Botox injections are used for many medical purposes including migraine, anal fissures. The amount of botox getting into milk is low based on the research on one mother who caught botulism from eating fermented salmon eggs. She continued to breastfeed. No botulinum toxin or botulism was found in the breastmilk or the baby. The doses that are used medically are far lower than that which would have caused the mother’s botulism so the amount in breastmilk is assumed to be too low to produce adverse effects.

Hale also comments that when Botox is injected into the muscle, it produces a partial chemical denervation resulting in paralysis of the muscle. When injected properly, and directly into the muscle, the toxin does not enter the systemic circulation. Thus levels in maternal plasma, and milk are very unlikely. Waiting a few hours for dissipation of any toxin would all but eliminate any risk to the infant. Also, avoid use of generic or unknown sources of botulinum toxin, as some are known to produce significant plasma levels in humans. (Hale TW Medications and Mothers Milk online version accessed Feb 2024)

In February 2024 a study of 4 mothers was published https://www.liebertpub.com/doi/abs/10.1089/fpsam.2023.0326

Objective: To detect the presence of botulinum toxin in breast milk from lactating subjects treated with facial botulinum toxin injections, as measured by enzyme-linked immunosorbent assay (ELISA).

Methods: For this pilot study, lactating women were injected with standardized facial botulinum toxin type A (BTXA) (range 40–92 U). Collected breast milk samples over 5 days were analyzed for the presence of botulinum toxin. Exclusion criteria included (1) lactating women still using their breast milk for their infant, (2) muscular disorders, (3) any medication that could interfere with neuromuscular function, (4) uncontrolled systemic disease, (5) pregnant, and (6) neuromodulator injection in the past 90 days.

Results: Four lactating women were recruited. Eight samples had no BTXA detected, whereas 8 of the 16 total had detectable amounts, which were well below the reported lethal oral dose for an infant.

Conclusion of the authors: Although the exclusion of lactating women from receiving cosmetic botulinum toxin injections is out of an abundance of caution to the theoretical risk to the infant, this study helps support the notion that facial botulinum toxin injections do not warrant an interruption in breastfeeding. Further studies with larger sample sizes are needed.

Hudson C, Wilson P, Lieberman D, Mittelman H, and Parikh S. Analysis of Breast Milk Samples in Lactating Women After Undergoing Botulinum Toxin Injections for Facial Rejuvenation: A Pilot Study.Facial Plastic Surgery & Aesthetic Medicine.ahead of print

See also https://infantrisk.com/content/botox-injections-and-breastfeeding (April 2025)

I have written extensively about the use of decongestants in the past ( https://breastfeeding-and-medication.co.uk/fact-sheet/coughs-colds-flu-and-covid-when-breastfeeding and https://www.breastfeedingnetwork.org.uk/factsheet/decongestants/)

Pseudoephedrine has been shown to reduce milk supply in some women. The effect of phenylephrine on supply has not been demonstrated but use of oral decongestants is generally not advised for breastfeeding women.

 I have always recommended the use of nasal sprays as decongestants together with the use of steam inhalation as being more effective than oral medication and with no potential  impact on supply.

In September 2023 the FDA reported that oral phenylephrine is not effective at relieving nasal stuffiness. It is important to note that neither FDA nor the Non-prescription Drug Advisory Committee raised concerns about safety issues with use of oral phenylephrine at the recommended dose. Key Information about Nonprescription, Over-the-Counter (OTC), Oral Phenylephrine | FDA

According to one USA website the evidence for efficacy was first questioned in 2007. The manufacturers have cited a survey that many people find its use beneficial as shown by sales volume of cough and cold products.

The vote that formally declared phenylephrine ineffective was in line with a review of pharmacology and clinical data presented by the FDA, which found the oral bioavailability of the drug is less than 1%, compared with 38%, a number often cited in the literature and based on outdated technology. (Medscape https://www.medscape.com/viewarticle/996369).

