Hello everyone

The WABA secretariat has received a question from a pregnant woman 
with narcolepsy, passed on to me, about the safety of taking Ritalin 
while breastfeeding a newborn.  She is not taking Ritalin while 
pregnant, and is debating the pros and cons of resuming her 
medication once her baby is born, stating that she would like to 
breastfeed for 12 months.

I have the 2002 edition of Tom Hale's Medications and Mothers' 
Milk.  I've also checked the LACTNET archives, but the last posting 
on this topic was in April 2002.   Before I respond to WABA I'd like 
to check that the info I have (excerpted below) is not out of 
date.  If anyone can provide comments, or update me, this would be 
greatly appreciated.  Due to imminent deadlines, I'm skipping LACTNET 
for the time being, so would appreciate any reply being copied to my 
private email <[log in to unmask]> if at all possible.

Many thanks,

Pamela Morrison IBCLC
Co-coordinator, WABA Task Force on Breastfeeding and HIV
email: [log in to unmask]
-------------------------------
 From MMM 2002
Brand name:  Ritalin
Generic:         Methylphenidate Hydrochloride
Mild CNS Stimulant
AAP:  not reviewed
Lactation Risk Category:  Possibly hazardous, positive evidence of 
risk to a breastfed infant or to breastmilk production, but the 
benefits may be acceptable despite the risk to the infant.
Pharmacologic effects, similar to those of amphetamines, include CNS 
stimulation.  No current data available on transfer into 
breastmilk.  However, due to its small molecular weight and other 
kinetic data, assumption that it readily enters breastmilk and would 
be absorbed by the infant.  Prolonged release formulation (which 
mother takes) would extend the half-life.
Pediatric concerns: none reported, but observe for stimulation, 
insomnia, anorexia.

 From the LACTNET archives, Tom Hale wrote twice in November 1999 as follows:
1) I suppose that if the mom did not
breastfeed the infant for 5-8 hours after taking the med, then the
infants exposure would be lessened.  However, I would still observe
this infant closely for hyperactivity, insomnia, and anorexia.  At the
first sign of any of these, then I would question the use of Ritalin.

2) Methylphenidate(Ritalin):
As of now, we have no data on its transfer into human milk.  I suspect
small, but perhaps significant quantities might transfer.  Ritalin is well
absorbed, has a small molecular weight(233), and is lipophilic, which
accounts for its entering the brain compartment.  For these reasons alone,
it is likely to enter milk.  Now I don't really know if this is still enough
to produce side effects in an infant, but I would be cautious.  Observe for
stimulation and anorexia.  If your baby stays awake all night, then you know
the reason.

Tom's website indicates that he still welcomes nursing mothers taking 
this medication to contact him for inclusion in the International 
Registry for Lactation Research.

An English website provides the following info:
As well as narcolepsy in adults, Ritalin is used to treat attention 
deficit hyperactivity disorder (ADHD) in children.  It works by 
affecting some of the natural chemicals that are found in the brain. 
In particular, it increases the activity of chemicals called dopamine 
and noradrenaline in areas of the brain that play a part in 
controlling attention and behaviour.
Contraindications: Children under six years of age, marked anxiety, 
agitation or tension
Personal or family history of involuntary muscle spasms (twitches or 
tics), personal or family history of Tourette's syndrome 
(characterised by involuntary repetition of speech, in particular 
obscene or vulgar words), severe depression, people who have taken a 
monoamine-oxidase inhibitor antidepressant (MAOI) in the last 14 
days, current psychotic symptoms, eg abnormal thoughts or visions or 
hearing abnormal sounds, current drug or alcohol dependence, anorexia 
nervosa, glaucoma,
hyperthyroidism, irregular heart beats (arrhythmias), severe angina pectoris,
breastfeeding (there is no information available about the safety of 
this medicine during breastfeeding. For this reason, the manufacturer 
states that it should not be used during breastfeeding. Seek medical 
advice from doctor.)
Side effects: Nervousness, difficulty in sleeping (insomnia), 
decreased appetite,
headache, drowsiness, dizziness, abdominal pain, nausea and vomiting, 
dry mouth,
increased heart rate, awareness of heartbeat (palpitations), rise in 
blood pressure, skin reactions such as rash or itching, pain in the 
joints (arthralgia), hair loss (alopecia), weight loss or delayed 
growth with prolonged use, abnormal involuntary movements (twitching 
or tics), emotional highs and lows, irritability, depression, 
disturbances in the composition of the blood, liver problems

The US PDR website lists additional information:
Most important fact about Ritalin: Excessive doses of Ritalin over a 
long period of time can produce addiction. It is also possible to 
develop tolerance to the drug, so that larger doses are needed to 
produce the original effect.
It is recommended that methylphenidate be taken 30 to 45 minutes 
before meals. If the drug interferes with sleep, take the last dose 
before 6 p.m.
Side effects may include: Anorexia, diarrhea, fever, headache, 
inability to fall or stay asleep, nervousness, runny nose, sore throat
This drug should not be taken during treatment with drugs classified 
as monoamine oxidase inhibitors, such as the antidepressants Nardil 
and Parnate, nor for the 2 weeks following discontinuation of these drugs.
This drug should not be given to children under 6 years of age; 
safety and effectiveness in this age group have not been established. 
There is no information regarding the safety and effectiveness of 
long-term treatment in children. However, suppression of growth has 
been seen with the long-term use of stimulants, so doctor will watch 
child carefully while he or she is taking Ritalin.

Cautions:
Blood pressure should be monitored in anyone taking Ritalin, 
especially those with high blood pressure. Some people have had 
visual disturbances such as blurred vision while being treated with 
Ritalin. The use of Ritalin by anyone with a seizure disorder is not 
recommended. Caution is also advisable for anyone with a history of 
emotional instability or substance abuse, due to the danger of 
addiction. If abused, Ritalin may lead to tolerance, dependence, and 
psychotic episodes. Careful supervision is necessary during Ritalin 
withdrawal, since it may cause severe depression.

Possible food and drug interactions when taking Ritalin:  If Ritalin 
is taken with certain other drugs, the effects of either can be 
increased, decreased, or altered.
Possible drug interactions: It is especially important to check 
with  doctor before combining Ritalin with: antiseizure drugs such as 
phenobarbital, Dilantin and Mysoline,
antidepressant drugs such as Tofranil, Anafranil, Norpramin, and 
Effexor, blood thinners such as Coumadin, Clonidine (Catapres-TTS), 
drugs that restore blood pressure, such as EpiPen, Guanethidine 
(Ismelin), MAO inhibitors, the antidepressants Nardil and Parnate,
Phenylbutazone.

Special information if you are breastfeeding: If Ritalin is essential 
to your health, your doctor may advise you to discontinue nursing 
your baby until your treatment with Ritalin is finished.

Ritalin-SR, (taken by the mother) These tablets keep working for 8 
hours. They may be used in place of Ritalin tablets if they deliver a 
comparable dose over an 8-hour period.

Symptoms of Ritalin overdose (in children - ?? possible in babies of 
mothers who take Ritalin??) may include: agitation, confusion, 
convulsions (may be followed by coma), delirium, dryness of mucous 
membranes, enlarging of the pupil of the eye, exaggerated feeling of 
elation, extremely elevated body temperature, flushing, 
hallucinations, headache, high blood pressure, irregular or rapid 
heartbeat, muscle twitching, sweating, tremors, vomiting.
------------------------

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