First Exposure

Attention Deficit Hyperactivity Disorder (ADHD) in Pregnancy and Lactation

Authored by Rachela Smith and Dr. Jonathan Zipursky and reviewed by First Exposure Medical Review Team. 

Rachela Smith, BASc, is a medical student at the Michael G. DeGroote School of Medicine at McMaster University.  

Dr. Jonathan Zipursky MD, PhD, FRCPC, is a Medical Advisor at First Exposure, a Clinician-Scientist at Sunnybrook Health Sciences Centre and Sunnybrook Research Institute and an assistant Professor, Department of Medicine & Institute of Health Policy, Management, and Evaluation, University of Toronto. 

This health topic is an expert opinion about ADHD during pregnancy and lactation. 

* The information provided is the expert opinion of the First Exposure Medical Advisors. It is for informational purposes only and does not replace medical care and advice from a healthcare provider. Please contact your healthcare provider if you have any concerns or to discuss any questions that you believe may be relevant to you or your baby. In case of emergency, please go to the emergency room or call 911.  

If you do not have a healthcare provider please go to: Finding a Healthcare Provider 

 

Clinical scenario:

I have been taking medications for my ADHD since Grade 10. I just discovered I’m pregnant.  Can I keep taking my medications? 

Q. What is ADHD?

A. Attention Deficit Hyperactivity Disorder (ADHD) is a mental health disorder that affects daily functioning. 

People living with ADHD may have difficulties with: 

  • Attention – focusing on tasks and paying attention  
  • Hyperactivity – constantly moving, fidgeting, or talking too much  
  • Impulsivity – acting without thinking and difficulty with self-control. 

 

Q. What are the most common treatments for ADHD?

A. Non-medication treatments include cognitive-behavioral therapy, support groups, getting extra help at school, and learning organizational skills. Prescription stimulants are the most common medications used to treat ADHD, and include: 

  1.  

Non-stimulant medications such as guanfacine (Intuniv XR®) and atomoxetine (Strattera®) are also used to treat ADHD. This health topic will focus on the use of prescription stimulants for the treatment of ADHD. 

 

Q. Can prescription stimulants be used while trying to get pregnant?

A. Studies have not been done to see if use of prescription stimulants might make it harder to become pregnant.

 

Q. Does taking prescription stimulants in pregnancy increase the chance of a miscarriage?

A.  Miscarriage occurs in approximately 15-25% of pregnancies (1 in 4 pregnancies). Studies have not examined whether the use of prescription amphetamines increases the risk of miscarriage. Some studies suggested that methylphenidate use during pregnancy may be linked to a slightly higher rate of miscarriage. However, other studies suggested that this observed risk might not be related to methylphenidate, but instead to ADHD and other associated factors. Please see methylphenidate drug page for more details.

 

Q. Does taking prescription stimulants in pregnancy increase the chance of a birth defect?

A. Most pregnancies result in a healthy baby, but there are chances of complications and unexpected outcomes. These chances are called baseline risks. In Canada, the baseline risk of major birth defects is 3-5%. This means that 3-5 out of 100 babies born in the general population in Canada will be born with a major birth defect. Studies have not found an increased risk of birth defects among pregnancies exposed to prescription amphetamines or methylphenidate. However, some studies have reported a small increased risk of heart defects with methylphenidate use during pregnancy, while other studies have not.

 

Q. Does taking prescription stimulants in pregnancy increase the risk of any other harmful outcomes?

A. Most studies have not found an increased risk of preterm delivery, neonatal intensive care unit admission, small for gestational age (low birth weight), or placental abruption (when the placenta separates from the wall of the uterus before birth), in pregnancies exposed to prescription amphetamines or methylphenidate. However, these findings are based on limited studies, and more data are needed.

 

Q. Do prescription stimulants increase the risk of hypertensive disorders of pregnancy?

A. Stimulant use has been linked to high blood pressure (hypertension). Some data have suggested a small increased risk of developing hypertensive disorders of pregnancy (e.g., gestational hypertension, pre-eclampsia) in people taking prescription stimulants, while others have not. More information is needed to confirm these risks.

