Parenthood & Pregnancy

Considerations for People Who Have Hypersomnias

Published May 18, 2021
Revised March 7, 2022

Vetted by Our Medical Advisory Board

This content was developed by the Hypersomnia Foundation for use by person(s) who have hypersomnias (PWH), such as idiopathic hypersomnia (IH) or narcolepsy, in conjunction with their doctors. It is based on consultation with OB/GYN, pediatrics, sleep medicine and lactation experts and review of clinical findings in publications and at professional conferences.

We recommend that PWH and their doctors each familiarize themselves with the content in advance of an appointment to discuss specific concerns and questions. (For the clinician unfamiliar with IH, we also recommend review of our IH Summary and About IH web page.) It is always appropriate for the healthcare provider to be sensitive to their patient and their comfort regarding how they want to talk about their body. A simple way to begin that conversation is in introductions: “Hi, I’m Dr. X. I use ”she” and “her” pronouns. How would you like to be addressed?”

PWH confront many questions and challenges when making decisions about their health. The purpose of this content is to provide them and their doctors with information to help make informed choices. Hypersomnia genetics/inheritance patterns and symptoms and the medications commonly used in the management of hypersomnias may affect decisions regarding parenthood, pregnancy, and human milk feeding. It is important for PWH, with the help of their doctors, to seriously consider whether or not their personal symptoms and their severity and response to treatment are compatible with parenthood and/or pregnancy (also considering outside resources like financial and family support). Plenty of PWH are parents (whether via pregnancy, adoption, etc.), but for others, the severity of symptoms may make parenthood inaccessible. Reviewing Personal Journey Stories of other PWH may be helpful.

See also our related page, “Hormonal Therapy, Birth Control & Menstruation: Considerations for People Who Have Hypersomnias,” which covers the following topics:

  • Continuous Hormonal Therapy to Reduce Fatigue From Iron Deficiency Anemia
  • Modafinil/Armodafinil/Pitolisant & Birth Control (Including Emergency Contraception)
  • Modafinil/Armodafinil/Pitolisant  & Hormonal Therapy (Estrogen/Progesterone/Testosterone)

Inheritance/Risk to Offspring

Idiopathic Hypersomnia
Limited studies suggest that about one third of people with IH have a family member with similar symptoms, suggesting a genetic component. Familial frequency and inheritance patterns, if any, are largely unknown. Patterns of prolonged sleep appear familial, but can be difficult to distinguish from IH. (Read more HERE.) 

Narcolepsy
Several family studies including hundreds of individuals with narcolepsy have shown that it is rare for family members to have the same diagnosis. Experts believe the likelihood of offspring also being affected is 1-2%. (See related slides from Dr. Arnulf’s 2018 conference presentation HERE.) However, since sleepiness and prolonged sleep seem to be at least partially familial, people with narcolepsy may also be more likely to have children with other sleep disorders. The details are not yet known. (See Daly 1959 and Masri 2012.)

Medical/Parental Leave & Accommodations

Some people who have IH or narcolepsy feel more wakeful during pregnancy, probably because of changes in hormone levels. Others feel more tired and/or sleepy than usual, and of course discontinuing their medications may further worsen this. Work or school accommodations or medical leave may be necessary if symptoms prove too debilitating (whether that is while trying to conceive, during pregnancy, and/or after pregnancy). Prior to conceiving, a PWH should be familiar with their short- and long-term disability options, in case disability income proves necessary.

Treatment During Conception & Pregnancy

Ideally, PWH should review their treatment regimen with their provider prior to becoming pregnant, because many teratogenic effects (causing birth defects) occur early in pregnancy, as the organs begin to form (organogenesis). Because both pregnancy and parenthood while living with a chronic disease can be more difficult, it may also be helpful to consider counseling with a goal to maximize coping skills. Additionally, hypersomnia support groups may help PWH feel supported and less alone as they go through this complex decision-making process and significant life change.

