To the editor, We were most interested to read the review by Sie et al.1 The authors reviewed the literature on the effects of SRI use in pregnancy for mothers and their offspring, and formulated guidelines. However, although their review could have been more comprehensive, our main concern is with their "practical recommendations". Several guidelines produced by psychiatric governing bodies have been published regarding this subject, which were formulated using evidence-based information with a multidisciplinary approach.2 Therefore, we feel that some of Sie et al recommendations are not only redundant but may not be in the best interests of either the mother or baby. There were several recommendations that we found troubling: 1) there is no such thing as a "safe" antidepressant to use in pregnancy. The danger is that a woman will switch and her depression will not be treated effectively, increasing the risk of depression. 2) Tapering of antidepressants doses is not useful, since there is no linear dose- response curve, and therefore effects of changes in dose are very hard to predict.3 3) Regarding breastfeeding, because the pharmacodynamics of these drugs are individual, discouraging continuation of use of an antidepressant (fluoxetine) solely based on an M/P ratio of maximally 11 percent is arbitrary. In addition, none of the antidepressants (including fluoxetine) are excreted in breast milk in large enough amounts to disallow breastfeeding, and there are very few reports of adverse effects in the infant.4 4) The Finnegan score (as the authors acknowledge) was not designed for SRI-related symptoms in neonates, but for fetal exposure to opioids. Therefore, clinical decision making when suspecting poor neonatal adaptation syndrome, should not be based solely on a Finnegan score, and finally, 5) we are not aware of any evidence suggesting an anticonvulsant such as phenobarbital for treatment of symptoms.2

Geert.W. 't Jong MD PhD Clinical Fellow in Clinical Pharmacology Division of Clinical Pharmacology & Toxicology and The Motherisk Program, The Hospital for Sick Children, University of Toronto, Toronto ON, Canada Adrienne Einarson RN Consultant, The Motherisk Program, The Hospital for Sick Children, University of Toronto, Toronto ON, Canada

References 1. Sie SD, Wennink JMB, van Driel JJ, et al. Maternal use of SSRIs, SNRIs and NaSSAs: practical recommendations during pregnancy and lactation. Arch Dis Child Fetal Neonatal Ed. 2011. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21798871. Accessed August 4, 2011. 2. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009;31(5):403-413. 3. Burke MJ, Harvey AT, Preskorn SH. Pharmacokinetics of the newer antidepressants. Am. J. Med. 1996;100(1):119-121. 4 Kendall-Tackett K, Hale TW The use of antidepressants in pregnant and breastfeeding women: a review of recent studies. J Hum Lact. 2010 May;26(2):187-95. Review.

Conflict of Interest:

None declared