Q. Does prescription stimulant use during pregnancy result in any long-term risks to the child?

A. Studies show that prescription stimulant use during pregnancy is not associated with an increased risk of neurodevelopmental disorders (e.g., ADHD, autism spectrum disorder, seizure disorders) or growth impairment in children.

 

Q. Can prescription stimulants be used while nursing?

A. The relative infant dose (RID) is a measurement that estimates how much medication is ingested by a nursing infant as compared to the mother. Most medications with an RID of less than 10% are usually compatible with breastfeeding a healthy infant. There are limited data on the use of methylphenidate and prescription amphetamines during breastfeeding. The RID for methylphenidate is estimated to be less than 1% and for prescription amphetamines 4%-10.6%. No serious adverse effects were reported in infants exposed to stimulants via breastmilk. Please see the methylphenidate drug page for more information.  

Q. Advice for specific populations?

A. The effects of amphetamine and methylphenidate use during pregnancy and postpartum may differ for people using these drugs not as prescribed or purchased through the street supply. Use of stimulants not as prescribed or those purchased through the street supply during pregnancy has been associated with an increased risk of hypertensive disorders of pregnancy, preterm delivery, severe maternal illness, maternal death, placental abruption, low birth weight, intrauterine fetal death, and infant death. However, these adverse effects may also be related to factors associated with substance use (e.g., poor maternal nutrition, domestic violence, inadequate prenatal care, and use of other drugs or substances). Some studies also suggest that such use of amphetamines during pregnancy is also linked to abnormal infant development and behavior. Breastfeeding is not recommended with use of stimulants purchased through the street supply or when not used as prescribed. 

Key References

Admon LK, Bart G, Kozhimannil KB, Richardson CR, Dalton VK, Winkelman TNA. Amphetamine- and Opioid-Affected Births: Incidence, Outcomes, and Costs, United States, 2004-2015. Am J Public Health. 2019;109(1):148-54. [PMID: 30496001].  

American College of Obstetrics and Gynecology. Committee Opinion No. 479: Methamphetamine abuse in women of reproductive age. Obstet Gynecol. 2011;117(3):751-5. [PMID: 21343793].  

Anderson KN, Ailes EC, Danielson M, Lind JN, Farr SL, Broussard CS, et al. Attention-Deficit/Hyperactivity Disorder Medication Prescription Claims Among Privately Insured Women Aged 15-44 Years – United States, 2003-2015. MMWR Morb Mortal Wkly Rep. 2018;67(2):66-70. [PMID: 29346342]. 

Bang Madsen K, Robakis TK, Liu X, Momen N, Larsson H, Dreier JW, et al. In utero exposure to ADHD medication and long-term offspring outcomes. Mol Psychiatry. 2023;28(4):1739-46. [PMID: 36759544]. 

Barlow A, Mullany BC, Neault N, Davis Y, Billy T, Hastings R, et al. Examining correlates of methamphetamine and other drug use in pregnant American Indian adolescents. Am Indian Alsk Native Ment Health Res. 2010;17(1):1-24. [PMID: 20683821]. 

Bello G, Poirier J, Sharkey KM. Successful lactation after resuming methylphenidate in a woman with narcolepsy. J Clin Sleep Med. 2022;18(7):1891-4. [PMID: 35404225].  

Bro SP, Kjaersgaard MI, Parner ET, Sorensen MJ, Olsen J, Bech BH, et al. Adverse pregnancy outcomes after exposure to methylphenidate or atomoxetine during pregnancy. Clin Epidemiol. 2015;7:139-47. [PMID: 25657597].  

Camacho X, Zoega H, Gomes T, Schaffer AL, Henry D, Pearson SA, et al. The association between psychostimulant use in pregnancy and adverse maternal and neonatal outcomes: results from a distributed analysis in two similar jurisdictions. Int J Epidemiol. 2023;52(1):190-202. [PMID: 36135973]. 