It is also important to watch for additional sleep disorders that can arise during pregnancy, such as sleep apnea and restless legs syndrome. Both typically resolve quickly postpartum. (Read more HERE and HERE.) And any pregnancy-induced changes that can lead to worsened fatigue/sleepiness should also be extra-carefully monitored in PWH. These include iron, b12, and folate levels. (Read more HERE.)

Recommendations for using or stopping medications during conception and pregnancy are developed by comparing rates of birth defects. Even without medications, the rate of birth defects is about 2% in the general population. Registries track pregnancies to determine if the likelihood of birth defects is higher when the pregnant person is taking specific medications. If a medication is continued during pregnancy, it is very helpful to report this in pregnancy registries, as doing so provides valuable information to help future pregnancies. The U.S. FDA maintains a list of these pregnancy registries.

Unfortunately, little is currently known of the teratogenic effects of many medications commonly used to treat hypersomnias. Until more is known, the only reliable option to avoid risk from medications is to not take any such medications, especially during organogenesis. For some people, completely stopping one or more medications may not be acceptable, especially in cases of sleep disorders. Poor quality of life, depression, inability to drive, unemployment, and other challenges may arise as a result. Only the PWH can decide if the risks of these medications during pregnancy are justified compared to the risks of stopping the medications.

  • Strategies for Reducing Medication Risks

If a PWH and their doctors decide that taking medications during pregnancy is warranted, here are a few strategies for reducing risk:

    • Seek prenatal care as soon as possible, ideally before attempting conception.
    • Medications may affect fetal development at any time throughout the pregnancy. However, organogenesis occurs during the first trimester, making it especially important to consider avoiding medications with unknown risk during this timeframe. Therefore, it is also important to avoid these medications while trying to conceive (see below: Medications Prior to Conception).
    • Some medications can negatively affect labor and newborn behavior. This risk may be minimized by reducing medication dose to the lowest effective, or by discontinuing, late in pregnancy.
    • It may be unclear if adverse effects are connected with dose, but it is prudent to stabilize on the lowest effective dose as soon as possible.
    • Insomuch as some medications can adversely affect fetal growth, serial ultrasounds are necessary to estimate fetal size, typically every 4 weeks. At least in theory, if suboptimal growth is detected, reducing the dose or discontinuation may remedy this.
    • As long as fetal growth is adequate, daily kick counts should suffice for fetal monitoring. If fetal kick counts become low, hospitalization for further evaluation is advised, because the low count may indicate poor fetal oxygenation or altered acid/base status. Pregnant people taking medications may become very familiar with whether and how their medication affects their baby’s behavior, and this information is important for that evaluation. Although medications may affect fetal behavior, often in a predictable way, there is no need to change medications to affect fetal kick count. Rather, it is important to find any other causes of a reduced count.
  • Pregnancy Risk Profiles of Medications

In general, medications should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Below are short summaries of the pregnancy risk profiles of medications commonly used to treat IH and narcolepsy. Because the decision-making process for each medication may be quite complex, a PWH and their OB/GYN may decide that referral to a Maternal-Fetal Medicine (MFM) specialist for further discussion of the potential pregnancy and human milk feeding risks of these medications is preferred. (See also the MFM and Human Milk Feeding sections below.)

  • The U.S. FDA label states that dextroamphetamine “should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.” 
  • Studies in non-human animals are mixed, with some showing embryotoxic effects at doses much higher than those used for humans. 
  • However, when used as prescribed in humans, these do not appear to increase the chance of birth defects. 
  • One study found a small effect on birth weight among pregnant people who continued to use their prescribed dextroamphetamine past 28 weeks. 
  • Although those who misuse amphetamines may have babies born with withdrawal symptoms such as jitteriness, sleepiness, and trouble breathing, this has not been reported in people who are taking dextroamphetamine as prescribed. 
  • Read more HERE.