There appears to be no current UK recommendations although I am sure there is current discussion. Most oral cough and cold remedies currently contain phenylephrine as pseudoephedrine  sales have been restricted.   Between 2007 and 2008, the government introduced restrictions on their use because of concern that medicines containing these active substances could be used in the illicit manufacture of the Class A controlled drug methylamphetamine https://www.gov.uk/drug-safety-update/pseudoephedrine-and-ephedrine-update-on-managing-risk-of-misuse#:~:text=Sales%20restrictions,-Since%20April%202008&text=It%20is%20illegal%20to%20sell,mg%20ephedrine%20without%20a%20prescription

This information has been compiled from a variety of sources and does not imply recommendation other than that nasal decongestants and steam inhalation are effective in reducing symptoms of nasal congestion during breastfeeding without potential impact on supply. Most of us have our own preferred remedies which we find effective and that remains a personal choice

Having nursed my husband post-op this week the topic of laxatives is at the fore front of my mind particularly after opioid analgesics! But also very relevant post birth particularly after a c section or instrumental delivery

What is constipation:

It’s likely to be constipation if:

• you have not had a poo at least 3 times during the last week
• the poo is often large and dry, hard or lumpy
• you are straining or in pain when you have a poo
• You may also have a stomach ache and feel bloated or sick.

The most common causes of constipation include:

• not eating enough fibre, ( fruits, vegetables and cereals)
• not drinking enough fluids
• not moving enough and spending long periods sitting or lying down
• being less active and not exercising
• often ignoring the urge to go to the toilet
• changing your diet or daily routine
• a side effect of medicine especially opioid painkillers
• stress, anxiety or depression

Constipation is also common during pregnancy and for 6 weeks after giving birth.

Even if you decide you need medication you do need to make changes to your diet and toilet habits which can be particularly challenging with a new baby who needs you 24 hours a day and under whom you may be stuck feeding or sleeping when you need “ to go”.

Management of constipation

• In the management of short-duration constipation (where dietary measures have proved ineffective) start with a bulk-forming laxative, ensuring adequate fluid intake. Eg, ispaghula husk (Fybogel ™).
• If stools remain hard, add or switch to an osmotic laxative. Osmotic laxatives increase the amount of water in the large bowel, either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with. Eg Lactulose, Macrogols(Movicol™)
• Stool softeners act by decreasing surface tension and increasing penetration of intestinal fluid into the faecal mass Eg docusate (DulcoEase™)
• If stools are soft but difficult to pass or you feel inadequate emptying, a stimulant laxative should be added. Eg Senna (Sennokot™), Bisacodyl (Dulcolax™)
• Glycerol suppositories act as a lubricant and as a rectal stimulant by virtue of the mildly irritant action of glycerol.

Laxatives and breastfeeding

• Bulk forming laxatives just add to the bulk of faeces and are not absorbed into the body
• Osmotic laxatives just increase the volume of water in the faeces and are not absorbed into the body or breastmilk. Anecdotally some babies do develop loose bowel motions but there seems to be no reason for this.
• Stool softeners are poorly orally bioavailable. There are no studies on passage into breastmilk but it is believed to be minimal and should not affect the baby. (Hale 2023)
• Senna : In one dated uncontrolled study of 23 women who received Senokot (100 mg containing 8.602 mg of sennosides A and B), no sennoside A or B was detectable in their milk.[ Werthmann MW Jr, Krees SV. Quantitative excretion of Senokot in human breast milk. Med Ann Dist Columbia. 1973;42:4–5.] Of 15 mothers reporting loose stools, two infants had loose stools. Several controlled studies using modern senna products found no effect on the infant (LactMed 2023). Senna should only be used short term to treat constipation
• Bisacodyl: Bisacodyl is not absorbed from the gastrointestinal tract, and its active metabolite, which is absorbed, is not detectable in breastmilk. Bisacodyl can be taken during breastfeeding and no special precautions are required. (LactMed 2023). It’s oral bioavailability is less than 5% (Hale 2023)

See also https://www.sps.nhs.uk/articles/using-laxatives-during-breastfeeding

SPS Using laxatives and breastfeeding

Movicol now says that it can be used during pregnancy and breastfeeding! https://www.movicol.co.uk/

Bristol Stool Chart

Type 1: Separate hard lumps (hard to pass)

Type 2: Lumpy, hard, sausage-shaped.