Cohen JM, Hernandez-Diaz S, Bateman BT, Park Y, Desai RJ, Gray KJ, et al. Placental Complications Associated With Psychostimulant Use in Pregnancy. Obstet Gynecol. 2017;130(6):1192-201. [PMID: 29112657]. 

Colby JB, Smith L, O’Connor MJ, Bookheimer SY, Van Horn JD, Sowell ER. White matter microstructural alterations in children with prenatal methamphetamine/polydrug exposure. Psychiatry Res. 2012;204(2-3):140-8. [PMID: 23149028]. 

Collin-Levesque L, El-Ghaddaf Y, Genest M, Jutras M, Leclair G, Weisskopf E, et al. Infant Exposure to Methylphenidate and Duloxetine During Lactation. Breastfeed Med. 2018;13(3):221-5. [PMID: 29485905]. 

Damer EA, Edens MA, van der Loos MLM, van Esenkbrink J, Bunkers I, van Roon EN, et al. Fifteen years’ experience with methylphenidate for attention-deficit disorder during pregnancy: Effects on birth weight, Apgar score and congenital malformation rates. Gen Hosp Psychiatry. 2021;73:9-15. [PMID: 34507078]. 

Debooy VD, Seshia MM, Tenenbein M, Casiro OG. Intravenous pentazocine and methylphenidate abuse during pregnancy. Maternal lifestyle and infant outcome. Am J Dis Child. 1993;147(10):1062-5. [PMID: 7692723]. 

Diav-Citrin O, Shechtman S, Arnon J, Wajnberg R, Borisch C, Beck E, et al. Methylphenidate in Pregnancy: A Multicenter, Prospective, Comparative, Observational Study. J Clin Psychiatry. 2016;77(9):1176-81. [PMID: 27232650]. 

Dideriksen D, Pottegard A, Hallas J, Aagaard L, Damkier P. First trimester in utero exposure to methylphenidate. Basic Clin Pharmacol Toxicol. 2013;112(2):73-6. [PMID: 23136875].  

Eriksson M, Larsson G, Zetterstrom R. Amphetamine addiction and pregnancy. II. Pregnancy, delivery and the neonatal period. Socio-medical aspects. Acta Obstet Gynecol Scand. 1981;60(3):253-9. [PMID: 7270093].  

Garey JD, Lusskin SI, Scialli AR. Teratogen update: Amphetamines. Birth Defects Res Part A Clin Mol Teratol. 2020;112(15):1171-82. [PMID: 32755038]. 

Gorman MC, Orme KS, Nguyen NT, Kent EJ, 3rd, Caughey AB. Outcomes in pregnancies complicated by methamphetamine use. Am J Obstet Gynecol. 2014;211(4):429.e1-7. [PMID: 24905417]. 

Hackett LP, Ilett KF, Kristensen JH, Kohan R, Hale TW. Infant dose and safety of breastfeeding for dexamphetamine and methylphenidate in mothers with attention deficit hyperactivity disorder: Meeting Abstract – 40. Ther Drug Monit. 2005;27(2):220-1. [PMID. N/A] 

Hackett LP, Kristensen JH, Hale TW, Paterson R, Ilett KF. Methylphenidate and breast-feeding. Ann Pharmacother. 2006;40(10):1890-1. [PMID: 16940409]. 

Haervig KB, Mortensen LH, Hansen AV, Strandberg-Larsen K. Use of ADHD medication during pregnancy from 1999 to 2010: a Danish register-based study. Pharmacoepidemiology Drug Saf. 2014;23(5):526-33. [PMID: 24590619]. 

Hazan A, Kaduri NB, De-Haan T, Kohn E, Berlin M, Berkovitch M. I am a law student treated with amphetamines for Attention Deficit Hyperactive Disorder (ADHD): Can I breastfeed my child? A pilot study. Neurotoxicol Teratol. 2023;Conference: 34th ENTIS conference. Dublin Ireland. 98(no pagination). [EMBASE -2025482144]].  

