What nonstimulant medication is safe for a postpartum woman with a history of Attention Deficit Hyperactivity Disorder (ADHD) or depression who is breastfeeding?

Nonstimulant Medications for ADHD in Breastfeeding

Bupropion is the preferred nonstimulant option for breastfeeding mothers with ADHD, particularly when co-occurring depression is present, though caution is warranted due to limited data and two case reports of seizures in breastfed infants. 1

Primary Nonstimulant Options

Bupropion (First-Line Nonstimulant)

• Bupropion can be considered as an alternative for individuals requiring treatment for co-occurring ADHD and depression, given available safety data in the perinatal period. 1
• Start with 100-150 mg daily (SR formulation) or 150 mg daily (XL formulation), titrating to maintenance doses of 100-150 mg twice daily (SR) or 150-300 mg daily (XL), with a maximum of 450 mg per day. 1
• Bupropion is present in human milk and has been detected in infant serum at very low levels (sometimes undetectable). 1
• Very limited breastfeeding data exists (only 21 cases documented). 1
• Two case reports of seizures in breastfed infants have been documented, though causality remains uncertain. 1
• Generally, no adverse events have been reported in most cases. 1
• Monitor infants carefully for vomiting, diarrhea, jitteriness, sedation, and/or seizures. 1
• Important limitation: Bupropion is not as efficacious as stimulants for treating ADHD. 1

Atomoxetine (Use with Caution)

• Overall caution is advised for atomoxetine during breastfeeding. 1
• No published studies of atomoxetine use while breastfeeding exist. 1
• Based on pharmacokinetics (low molecular weight, long half-life), atomoxetine will likely be present in human milk. 1
• The effects on nursing infants are unknown, and current references advise caution. 1
• The FDA drug label confirms no data exists on atomoxetine presence in human milk or effects on breastfed children. 2

Alpha-2 Agonists (Limited Data, Use with Extreme Caution)

Clonidine:

• Overall caution is advised with very limited published data. 1
• Clonidine is found in human milk and detectable in infant serum following breastfeeding exposure. 1
• Milk-to-plasma (M:P) ratio reported as 2 with relative infant dose (RID) up to 7.1%. 1
• Majority of cases reported no adverse effects, but one case report documented an infant developing drowsiness, hypotonia, suspected generalized seizures, and episodes of apnea (exposed to 0.15 mg daily; symptoms resolved within 24 hours of breastfeeding cessation). 1
• Monitor infants for drowsiness, hypotonia, vomiting, diarrhea, jitteriness, sedation, and/or seizures. 1

Guanfacine:

• Overall caution is advised. 1
• No published studies of guanfacine use while breastfeeding exist. 1
• Alternative agents would be preferred. 1

Viloxazine:

• Overall caution is advised. 1
• No published studies of viloxazine use while breastfeeding exist. 1
• Not currently available in Canada; approved in the United States for children and adolescents aged 6 and older only. 1

Clinical Decision Algorithm

Step 1: Assess Clinical Need

• Determine if ADHD medication is essential for daily functioning during the postpartum period. 1
• Consider whether co-occurring depression is present. 1

Step 2: Select Medication Based on Clinical Profile

• If co-occurring depression: Bupropion is the preferred nonstimulant option. 1
• If ADHD only without depression: Consider methylphenidate (stimulant with excellent breastfeeding safety data, RID <1%) as an alternative to nonstimulants, as it may be safer than most nonstimulants. 1
• Avoid atomoxetine, guanfacine, and viloxazine due to complete absence of breastfeeding data. 1

Step 3: Implement Safety Monitoring

• For bupropion: Monitor infant for vomiting, diarrhea, jitteriness, sedation, and especially seizures. 1
• For clonidine (if used): Monitor for drowsiness, hypotonia, and respiratory symptoms. 1
• Ensure infants are gaining weight appropriately and meeting developmental milestones. 1
• Arrange early follow-up after hospital discharge. 3

Step 4: Optimize Dosing Strategy

• Use the lowest effective dose. 1
• Consider intermittent use on an as-needed basis to maximize functioning while reducing infant exposure. 1
• Time medication administration just after breastfeeding or before the infant's longest sleep period. 4, 5

Critical Caveats

Common Pitfall: Discontinuing necessary ADHD treatment due to fear of medication exposure can harm the mother-infant dyad more than continued treatment. 1 The consensus is that treatment should not be stopped if required for daily functioning. 1

Important Consideration: The evidence for nonstimulants during breastfeeding is substantially weaker than for stimulants (particularly methylphenidate). 1 If ADHD symptoms are severe and nonstimulants are insufficient, methylphenidate may actually represent a safer, better-studied option. 1

Bupropion Efficacy Limitation: While bupropion has the most breastfeeding data among nonstimulants, it is significantly less efficacious than stimulants for ADHD treatment. 1 Set realistic expectations with patients about symptom control.