SSRIs/SNRIs (e.g., Prozac/Effexor)

Clomipramine (e.g., Anafranil) 

  • Clomipramine is an antidepressant medication that can be used to treat cataplexy, as well as depression. 
  • Large human studies show no significant increased risk for birth defects or abnormal fetal growth. A smaller study showed a possible link with increased risk of heart defects in the baby, but the absolute risk is very low. (Read more HERE.) 
  • The dose used to treat cataplexy (10-50 mg) is significantly lower than that used to treat depression (75-150 mg), which may help to reduce any risks.

Newborn Withdrawal From Antidepressants

Although newborns may experience withdrawal symptoms from antidepressants (including both clomipramine and SSRIs/SNRIs), there is no evidence that tapering off these medications in the third trimester improves infant outcomes. Also, stopping antidepressants risks precipitating a depression relapse or postpartum depression, particularly in high-risk individuals. And if these medications are being used to treat cataplexy, that symptom will likely worsen when stopping them. If antidepressants are used continuously through delivery, the newborn should be monitored closely and may need to spend a few extra days in a neonatal unit or a “kangaroo unit”. (Read more HERE.)

  • The U.S. FDA label states that clarithromycin should only be used in pregnancy when “no alternative therapy is appropriate.” 
  • Studies in non-human animals show increased birth defects. 
  • However, the studies on clarithromycin and human birth defects have overall been reassuring (Lexicomp 2021). 
  • A very large 2021 study showed a small possible risk for AVSD (cardiac atrioventricular septal defect) and possibly a small association with orofacial clefts (but that would require further testing to conclude).
  • Although the risk for congenital anomalies overall seems quite low, the risk for fetal loss within the first 12-14 weeks of pregnancy is consistently elevated across studies. Therefore, one may consider stopping clarithromycin during this time period, which is also the time for organogenesis. 
  • It is important to note these recommendations pertain to clarithromycin use as a short-course antibiotic. Presumably the risks could be greater for the off-label long-term use of higher doses (500-1000 mg twice daily) to treat hypersomnias. Also, one may need to consider clarithromycin’s effects on microbial flora, especially when used long-term.
  • The U.S. FDA label states that methylphenidate “should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.” 
  • Studies in non-human animals show no increase in birth defects. 
  • One large human study suggests a possible small increase in cardiac malformations in babies born to pregnant people taking methylphenidate. (See also: Reuters article about this study.) Another large study suggests a possible small increase in other types of birth defects: omphalocele, gastroschisis, and transverse limb deficiency. (It is important to remember that even with the small increases in relative risk seen in these studies, there is an even lower absolute risk of these birth defects.) Also, a 2020 Danish study showed no increase in risk with methylphenidate in nearly 1000 first-trimester exposures. 
  • When taken as prescribed, use of methylphenidate has not shown a risk of newborn withdrawal.
  • Read more HERE.
  • European and Canadian regulators recommend that modafinil/armodafinil should not be used during pregnancy: Health Canada safety information for Modafinil; 2019 EMA PRAC Recommendations; U.S. FDA label for Modafinil (see section 8 Use in Specific Populations). 
  • Studies in non-human animals show an increase in birth defects. 
  • A 2020 Danish study of 49 human pregnancies exposed to modafinil in the first trimester showed a greater than 3-fold increased risk of major birth defects. A 2020 study of 131 Norwegian and Swedish pregnancies exposed to modafinil in the first trimester showed no significant increase in major malformations; however, because modafinil use is so rare, the confidence intervals allow for the possibility of the greater than 3-fold risk as previously reported. A 2020 U.S. study of nearly 150 pregnancies exposed to modafinil/armodafinil in the first trimester, based on the U.S. pregnancy registry, indicates a 13% risk of major congenital malformations. In contrast, the prevalence of major congenital malformations in the general population is roughly 3%; therefore, this 13% risk is a greater than 4-fold increase in risk. Taken together, these studies indicate that there appears to be a significant increase in risk of birth defects from use of modafinil/armodafinil. (Read more HERE.)
  • If modafinil/armodafinil is taken at any point during pregnancy, it is still recommended to consider discontinuing it two weeks before the expected delivery, so that the medication can be cleared from the baby’s system before birth.
  • Studies in non-human animals show an increase in birth defects. 
  • There are no well-controlled studies in humans. 
  • According to the U.S. FDA label, “Available case reports from clinical trials and postmarketing reports with . . . use in pregnant women have not determined a drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes.” There is not yet further data, but there is an ongoing pregnancy exposure registry, in which PWH exposed to pitolisant during pregnancy are encouraged to enroll (1-800-833-7460).
  • Studies of sodium oxybate in non-human animals reveal an increased incidence of early miscarriage, increased stillbirths, increased number of deaths in baby rats once born, and decreased growth rates in those baby rats that survived. 
  • There are no well-controlled studies in humans, but it appears that exposure to sodium oxybate during the first trimester may be associated with an increased risk of fetal loss. (Read more HERE and via section 8 of the U.S. FDA label for sodium oxybate.) 
  • The indication itself (severe sleepiness and cataplexy) suggests that the benefit to the pregnant person, “under close medical supervision, may outweigh the unknown risk to the embryo-fetus” (Sodium Oxybate Briggs Drugs 2017).
  • The U.S. FDA label states that available data is not yet sufficient to determine human risk. 
  • Studies in non-human animals showed birth defects only at doses substantially higher than the equivalent human dose. 
  • There is an ongoing pregnancy exposure registry, in which PWH exposed to solriamfetol during pregnancy are encouraged to enroll (1-877-283-6220).
  • Medications Prior to Conception