Type 3: Sausage-shaped with cracks on the surface.

Type 4: Sausage-shaped or snake-like; smooth and soft.

Type 5: Soft blobs with clear-cut edges (easy to pass)

Type 6: Fluffy pieces with ragged edges; mushy.

Levonelle™ (levonorgestrel), when originally marketed was licensed to be given to women during breastfeeding.  However, the patient information leaflet in the packet now suggests that women should not breastfeed for 8 hours.  This is not supported by research and breastfeeding can continue as normal.

The tablet should be taken as soon as possible after unprotected intercourse – up to 72 hours after.  The longer the interval between intercourse and taking the tablet the greater is the chance that it will not be effective.  No contraception has a 100% success rate.  If vomiting occurs soon after taking the tablet medical advice should be sought as soon as possible.

The next period may be early or late and barrier contraception should be continued until the next period.  Levonorgestrel can be purchased over the counter from a pharmacist as well as being prescribed by a GP, pharmacies, family planning clinic or accident and emergency departments.

Should the next period be delayed more than 5 days further medical advice should be sought.  Levonelle™ is reported by the manufacturers not to show evidence of teratogenicity even if it fails to prevent pregnancy.  However emergency hormonal contraception should not be used if there is any possibility that the woman is already pregnant.

In a cohort study of 71 women who took levonorgestrel as a postcoital contraceptive no obvious decrease in milk supply was found after the drug was used according to maternal reports.  75% of mothers re-initiated breastfeeding before 8 hours after the dose.  None noticed any adverse effect in their infants (Polakow-Farkash 2013).  One study demonstrated that levonorgestrel passes into breastmilk but in minimal quantities (Jatlaoui 2016).  Polakow-Farkash reports that the study findings support the safety of using levonorgestrel as an emergency contraceptive during lactation without the need for withholding breastfeeding.

The recommendation to avoid breastfeeding for 8 hours comes from a study by Gainer (2007) where  12 exclusively breastfeeding mothers received a single 1.5 mg dose. Levonorgestrel concentrations were found to peak in milk 2-4 hours after the dose was taken. Milk/plasma ratios averaged 0.28. The estimated infant dose of levonorgestrel was only 1.6 µg during the first 24 hours. If the mother interrupts breastfeeding for 8 hours, this dose was reduced to only 1 µg. The authors recommended that to limit exposure, the mother should not breastfeed for the first 8 hours, or at most 24 hours. However, the amount in milk after 24 hours was only 0.09% of the total dose which is insignificant.

For other options of emergency contraception

See also Ulipristal Acetate (EllaOne) as an emergency hormonal contraceptive and Breastfeeding – Breastfeeding and Medication

A copper intra-uterine contraceptive can be inserted up to 5 days after intercourse as an alternative method of emergency contraception.

Women who do not wish to expose their baby to any medication may wish to consider how frequently they are breastfeeding and therefore the likelihood of ovulation.  Factors which can be taken into consideration are whether she is still exclusively breastfeeding or has introduced solids or complimentary feeds which make it more likely that she is ovulating.  She and her partner also need to consider the consequences of a subsequent pregnancy for them.

