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ADHD Medications and Breastfeeding

Christina Victoria Craft - Orange and White Pills

Breastfeeding is the gold standard of infant nutrition and provides unmatched health benefits for both mother and infant. Women who plan to breastfeed while taking medications for attention deficit hyperactivity disorder (ADHD) should discuss treatment options with their healthcare provider.

 

It is rare that a breastfeeding mother needs to discontinue breastfeeding to take a medication.1,2 Multiple studies have demonstrated that the risk for adverse outcomes in breastfed infants is minimal if a mother takes her ADHD medication as prescribed.3 While the long-term neurodevelopmental effects of ADHD medications have not been adequately studied,3 the most up-to-date recommendations and evidence1 can help guide the decision-making process.

 

For most lactating mothers with ADHD, benefits of breastfeeding2 outweigh the risks of concurrent treatment with stimulants, the most commonly prescribed medications3 available in immediate-release and extended-release formulations.4 Few patients with ADHD require management that may be a contraindication to breastfeeding.1,5 In all cases, the risk of exacerbation of symptoms in the mother if medication were to be stopped must be balanced against any risks to the infant if medications are to be continued.5

 

Transfer of Drugs in Breast Milk

 

If a medication was of concern during pregnancy, patients should discuss those medications with their healthcare provider, since medications that are unsafe during pregnancy may be safe during breastfeeding and vice versa.6 Several factors—solubility, size, blood level, protein binding, oral bioavailability, and half-life—can influence the transfer of drugs into breast milk.1

 

When assessing the compatibility of a drug with breastfeeding, the relative infant dose (RID) provides an estimate of a baby’s exposure to that drug from breast milk. If the RID is less than 10%, the medication is generally considered safe for breastfeeding.3 Calculations are based on the mother’s weight-adjusted dose, using an infant’s average daily milk intake of 150 mL/kg/day.1 Keep in mind that differences exist among patients, so monitor the breastfed infant for any clinically significant changes (see table below).1

 

ADHD Medications and Breastfeeding

 

ADHD in adulthood is associated with significant impairment in occupational, academic, and social functioning.7 The mechanism of action of stimulants (methylphenidate and amphetamines) in the reduction of ADHD symptoms is not fully known8, but most likely involves the improvement of daily functioning via increased neurotransmission of dopamine and norepinephrine.8 Breastfeeding mothers should be aware that stimulants have a higher potential for misuse9 and dependence than other ADHD medications.10 Regardless of the treatment of choice it important for a breastfeeding mother to use her medication as prescribed5,11 to minimize infant exposure. Non-stimulant medications may sound appealing while breastfeeding, but their transfer into breastmilk can be higher or unstudied.

 

When making a decision about medications and breastfeeding, risks1 and benefits5 should be weighed for the following:

  • Breastfeeding + continuing ADHD medication
  • Breastfeeding + temporarily adjusting ADHD medication
  • Not breastfeeding + continuing ADHD medication

 

Commonly prescribed ADHD medications include:

 

The following table shows data1 for some of the medications used for ADHD.

 

ADHD Medications & Breastfeeding

 

Methylphenidate is excreted into breast milk in miniscule amounts—and no adverse effects of methylphenidate have been reported in breastfed infants.1 Babies must be monitored for agitation, irritability, and poor sleep, along with changes in weight and feeding.

 

Dexmethylphenidate is the more pharmacologically active enantiomer of methylphenidate. There are no studies on its transfer through breast milk, but its transfer is likely similar to that of methylphenidate. Monitor the infant for agitation, irritability, decreased sleep, poor feeding, and poor weight gain.

 

Amphetamines have a variable RID that remains under 10%.1 The lowest effective dose should be used to manage the mother’s symptoms.5 Even at maximum recommended doses for ADHD, the RID of amphetamines is generally safe for the recommended duration (6-48 months) of breastfeeding. Monitor the infant and, if necessary, medication can be adjusted accordingly—use a lower dose as tolerated by breastfeeding mother.

 

Atomoxetine does not have enough data to support its routine use during breastfeeding.5 Limited experience with atomoxetine during lactation has demonstrated that it may have adverse effects on the infant or adversely affect milk production.1

 

Bupropion has a low RID (less than 2%).1 Notably, there are 2 reports of seizure-like episodes in infants whose mothers were taking bupropion along with other psychiatric medications.5 External factors for these rare instances of seizures could not be ruled out as the cause. When breastfeeding and taking bupropion, monitor the infant for sedation, irritability, seizures, poor feeding, and poor weight gain.

 

Clonidine has RID from 0.9% to 7.1%.1 Clonidine can cause decreased milk production by reducing prolactin secretion.8 Because this reduction varies, clonidine may still be compatible with breastfeeding if the infant is able to get 150mL/kg/day.1 Note that clonidine cannot be immediately discontinued. Prescribers can manage gradual dose adjustments if a mother observes changes in the infant and wishes to continue breastfeeding. Monitor the breastfed infant for hypotension, drowsiness, pallor, and decreased muscle tone.