Huybrechts KF, Broms G, Christensen LB, Einarsdottir K, Engeland A, Furu K, et al. Association Between Methylphenidate and Amphetamine Use in Pregnancy and Risk of Congenital Malformations: A Cohort Study From the International Pregnancy Safety Study Consortium. JAMA Psychiatry. 2018;75(2):167-75. [PMID: 29238795]. 

Ilett KF, Hackett LP, Kristensen JH, Kohan R. Transfer of dexamphetamine into breast milk during treatment for attention deficit hyperactivity disorder. Br J Clin Pharmacol. 2007;63(3):371-5. [PMID: 17380592]. 

Jiang HY, Zhang X, Jiang CM, Fu HB. Maternal and neonatal outcomes after exposure to ADHD medication during pregnancy: A systematic review and meta-analysis. Pharmacoepidemiol Drug Saf. 2019;28(3):288-95. [PMID: 30585374]. 

Kallen B, Borg N, Reis M. The use of central nervous system active drugs during pregnancy. Pharmaceuticals (Basel). 2013;6(10):1221-86. [PMID: 24275849]. 

Kolding L, Ehrenstein V, Pedersen L, Sandager P, Petersen OB, Uldbjerg N, et al. Associations Between ADHD Medication Use in Pregnancy and Severe Malformations Based on Prenatal and Postnatal Diagnoses: A Danish Registry-Based Study. J Clin Psychiatry. 2021;82(1):05. [PMID: 33406323]. 

Koren G, Barer Y, Ornoy A. Fetal safety of methylphenidate-A scoping review and meta analysis. Reprod Toxicol. 2020;93:230-4. [PMID: 32169555]. 

Li L, Sujan AC, Butwicka A, Chang Z, Cortese S, Quinn P, et al. Associations of Prescribed ADHD Medication in Pregnancy with Pregnancy-Related and Offspring Outcomes: A Systematic Review. CNS Drugs. 2020;34(7):731-47. [PMID: 32333292]. 

National Institutes of Mental Health. Attention-Deficit/Hyperactivity Disorder Washington, DC: National Institutes of Mental Health; 2023 [updated September 2023; cited 2024 June 5]. Available from: https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd. 

Newport DJ, Hostetter AL, Juul SH, Porterfield SM, Knight BT, Stowe ZN. Prenatal Psychostimulant and Antidepressant Exposure and Risk of Hypertensive Disorders of Pregnancy. J Clin Psychiatry. 2016;77(11):1538-45. [PMID: 28076672]. 

Nguyen D, Smith LM, Lagasse LL, Derauf C, Grant P, Shah R, et al. Intrauterine growth of infants exposed to prenatal methamphetamine: results from the infant development, environment, and lifestyle study. J Pediatr. 2010;157(2):337-9. [PMID: 20570284]. 

Norby U, Winbladh B, Kallen K. Perinatal Outcomes After Treatment With ADHD Medication During Pregnancy. Pediatrics. 2017;140(6):e20170747. [PMID: 29127207]. 

Ornoy A, Koren G. The Effects of Drugs used for the Treatment of Attention Deficit Hyperactivity Disorder (ADHD) on Pregnancy Outcome and Breast-feeding: A Critical Review. Curr Neuropharmacol. 2021;19(11):1794-804. [PMID: 33245274]. 

Oro AS, Dixon SD. Perinatal cocaine and methamphetamine exposure: maternal and neonatal correlates. J Pediatr. 1987;111(4):571-8. [PMID: 3655989]. 

Posner J, Polanczyk GV, Sonuga-Barke E. Attention-deficit hyperactivity disorder. Lancet. 2020;395(10222):450-62. [PMID: 31982036]. 

Pottegard A, Hallas J, Andersen JT, Lokkegaard EC, Dideriksen D, Aagaard L, et al. First-trimester exposure to methylphenidate: a population-based cohort study. J Clin Psychiatry. 2014;75(1):e88-93. [PMID: 24502866]. 