References

Hale TW  and Krutsch K. Medications and Mothers Milk

Jatlaoui, Tara C. Riley H,. Curtis KM 2016 Contraception ,2016;93(2): 93 – 112Safety data for levonorgestrel, ulipristal acetate and Yuzpe regimens for emergency contraception

Polakow-Farkash S, Gilad O, Merlob P et al. Levonorgestrel used for emergency contraception during lactation-A prospective observational cohort study on maternal and infant safety. J Matern Fetal Neonatal Med. 2013;26:219

World Health Organization . Medical Eligibility Criteria For Contraceptive Use: Fifth Ed. 2015. www.who.int/reproductivehealth/publications/family_planning/MEC-5/en/

Gainer E, Massai R, Lillo S, Reyes V, Forcelledo ML, Caviedes R, Villarroel C, Bouyer J. Levonorgestrel pharmacokinetics in plasma and milk of lactating women who take 1.5 mg for emergency contraception. Hum Reprod 2007; 22(6):1578-1584.Highlight

E lactancia https://e-lactancia.org/breastfeeding/levonorgestrel-emergency-contraceptive/product/

SPS https://www.sps.nhs.uk/articles/levonorgestrel-1500-microgram-tablets-for-emergency-contraception/

Over the years I have had many questions from  mothers about the lactose content of their medication and how this might affect their CMPA babies by passage through breastmilk.

If a breastfeeding mother is taking a tablet which contains lactose it is unlikely to affect the levels of lactose in her milk and therefore produce symptoms in her baby.

Lactose intolerance is very different to CMPA. Lactose is the sugar in breastmilk which varies little with maternal consumption. Lactose intolerance is usually identified soon after birth with failure to thrive (Savilahti).

Lactose intolerance occurs when a person does not produce the enzyme lactase, or does not produce enough of it, and is therefore unable to digest lactose. If it is not digested and broken down, lactose cannot be absorbed. The undigested lactose passes rapidly through the gut until it is broken down by bacteria, producing gastric pain, bloating and diarrhoea.

See https://www.breastfeedingnetwork.org.uk/factsheet/lactose-intolerance-and-breastfeeding/

The production of lactase decreases in most humans from the age of two years although symptoms of intolerance are rare before the age of six. Lactose intolerance in adults is very common. This is probably a throwback to early dietary consumption in pre-historic humans. Production of lactase also varies between cultures. It is most common in people of African, Asian, Hispanic and American Indian descent. One article I found suggests that 100% of the residents of Ghana, Malawi, South Korea, and Yemen are believed to be lactose intolerant.

CMPA is due to an allergy to the protein in dairy products (not the same as the sugar). Cows’ Milk Protein Allergy (CMPA) and Breastfeeding – The Breastfeeding Network

Savilahti et al identified only 16 cases of congenital lactase deficiency over 17 years despite the fact that the gene for lactose intolerance is very common in Finland. In each case the mother reported watery diarrhoea usually after the first breastfeed but up to 10 days after birth. Poor absorption of lactose was confirmed between 3 and 90 days after delivery at which time all infants were dehydrated and 15 of the 16 weighed less than at birth. On a lactose feed diet the children all caught up with their growth.

Temporary lactose intolerance

Some premature babies are temporarily lactose intolerant due to their immaturity. Babies may also show temporary secondary lactose intolerance following exposure to maternal antibiotics passing through breastmilk. There is no need to alter feeding or add probiotics as all factors to restore the gut are in breastmilk. It is self-limiting.

Lactose in maternal medication

So, if a breastfeeding mother is taking a tablet which contains lactose it is unlikely to affect the levels of lactose in her milk and therefore produce symptoms in her baby.

SPS also provided information on the absorption of lactose from medication in January 2024. https://www.sps.nhs.uk/articles/assessing-the-clinical-impact-of-lactose-in-medicines/

“Lactose in medicines

Lactose is widely used as an excipient in pharmaceutical manufacturing. Although anecdotal reports of drug-induced lactose intolerance exist, when used as an excipient the lactose content in most medicines is too small to cause problems. Daily lactose exposure from medicines is unlikely to exceed 2g per day. Whereas the threshold for lactose intolerance symptoms is approximately 12g (equivalent to 250ml of milk). Therefore, it is unlikely that severe gastrointestinal (GI) symptoms will be due to lactose in medicines, especially in adults without a diagnosis of severe intolerance.  “

