hours and did not require medical intervention.

In this study, published in the Archives of Pediatrics & Adolescent Medicine, 60 infants exposed to SSRIs during pregnancy and 60 non-exposed infants were assessed using the Finnegan scale, an objective rating used to assess the severity and resolution of neonatal abstinence symptoms. Of the 60 SSRI-exposed infants, 37 were exposed to paroxetine, 12 to fluoxetine, 8 to citalopram, 2 to venlafaxine, and 1 to sertraline. Elevated Finnegan scores were observed in 30% (n=18) of neonates exposed to SSRIs. None of the non-exposed infants had elevated scores. Of the 60 exposed neonates, 8 showed severe and 10 showed mild withdrawal symptoms. The most commonly observed symptoms were tremor, increased muscle tone, sleep disruption, gastrointestinal disturbance and high-pitched crying. In the infants who exhibited severe symptoms, the symptoms were most severe within 2 days after birth. No infants with symptoms required any specific medical treatment.

Several other reports have demonstrated similar symptoms in infants exposed to SSRIs in utero (reviewed in the Newsletter: Fall 2004). While the investigators carrying out this study suggest that these symptoms represent a withdrawal phenomenon, others have hypothesized that they reflect serotonergic hyperstimulation (Laine 2003). It should also be noted that infants born to mothers with untreated depression are at higher risk for adverse neonatal outcomes than those born to non-depressed mothers (Zuckerman 1990, Misri 2004), suggesting that it may be the underlying illness – rather than the medications used to treat the disorder – that is associated with poor neonatal outcomes.

Reassuringly, the reported adverse events appear to be relatively mild and short-lived and rarely require any type of medical intervention. Furthermore, there is no indication of longer-term problems in children exposed to SSRIs during pregnancy (Laine 2003, Nulman 2002). Clearly further research is essential, but pending more controlled study, appropriate vigilance of exposed newborns after delivery is good clinical practice. It is unclear at this point if discontinuing or lowering the dosage of the mother’s antidepressant shortly before delivery will reduce the risk of neonatal toxicity; however, it is clear that this type of intervention may significantly increase the risk of recurrent depression in the mother. Given the adverse effects of maternal depression on the child, maintaining mood stability in the mother should remain the highest priority.

Ruta Nonacs, MD PhD

Levinson-Castiel R, Merlob P, Linder N, Sirota L, Klinger G. Neonatal abstinence syndrome after in utero exposure to selective serotonin reuptake inhibitors in term infants. Arch Pediatr Adolesc Med. 2006 Feb;160(2):173-6.

Laine K, Heikkinen T, Ekblad U, Kero P. Effects of exposure to selective serotonin reuptake inhibitors during pregnancy on serotonergic symptoms in newborns and cord blood monoamine and prolactin concentrations. Arch Gen Psychiatry. 2003 Jul;60(7):720-6.

Misri S, Oberlander TF, Fairbrother N, Carter N, Ryan D, Kuan AJ, Reebye P.Relation between prenatal maternal mood and anxiety and neonatal health. Can J Psychiatry. 2004 Oct;49(10):684-9.

Nulman I, Rovet J, Stewart DE, Wolpin J, Pace-Asciak P, Shuhaiber S, Koren G. Child development following exposure to tricyclic antidepressants or fluoxetine throughout fetal life: a prospective, controlled study. Am J Psychiatry. 2002 Nov;159(11):1889-95.

Zuckerman B, Bauchner H, Parker S, Cabral H. Maternal depressive symptoms during pregnancy, and newborn irritability. J Dev Behav Pediatr. 1990 Aug;11(4):190-4.

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