Are ADHD Medications Safe to Take While Pregnant or Breastfeeding?
Should a woman stop taking ADHD medication — like Adderall, Vyvanse, or Ritalin — during pregnancy? While nursing? Larry Silver, M.D., answers new moms’ critical questions about ADD while expecting and caring for a baby.
Are ADHD Medications Safe During Pregnancy?
Women with ADHD who become pregnant must decide whether to remain on medication or cease taking their Adderall or Vyvanse or other prescription for at least nine months. For women hoping to breastfeed, this decision may impact life — for the mother, the child, and the rest of the family — for two years or more.
Complicating this decision is the fact that there are no clear-cut studies regarding the safety of stimulant medication use while pregnant. None of the medications used to treat ADHD — including Vyvanse, Adderall, and Ritalin — are proven to be safe to use during pregnancy, but they are also not proven to be harmful, according to the Federal Drug Administration (FDA). In short, there is no ethical way to conduct a study, giving medication or a placebo to a population of pregnant or nursing women, and then collecting data on the outcome for the babies.
As a result, medication use during pregnancy is often determined by a physician’s best practices in concert with the individual patient’s needs and concerns. “Best practices” means making decisions based on the physician’s best knowledge of what other physicians do, the outcomes documented when these medications have been used, and their best judgment for each patient. Each physician must educate their patients, make reasonable recommendations, and act based on collaborative decisions.
Treatment must strike a balance between assumed safety and the needs of the mother. Many women with ADHD also arrive at a decision in consultation with their partner.
Research on ADHD Medications’ Impact on Pregnancy and Breastfeeding
Clinicians once believed that the placenta served as a barrier that protected the fetus from the adverse effects of medications and toxins taken by the mother. This is wrong. We now know that medication can pass through the placenta to the fetus. However, researchers from the FDA and Centers for Disease Control (C.D.C)— among others — are still working to obtain a clear understanding of the effects of psychotropic medicine on a child in utero and/or while breastfeeding.
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For example, the C.D.C’s program, Treating for Two “aims to improve the health of women and babies by identifying the safest treatment options for common conditions before, during, and after pregnancy.”1
Treating for Two is now accumulating and publishing current research studies regarding medication use during pregnancies. One ADHD-related research study appears in their ‘Key Findings’ section. One such study, published in the Journal of Attention Disorders in 2018, found that the rate of women taking ADHD medication during pregnancy more than doubled between 1998 and 2011.2 Though lacking evidence about the risks of stimulant use during pregnancy or nursing, this study confirms the need for concentrated research for women making prenatal health decisions.
Additionally, in 2015, the FDA replaced its older, 5-letter classification system for judging the safety of medications with a new system that emphasizes helpful information pertaining to each medication. This new system has eliminated standardized risk statements on labels of prescription medication in favor of revised and detailed information in the pregnancy and lactation sections of drug labels.3
Under the FDA’s older classification system, all of the medications used to treat ADHD fell into Class C, which was used to indicate that medications are considered potentially harmful, based on animal studies. Additionally, an assignment of Class C indicated that there are no available human studies from which to gather relevant information. This is remains true today; researchers still don’t know much about risks of continuing ADHD medication through pregnancy or breastfeeding.
However, some studies, collecting data from pregnancy exposure registries, are underway. Pregnancy exposure registries collect health data from women who take prescription medication while pregnant for observational studies. The FDA does not conduct pregnancy exposure registries, but The FDA’s Office of Women’s Health keeps an updated list of registries posted on their website, accessible here.
Answers to Questions about Ritalin, Vyvanse, Adderall and Pregnancy
The decision to continue ADHD medications during pregnancy is ideally made when the patient informs her physician that she plans to start a family, when there is time to do research and make the best decision. But life does not always go as planned: the C.D.C reports that around half of all U.S. pregnancies are unintended and this number may be even higher among women with ADHD.4 Frequently, the medication decision is first discussed after the woman learns that she is pregnant, often four or more weeks into the pregnancy, after the fetus has already been exposed to medications.
Most studies regarding amphetamine or methylphenidate use during pregnancy come from drug abuse studies. Thus, the results of these studies may not be applicable to women with ADHD who rely on amphetamine medications, such as Adderall or Vyvanse, or methylphenidate medications, such as Concerta or Ritalin, to manage their symptoms. However, the serious negative outcomes of these studies — such as higher infant mortality rates, preterm deliveries, and lower ratings on the Apgar scale — cause many clinicians to take caution when advising their patients about continuing ADHD medication in pregnancy.5
For women with mild to moderate symptoms of ADHD, the Massachusetts General Hospital Center for Women’s Mental Health recommends switching to non-pharmacological interventions to manage ADHD symptoms. Exercise, CBT, DBT, and diet are just a few of the many natural treatments for ADHD prescribed to expectant mothers.5
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Still, it’s worth emphasizing that there is no firm or consistent data on how ADHD stimulants affect the fetus during pregnancy. The current data suggest that there is little to no impact, but the information from these studies does not confirm that this is “absolutely correct in all cases.” Thus, the course of treatment should be based on a balance between the mother’s need for medication and her desire not to expose her baby to drugs about which very little is known.