Poulton AS, Armstrong B, Nanan RK. Perinatal Outcomes of Women Diagnosed with Attention-Deficit/Hyperactivity Disorder: An Australian Population-Based Cohort Study. CNS Drugs. 2018;32(4):377-86. [PMID: 29557079]. 

Ramer CM. The case history of an infant born to an amphetamine-addicted mother. Clin Pediatr (Phila). 1974;13(7):596-7. [PMID: 4834227]. 

Richardson JL, George N, Greenall AJ, Oliver AM, Stephens S, Hodson KK. Cardiac Malformation Risks Following Maternal First Trimester Methylphenidate Use. J Clin Psychiatry. 2023;84(4):15. [PMID: 37195811]. 

Roos A, Jones G, Howells FM, Stein DJ, Donald KA. Structural brain changes in prenatal methamphetamine-exposed children. Metab Brain Dis. 2014;29(2):341-9. [PMID: 24553878]. 

Roos A, Kwiatkowski MA, Fouche JP, Narr KL, Thomas KG, Stein DJ, et al. White matter integrity and cognitive performance in children with prenatal methamphetamine exposure. Behav Brain Res. 2015;279:62-7. [PMID: 25446763]. 

Rose SJ, Hathcock MA, White WM, Borowski K, Rivera-Chiauzzi EY. Amphetamine-Dextroamphetamine and Pregnancy: Neonatal Outcomes After Prenatal Prescription Mixed Amphetamine Exposure. J Atten Disord. 2021;25(9):1295-301. [PMID: 31931669]. 

Roussotte FF, Bramen JE, Nunez SC, Quandt LC, Smith L, O’Connor MJ, et al. Abnormal brain activation during working memory in children with prenatal exposure to drugs of abuse: the effects of methamphetamine, alcohol, and polydrug exposure. Neuroimage. 2011;54(4):3067-75. [PMID: 21040792]. 

Roussotte FF, Rudie JD, Smith L, O’Connor MJ, Bookheimer SY, Narr KL, et al. Frontostriatal connectivity in children during working memory and the effects of prenatal methamphetamine, alcohol, and polydrug exposure. Dev Neurosci. 2012;34(1):43-57. [PMID: 22472800]. 

Smith L, Yonekura ML, Wallace T, Berman N, Kuo J, Berkowitz C. Effects of prenatal methamphetamine exposure on fetal growth and drug withdrawal symptoms in infants born at term. J Dev Behav Pediatr. 2003;24(1):17-23. [PMID: 12584481]. 

Spigset O, Brede WR, Zahlsen K. Excretion of methylphenidate in breast milk. Am J Psychiatry. 2007;164(2):348. [PMID: 17267805]. 

Suarez EA, Bateman BT, Hernandez-Diaz S, Straub L, McDougle CJ, Wisner KL, et al. Prescription Stimulant Use During Pregnancy and Risk of Neurodevelopmental Disorders in Children. JAMA Psychiatry. 2024;81(5):477-88. [PMID: 38265792]. 

Szpunar MJ, Freeman MP, Kobylski LA, Rossa ET, Gaccione P, Chitayat D, et al. Risk of Major Malformations in Infants After First-Trimester Exposure to Stimulants: Results From the Massachusetts General Hospital National Pregnancy Registry for Psychiatric Medications. J Clin Psychopharmacol. 2023;43(4):326-32. [PMID: 37235505].  

Wong S, Ordean A, Kahan M. SOGC clinical practice guidelines: Substance use in pregnancy: no. 256, April 2011. Int J Gynaecol Obstet. 2011;114(2):190-202. [PMID: 21870360]. 

Wright TE, Schuetter R, Tellei J, Sauvage L. Methamphetamines and pregnancy outcomes. J Addict Med. 2015;9(2):111-7. [PMID: 25599434]. 

Disclaimer

First Exposure does not offer health care treatment. If you have an urgent question about your pregnancy or your baby’s health, you should contact your health care provider directly. If you don’t have a health care provider and you live in Ontario, you have a variety of health care options. In the case of an emergency, visit a hospital emergency room or call 911.