References

• Anderson J Lactose intolerance and the breastfed baby. www.breastfeeding.asn.au/bf-info/lactose
• BfN Lactose intolerance and Breastfeeding https://www.breastfeedingnetwork.org.uk/factsheet/lactose-intolerance-and-breastfeeding/
• Jones W Breastfeeding and Medication Routledge 2018
• Savilahti E, Launiala K, Kuitunen P. Congenital lactase deficiency. A clinical study on 16 patients. Arch Dis Child 1983;58:246-252
• Shulman R, Feste A, Ou C (1995). Absorption of lactose, glucose polymers or combination in premature infants. Journal of Pediatrics, 127, 626-631.
• SPS Assessing the clinical impact of lactose in medicines https://www.sps.nhs.uk/articles/assessing-the-clinical-impact-of-lactose-in-medicines/

Tirzepatide is a long-acting GIP (glucose-dependent insulinotropic polypeptide) receptor and GLP-1 (glucagon-like peptide-1) receptor agonist that increases insulin sensitivity and secretion, suppresses glucagon secretion, and slows gastric emptying.

Tirzepatide is used to treat Type 2 diabetes mellitus as monotherapy (if metformin is inappropriate), or in combination with other antidiabetic drugs (including insulin) if existing treatment fails to achieve adequate glycaemic control. It is also used in the treatment of obesity by weekly subcutaneous administration.

No information is available on the clinical use of tirzepatide during breastfeeding. Because tirzepatide is a large peptide molecule with a molecular weight of 4814 Da, the amount in milk is likely to be low and absorption is unlikely because it is probably partially destroyed in the infant’s gastrointestinal tract. Until more data become available, tirzepatide should be used with caution during breastfeeding, especially while nursing a newborn or preterm infant. (LactMed).

Due to its protein nature, it is inactivated in the gastrointestinal tract and is not absorbed (oral bioavailability is practically nil), which makes it difficult or impossible for it to pass into the infant’s plasma from ingested breast milk, except in premature infants and in the immediate neonatal period, where there may be greater intestinal permeability. (E-lactancia).

While caution is still necessary without confirmatory data, it is unlikely to be present in large quantities in the milk compartment (Hale )

See also https://www.infantrisk.com/content/weight-loss-lactation

https://www.springerpub.com/blog/weight-loss-drugs-breastfeeding

Hale and Krutsch (Infantrisk pharmacists express concern on the use of weight loss medications and breastfeeding due to inadequate consumption of nutrients.

“Concerns have been expressed about how the pharmacodynamics of GLP-1 agonists such as tirzepatide or semaglutide could impact the nutritional constituents of milk. These drugs are analogs of natural GLP-1 with small modifications to slow their degradation by the DPP-4 enzyme. However, lactation, in general, is expected to occur during a catabolic physiological state – GLP-1 agonists catalyze the catabolism to encourage weight loss. As long as the mother has sufficient weight to lose, the nutrient profile of milk would likely be similar if compared to a diet producing equivalent weight loss. If a mother is reducing caloric intake for any reason, we recommend a postnatal vitamin and attention to consuming enough calories to meet the elevated nutrient needs required during lactation”.

Other sources of information

NICE  TA 1026 Tirzepatide for managing overweight and obesity . https://www.nice.org.uk/guidance/ta1026

See also Semaglutide and Breastfeeding https://breastfeeding-and-medication.co.uk/fact-sheet/semaglutide-and-breastfeeding

Liraglutide and Breastfeeding https://breastfeeding-and-medication.co.uk/fact-sheet/liraglutide-saxenda-and-breastfeeding

I have shared the chapter on ADHD from my book Breastfeeding and Chronic Medical Conditions multiple times this week. Many mothers seem to be diagnosed in later life and are concerned about breastfeeding. Hope this is a useful link.

More information

ADHD and Breastfeeding Factsheet

If this is useful maybe you need the book available on Amazon. I published on Kindle to try to make this more affordable and available to mothers and breastfeeding supporters as well as professionals

https://infantrisk.com/content/adhd-medications-and-breastfeeding

I came off my medication to conceive and my baby is now 6 months old. I am really struggling to think straight now and getting really overwhelmed by the smallest of things.

