A growing number of studies show that most women can continue using ADHD medication during pregnancy, and more often also do so. In consultation with a doctor and with regular check-ups any risk for mother or child seems to be small. The potential benefits of having a woman, who feels and functions well during pregnancy, are of course also significant. But then what?
Is it ok to continue taking your meds if you choose to breastfeed? In this blog, we explore what the latest research says on the matter.
Importantly however, what applies at a group level may not be true for you specifically. The information in this blog is not intended to be used without guidance from healthcare professionals. But rather to make you better prepared for discussions and shared decision-making with your doctor and midwife.
As many probably already know, pregnancy involves significant hormonal changes in the body. But perhaps you don’t know as much about what happens to hormones after childbirth?
The fact is that when the baby comes out, so does the placenta. And with the placenta goes the production of estrogen and progesterone. This drop opens up for the hormone prolactin, that’s responsible for milk production. While you breastfeed, your prolactin levels will be high.
This, in turn, means that you do not ovulate and that estrogen levels remain low as long as you breastfeed regularly1.
It’s overall quite rare that breastfeeding mothers need to stop taking their medication when they breastfeed or refrain from breastfeeding to be able to take their medication.
But is the same true for central stimulant ADHD medication?
Well, even though knowledge about the potential long-term effects of central stimulant ADHD medication is limited. Several studies today indicate that any risk of negative consequences for the baby is minimal. That goes for if the mother takes her ADHD medication as prescribed by her doctor2.
However, there are more ADHD medications than just the central stimulants. What about them? Is the chemical nature of central stimulant ADHD medications a reason to be extra cautious?
Well, even though it might sound safer to use non-stimulants (atomoxetine and guanfacine) it seems that they are transferred to breast milk to a greater extent than the stimulants.
For those interested in more details or who meet mothers with ADHD in their profession there is an excellent website from Texas Tech University Health Science Center3. It gives an overview of what is known about breastfeeding and the different medications used for ADHD treatment. The site also provides clear guidance for healthcare professionals.
Remember that it’s never possible to provide any personal recommendations through a blog when it comes to individual medical decisions. There are simply too many unique personal factors that only you and your doctor are aware of. Always use information like this to increase your general knowledge!
The measure “Relative Infant Dose” (RID) can be used to estimate how much of a specific substance passes over from the mother’s blood to the breast milk. And eventually is ingested by the child.
An RID value of less than 10% is considered a safe value for most medications.
Overall, methylphenidate (RID 0.2-0.4) is excreted in small amounts in breast milk. No serious side effects have been shown in studies investigating breastfeeding infants to mothers using methylphenidate. The recommendation is, as always when mothers are using medication, that the child is monitored for signs that could be suspected to be related to the specific medication. That could be irritability, sleep difficulties, decreased appetite and weight loss4.
Dexamphetamine (RID 1.8–7.3) is also considered safe during breastfeeding as it has an RID value below 10%. The recommendation is to aim for the lowest effective dose, but doses up to the maximum dose for ADHD are considered safe during breastfeeding. The child should (as for other stimulants) be monitored for irritability, sleep, appetite, and weight. And the medication to be adjusted as needed4.
For atomoxetine, there is not yet enough research to give any recommendations. So it’s difficult to give any advice and is usually avoided during breastfeeding5.
The same applies to guanfacine, namely that there are not enough studies. Additionally, guanfacine is a small molecule (or rather, it has a low molecular weight). It means that it may pass into breast milk in even greater amounts than other substances4.
Guanfacine also affects (lowers) prolactin levels. Accordingly, it can reduce milk production, which is another reason to be cautious before and during breastfeeding.
Most ADHD medications are available as immediate, intermediate and long-acting.
The mode of action can itself affect how much medication is present in the breast milk at any given time. When taking medication it will take some time before it passes through the stomach, is absorbed by the intestines, reaches peak concentration in the blood and finally shows up in the breast milk. After the levels have peaked, they decrease until the next dose is taken.
Therefore, if a mother wants to minimize the amount of medication her child receives, she can breastfeed immediately after taking her medication.
However, trying to determine when the baby needs to breastfeed may add stress that, amid everything else, may become quite overwhelming. Long-acting medications don’t give the same “peaks”, accordingly there is no need to consider potential times for breastfeeding.
Of course! In conclusion, knowing what we know today most mothers who need their central stimulant ADHD medication during breastfeeding:
can continue without feeling worried that this will affect their child negatively in any regard.
We still have too little knowledge regarding the non-stimulant medication atomoxetine and guanfacine2, thus this medication may need to be discontinued while we await better data.
We hope that you may use this information in your discussions with your doctor, midwife or nurse at the maternal health center. To weigh benefits against potential risks in shared decision-making.
1) Hotham N, Hotham E. Drugs in breastfeeding. Aust Prescr. 2015 Oct;38(5):156-9. doi: 10.18773/austprescr.2015.056. Epub 2015 Oct 1. Erratum in: Aust Prescr. 2016 Feb;39(1):27. PMID: 26648652; PMCID: PMC4657301.
2) Marchese M, Koren G, Bozzo P. Is it safe to breastfeed while taking methylphenidate? Can Fam Physician. 2015 Sep;61(9):765-6. PMID: 26623462; PMCID: PMC4569107.
3) https://infantrisk.com/content/adhd-medications-and-breastfeeding
4) Hale, Thomas Wright. Hale’s Medications & Mothers’ Milk, 2021: A Manual of Lactational Pharmacology. Springer Publishing Company, 2021.
5) Ornoy A. Pharmacological Treatment of Attention Deficit Hyperactivity Disorder During Pregnancy and Lactation. Pharm Res. 2018 Feb 6;35(3):46. doi: 10.1007/s11095-017-2323-z. PMID: 29411149.
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