Discussion

A survey of neonatal units in England has demonstrated wide variation in the management of neonates exposed to SSRI antidepressants in utero. Only four units had written protocols on the subject and much of this guidance relies on principles used and designed for exposure to other drugs, including the Finnegan and Rivers withdrawal scoring systems.10 11 These scores are designed for monitoring opiate withdrawal and are non-validated tools for SSRI-exposed neonates. An adapted version of the Finnegan scoring system has been developed in the Netherlands for screening babies exposed to SSRIs, but we are not aware of any English units currently using this.12

This study has demonstrated variation in the length of routine observations (if any) carried out on SSRI-exposed babies. It is therefore possible that either some units are not adequately assessing exposed babies and may miss important signs and symptoms, or that in some units babies are being kept unnecessarily in hospital for prolonged periods of observation. Estimates of the prevalence of neonatal symptoms in the literature vary, possibly reflecting differences in length of exposure and individual SSRIs used between studies.4 5 The Canadian Paediatric Society advocate for a 48 hours period of hospital observation for all babies with third trimester exposure to SSRIs,7 with a review article from the Netherlands taking a similar stance while also acknowledging that in the majority of cases any neonatal symptoms are mild and self-limiting.13 Maternal health and well-being may not be best supported by prolonged periods of hospital admission and there is a potential stigma associated with not being able to have an early discharge. There is also ever-increasing pressure on postnatal bed availability in neonatal units across the country. For all these reasons, it is essential that any routine periods of observation are evidence-based, cost-effective and baby-friendly.

There was much variation in what treatment, if any, neonatal units reported they would give to a baby withdrawing from SSRIs, likely reflecting the lack of clear evidence supporting any particular pharmacological treatments. There has been uncertainty as to whether SSRI exposure in utero produces a withdrawal syndrome or toxicity,6 with treatment generally aimed at treating symptoms rather than gradual weaning of the causative medication as with opiate withdrawal. There is also some evidence to suggest breastfeeding reduces the risk of developing symptoms.14 More recent studies have suggested potential neurodevelopmental consequences beyond the first few days of life with research demonstrating lower motor scores and increased stress signs throughout the first month of life in babies of mothers treated with SSRIs compared with those with untreated depression.15 Additionally, there is evidence of subtle electroencephalogram changes in neonates exposed to SSRIs in utero compared with healthy controls.16 In both of these studies, potential confounding of maternal depression could not be fully excluded, but this does challenge some units’ focus on the first 24 or 48 hours of life rather than longer term neurodevelopment.

A strength of this study is the high response rate, with 70% of neonatal units providing information as to their management of SSRI-exposed babies. The accuracy of the data received relies on the staff members responding having a good knowledge and understanding of their units’ practice with regard to babies exposed to SSRIs. This was mitigated by contacting Clinical Leads in the first instance, and then if unable to get a response, contacting other senior medical or nursing staff.

This study has demonstrated wide variation in the management of babies exposed to SSRIs across England and the associated lack of a UK national guideline in this area. This is clearly not a good way to manage a clinical situation affecting thousands of mothers and babies each year. As a neonatal community, we need to seek to better understand the clinical problem posed by SSRI-exposed babies, how we identify babies most at risk and whether any additional observations or treatments affect long-term outcomes. Further research is needed to help answer these questions and enable the development of evidence-based guidelines to support neonatal units and individual clinicians in managing SSRI-exposed babies.