Description

ADHD is a disorder that includes symptoms such as inattentiveness, hyperactivity, and impulsiveness. It is normally diagnosed in childhood, but some parents have found themselves being diagnosed when seeking a diagnosis for their children. The cause is unknown, but it seems to at least in part, genetic. It has been suggested that being born prematurely (before the 37th week of pregnancy), having a low birth weight or maternal smoking or alcohol or drug abuse during pregnancy may be linked. Attention deficit hyperactivity disorder (ADHD) is thought to affect about 1 in 20 children in the UK with incidence being three times higher in boys.

Symptoms fall into 2 categories:

inattentiveness main symptoms of which are:

• having a short attention span and being easily distracted
• making careless mistakes
• appearing forgetful or losing things
• being unable to stick to tasks that are tedious
• appearing to be unable to listen to or carry out instructions
• constantly changing activity or task
• having difficulty organising tasks

hyperactivity and impulsiveness main symptoms of which are:

• being unable to sit still and constantly fidgeting
• being unable to concentrate on tasks
• excessive physical movement
• excessive talking
• being unable to wait turn
• acting without thinking
• interrupting conversations
• little or no sense of danger
• ADHD may be linked with anxiety, autism, and several other conditions. By the age of 25, an estimated 15% of people diagnosed with ADHD as children still have a full range of symptoms, and 65% still have some symptoms that affect their daily lives. ( https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/symptoms/)

Treatment

•        Methylphenidate (Ritalin ™, Concerta ™); works by increasing the amount of a dopamine in the parts of the brain responsible for self-control and attention. It is usually the first line treatment. There are side effects of loss of appetite and difficulty sleeping and mood swings. Limited evidence indicates that methylphenidate levels in milk are very low and not detectable in infant serum. The effects of methylphenidate in milk on the neurological development of the infant have not been well studied. Monitor the baby for agitation, irritability, poor sleeping patterns, changes in feeding and poor weight gain.
•         Atomexatine is a selective noradrenaline reuptake inhibitor (SNRI), increasing levels of noradrenaline rather than dopamine. It can aid concentration and help control impulses. Side effects include rise in blood pressure and heart rate, nausea and vomiting, gastric pain, difficulty sleeping, dizziness, headaches, and irritability. More importantly it has been associated with suicidal thoughts and liver damage. There is no published experience with atomoxetine during breastfeeding, although reports from the manufacturer found no serious adverse effects in two breastfed infants (Besag 2014).
•         Dexamphetamine. Side effects include decreased appetite, mood swings, agitation and aggression, dizziness, headaches, nausea, vomiting and diarrhoea. Only used if lisdexamphetamine is helpful but not tolerated. In dosages prescribed for medical indications, some evidence indicates that dextroamphetamine might not affect nursing infants adversely. The effect of dextroamphetamine in milk on the neurological development of the infant has not been well studied. It is possible that large dosages of dextroamphetamine might interfere with milk production.  Infant Monitoring for agitation, hyperactivity, insomnia, decreased appetite, weight gain, and tremor.
•         Lisdexamphetamine (Vyvance ™) may be offered as first line treatment in adults. Side effects include decreased appetite, aggression or drowsiness, dizziness, headaches, nausea, vomiting and diarrhoea. Lisdexamfetamine is a prodrug of dextroamphetamine. In medicinal dosages, some evidence (5 mothers studied) indicates that dextroamphetamine might not affect nursing infants adversely. The effect of dextroamphetamine in milk on the neurological development of the infant has not been well studied. Infant Monitoring should be for agitation, irritability, poor sleeping patterns and poor weight gain.
• The NHS website suggests that for adults with ADHD if you find it hard to stay organised, then make lists, keep diaries, stick up reminders and set aside some time to plan what you need to do
• let off steam by exercising regularly
• find ways to help you relax, such as listening to music or learning relaxation techniques
• if you have a job, speak to your employer about your condition, and discuss anything they can do to help you work better
• talk to your doctor about your suitability to drive, as you will need to tell the Driver and Vehicle Licensing Agency (DVLA) if your ADHD affects your driving
• contact or join a local or national support group – these organisations can put you in touch with other people in a similar situation, and can be a good source of support, information, and advice