Adderall and Breastfeeding: Can You Use ADHD Stimulants While Nursing?
There exist no controlled studies on the safety of psychiatric medications of all types in nursing mothers. Thus, as with pregnancy, whether to take ADHD medication while nursing is another decision pregnant women need to make without clear scientific evidence to guide them.
The “Lactation Risk Category,” developed by Thomas Hale, M.D., is most frequently used by medical professionals, though it’s not universally accepted. For nursing, ADHD medications are classified as L3: Moderately Safe. This classification indicates that “There are no controlled studies in breastfeeding women, however the risk of untoward effects to a breastfed infant is possible. Drugs should be given only if the potential benefit justifies the potential risk to the infant.”
Concerning lactation, many health professionals believe that the risks associated with not breastfeeding may outweigh the risks of using stimulants. The American Academy of Pediatrics recommends that women breastfeed their babies for at least one year. Additionally, most doctors advise their pregnant patients to discontinue any inessential medication while pregnant or nursing, as traces of the medication may show up in the mother’s milk.
If a mother decides to continue taking ADHD medication while breastfeeding, I recommend using short-acting meds, which peak and leave the system relatively quickly. Thus, a mother can time her baby’s feeding schedule to nurse just before taking a dose. This is easier to achieve after three months of age, when infants typically begin nursing less often.
While breastfeeding, it is recommended that the mother work closely with her pediatrician to understand reactions in the baby that might suggest a negative effect from the medication. For stimulant medications, these behaviors include irritability and poor sleeping patterns. If a parent notices these behaviors, the medication should be decreased in dose or stopped entirely.
Ceasing Use of ADHD Medication During Pregnancy and Breastfeeding
When a mother decides to stop taking ADHD medication during pregnancy and/or nursing, it’s helpful for her to educate her spouse or partner, other children, extended family members, and employer about this decision. Symptoms of hyperactivity, inattention, and/or impulsivity may return during pregnancy, and may take some people off guard.
Explain that you are stopping medication because you feel it’s best for your baby, and welcome any support they can offer — bringing over some meals, reminding you of appointments, etc. You may also want to consider decreasing or eliminating certain responsibilities.
The Effect of ADHD Medication Use On the Mother
Adults with ADHD usually function well on medication. Off medication, hyperactivity, distractibility, and impulsivity can lead to marital strife, poor job performance, and social problems. And let’s not forget problems with organization of thoughts, activities, and time — the nexus at which life can fall apart. This dilemma almost always occurs with ADHD and pregnancy, or nursing.
It’s critical to weigh the effect on the mother of ceasing ADHD medication, considering what little is known about the impact of such medications on the fetus and, later, the baby. Your obstetrician will be able to provide you with literature on medications taken during pregnancy.
After pregnancy, your pediatrician will be able to provide you with literature on medications taken while breastfeeding. Even though physicians have even less data on the impact of ADHD medications during nursing than with their use during pregnancy, read this literature. Then think through how seriously you might need the ADHD medication during the nine months of pregnancy and additional months of breastfeeding and caring for a small child who requires constant, vigilant attention.
Remember, too, that there are other non-invasive treatments and strategies for managing ADHD symptoms that don’t involve such painful decisions. One is to get an ADHD coach to help you plan your day and follow through on your plans. Coaches can’t take away the symptoms of ADHD, but they can certainly help their clients deal with them. Most coaching is done by phone.
Each mother must discuss these issues with her physician and make her own decision. With this little research, there is no easy answer. You, your doctors, and your partner must weigh all the information and make the best decision for your family.
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Sources:
1Treating for Two: Medicine and Pregnancy. (2020, February 3). Retrieved March 3, 2020, from https://www.(d(.gov/pregnancy/meds/treatingfortwo/index.html
2Use of ADHD Medicine is Increasing among Pregnant Women. (2019, November 8). Retrieved March 3, 2020, from https://www.(d(.gov/pregnancy/meds/treatingfortwo/features/keyfinding-ADHD-med-increase.html
3Center for Drug Evaluation and Research. (2014, December 3). Questions and Answers on the Pregnancy and Lactation Labeling Rule. Retrieved March 3, 2020, from https://www.fda.gov/drugs/labeling-information-drug-products/questions-and-answers-pregnancy-and-lactation-labeling-rule
4Attention-Deficit/Hyperactivity Disorder Medication Prescription Claims Among Privately Insured Women Aged 15–44 Years – United States, 2003–2015. (2018, January 18). Retrieved March 3, 2020, from https://www.(d(.gov/mmwr/volumes/67/wr/mm6702a3.htm?s_cid=mm6702a3_e
5Milanovic, S. (2010, September 27). Clinical Update: Use of Stimulant Medications in Pregnancy. Retrieved March 3, 2020, from https://womensmentalhealth.org/posts/clinical-update-use-of-stimulant-medications-in-pregnancy/