 

Guanfacine, rarely used in ADHD, does not have enough data to support its use during breastfeeding.1,5 Due to guanfacine’s low molecular weight, it is likely to penetrate milk at significant levels.1,4

 

Modafinil has RID 5.3%1 and can be compatible with breastfeeding. Its use as an ADHD medication is rare. Monitor the breastfed infant for agitation, irritability, poor sleep patterns, and poor weight gain.

 

Medication Formulations and Delivery Systems

Immediate-release (IR), sustained-release (SR), and extended-release (ER or XR) formulations may have an impact on a medication’s compatibility with breastfeeding.1,3 Briefly explained, when a drug is taken orally it takes some time to be absorbed by the body and then to reach a peak concentration in the blood (and then in milk). After reaching its peak, the concentration in the blood then decreases until it is time to take the next dose.4 Theoretically, a mother wishing to minimize exposure could take her medication and immediately start breastfeeding (i.e. medication has lowest levels in the blood and peak concentration has not been reached). However, depending on the frequency of feeds for a young infant, scheduling breastfeeding with a prescribed medication schedule may not reduce their drug exposure. Furthermore, extended-release formulations will not have the same “spikes” of drug in the blood and milk as seen in immediate-release forms, so timing breastfeeding around medication may not be necessary. If concerned about the formulation, monitor the breastfed infant for symptoms.3

 

Effects on Milk Production

Clonidine and guanfacine are not commonly used in adults with ADHD, but may be prescribed for persistent symptoms based on efficacy in children.10 Guanfacine is likely to penetrate milk at significant levels.1 Both clonidine and guanfacine have an impact on prolactin and may reduce milk supply, particularly prior to established lactation.1 Consider asking your healthcare provider to adjust your medication if milk production levels are not sufficient to maintain adequate nutrition for the infant.

 

Conclusion

We recommend infant safety and monitoring when mothers taking ADHD drugs wish to breastfeed. First-line ADHD medications are generally compatible with breastfeeding, while atomoxetine and guanfacine have less data for lactation.1,5 Using the evidence provided above, consider the benefits and risks for both mother and infant before making an informed decision.

 

 

Clarissa A Ramirez, MS, MBA

Christine D Garner, PhD, RD, CLC

Kaytlin Krutsch, PharmD, MBA, BCPS

Thomas W Hale, PhD, RPh

 

References

 

  1. Hale, Thomas Wright. Hale's Medications & Mothers' Milk, 2021: A Manual of Lactational Pharmacology. Springer Publishing Company, 2021.
  2. Hotham, Neil, and Elizabeth Hotham. “Drugs in Breastfeeding.” Australian Prescriber, NPS MedicineWise, Oct. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4657301/
  3. Marchese Maria, et al. “Is It Safe to Breastfeed While Taking Methylphenidate?” Canadian Family Physician Medecin De Famille Canadien, College of Family Physicians of Canada, Sept. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4569107/
  4. Cascade, Elisa, et al. “Short-Acting versus Long-Acting Medications for the Treatment of ADHD.” Psychiatry (Edgmont (Pa:Township)), Matrix Medical Communications, Aug. 2008, www.ncbi.nlm.nih.gov/pmc/articles/PMC2695738/.
  5. Ornoy, Asher. “Pharmacological Treatment of Attention Deficit Hyperactivity Disorder During Pregnancy and Lactation.” Pharmaceutical Research, U.S. National Library of Medicine, 6 Feb. 2018, pubmed.ncbi.nlm.nih.gov/29411149/.
  6. “Why It Matters.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 29 Nov. 2020, www.cdc.gov/breastfeeding/about-breastfeeding/why-it-matters.html.
  7. American Psychiatric Association. Diagnosis of Attention Deficit Hyperactivity Disorder in Adults. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
  8. Wilens, et al. “An Update on the Pharmacotherapy of Attention-Deficit/Hyperactivity Disorder in Adults.” Expert Review of Neurotherapeutics, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/21955201/. 
  9. Wilens, et al. “Misuse and Diversion of Stimulants Prescribed for ADHD: a Systematic Review of the Literature.” Journal of the American Academy of Child and Adolescent Psychiatry, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/18174822/.
  10. Cortese, et al. “Comparative Efficacy and Tolerability of Medications for Attention-Deficit Hyperactivity Disorder in Children, Adolescents, and Adults: a Systematic Review and Network Meta-Analysis.” The Lancet. Psychiatry, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/30097390/.
  11. Schonwald. “Update: Attention Deficit/Hyperactivity Disorder in the Primary Care Office.” Current Opinion in Pediatrics, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/15800424/.