References

• Attention deficit hyperactivity disorder: diagnosis and management; NICE guideline (March 2018, updated September 2019)
• Attention deficit hyperactivity disorder; NICE CKS, May 2018
• Besag FM. ADHD treatment and pregnancy. Drug Saf. 2014; 37:397-40
• NHS ADHD https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/living-with/
• Further Information
• AADUK https://aadduk.org/

Can women with ADHD stay on medication while they breastfeed?

Anecdotally there are many mothers who take medication for ADHD during their breastfeeding journey despite a lack of published studies on the effect of the level of medication passing through breastmilk to babies. It is a topic regularly raised on social media discussions from which many parents take their information. Since the pandemic the increase in diagnoses of adults has driven the discussions too.

As with many drugs we rely on the pharmacokinetics of the products: that is the way that the drugs are handled by the body. Drugs used to treat ADHD are not recommended during breastfeeding as the manufacturers are not required to take responsibility as they cannot ethically conduct clinical trials during the development of the medication. This is true of virtually all products used by breastfeeding women – they are used outside of the product licence and prescribed with the professionals being required to take responsibility.

For example methylphenidate (Concerta™ and Ritalin™) was studied in 3 women taking between 35 and 80mg daily. The average milk levels measured were very low.  The infants had no drug-related adverse reactions and were developing normally for their ages which averaged 4.4 months. No adverse events have been identified according to specialist sources although it would be wise to monitor changes in sleep patters and feeding including weight gain.

What ones are safest?

It is difficult to say which one is “safest” as this is a relative term. No drug is absolutely safe, but all of the drugs used to treat ADHD are recognised as compatible with breastfeeding by expert, specialist sources. The drug which would generally be chosen is the one that has proven to be most effective for the mother. Methylphenidate could perhaps be said to have the best evidence but as has already been discussed, the data published is limited. The decision to prescribe should be agreed between the mother and her professionals with full, accessible information so that she can make an informed choice in the risks and benefits for her and her nursling. Ongoing breastfeeding has many health advantages but if the mother has concerns about exposing her child to the medication (in however low a level) that may influence her choice as to whether to take the drug and continue to breastfeed, breastfeed but delay the drug or take the medication and choose to formula feed. We all have individual feelings as to the risks and benefits of each choice.

Is there a risk to the baby at all?

In the first 6 weeks after birth a baby has immature kidney and liver function and is at greater risk of not being able to metabolise the levels of drug passing through breastmilk. This in turn makes it more likely that side effects such as changes in sleep and feeding patters may occur but are difficult to identify from normal neonatal behaviour.

Individual reactions are always possible although reporting in specialist expert sources suggest these are limited.

Is it advised to stay on rather than coping without it?

That is very much an individual decision depending on how well the mother is coping with her symptoms alongside the complexity of life with a newborn which will all be associated with loss of routine and long periods sitting to breastfeed. Most mothers stop medication during pregnancy and may be desperate to re start. A fully informed discussion with appropriate, accessible data puts the decision with the mother on what she feels comfortable with.

Specialist sources of information

https://www.ncbi.nlm.nih.gov/books/NBK501922

https://www.e-lactancia.org

https://www.infantrisk.com/content/adhd-medications-and-breastfeeding#:~:text=It%20is%20rare%20that%20a,breastfeeding%20to%20take%20a%20medication.&text=Multiple%20studies%20have%20demonstrated%20that,her%20ADHD%20medication%20as%20prescribed.

https://www.sps.nhs.uk/articles/safety-in-lactation-drugs-for-adhd