Poor Neonatal Adaptation After in Utero Exposure to Duloxetine

To The Editor: Risk-benefit analysis is central when forming a treatment plan for pregnant women with mental illness. This task is further complicated by limited data pertaining to the effects of antidepressants on the fetus, neonate, and child. To our knowledge, this is the first case report of in utero exposure to duloxetine.

This case demonstrates the syndrome referred to as poor neonatal adaptation or neonatal behavioral syndrome, characterized by jitteriness, poor muscle tone, weak cry, respiratory distress, hypoglycemia, low Apgar score, and seizure (1) . These symptoms start within hours, generally require only supportive care, and end within 1 to 2 weeks. The syndrome may occur in up to 30% of infants with selective serotonin reuptake inhibitor exposure (2), with a risk ratio of approximately 3.0 (3) or higher for premature infants (4) . The mechanism underlying the syndrome is unclear. A dose of fluoxetine or nursing may decrease symptoms assuming they stem from withdrawal. Reports indicate a higher risk with exposure to paroxetine and venlafaxine, agents with the shortest half-lives, but data are very limited pertaining to newer antidepressants such as duloxetine, mirtazapine, and bupropion. Better characterization of poor neonatal adaptation and its etiology could reduce invasive procedures and inform the difficult decisions in treating mental illness during pregnancy.