On average, it takes six months to become pregnant. It can be difficult to give up medications completely during the months, or perhaps years, that may pass before pregnancy begins. Instead of stopping all medications completely, it is possible to take medications during some days of the month when there is very low risk to a potential pregnancy. During the early part of the cycle before the egg has formed, been fertilized and implanted in the uterus, there are a number of days where medications may be taken safely.

Medications in the blood of the pregnant person do not pass to the embryo until the embryo is implanted on the wall of the uterus. Ideally, a PWH should be aware of their menstrual cycle, specifically frequency, timing, and duration of menses. In so doing, the timing of ovulation can also be determined. This would also allow identification of a “safety zone” when taking medications with unknown risk is safe, as there should be no exposure to a developing embryo if conception does indeed occur.

The following table (Table 1) shows the days to elimination and “safety zone” period for common IH and narcolepsy medications with varying half-lives.

  • Medication elimination is considered to be sufficiently complete after 5 half-lives have passed.
  • This table assumes a regular 28-day cycle with ovulation on Day 14. Day 1 of the cycle is the first day of menstruation. If the cycle is longer, or if temperature tracking demonstrates that ovulation is later than Day 14, the safety zone may be extended by a few more days. If the cycle is shorter, or ovulation is earlier, the safety zone must be reduced.
  • It usually takes 8 days from ovulation for a fertilized embryo to implant in the uterus. (Note that implantation can more rarely happen as early as 6 days or as late as 12 days, so a PWH may choose to use the more conservative 6 days to calculate their safety zone.) One can calculate the day of implantation by adding 8 to the day of ovulation (in this regular cycle scenario, that is Day 22).
  • Therefore, the medication needs to have been eliminated by the end of Day 21 for safe implantation on Day 22. To calculate the safety zone days, subtract the number of days needed to eliminate the medication from Day 21.

Table 1

MedicationHalf-LifeDays to EliminateSafety Zone Days
Adderallup to 14 hours31 – 18
Clarithromycinup to 9 hours21 – 19
Methylphenidateabout 3.5 hoursless than 11 – 20
Modafinil/Armodafinilabout 15 hours31 – 18
Pitolisant7.5 to 24.2 hoursup to 51 – 16
Ritalin LA1.3 – 7.7 hoursup to 21 – 19

Sodium (& Lower-Sodium) Oxybate

0-1 hourless than 11 – 20
Solriamfetolabout 7.1 hours21 – 19

For example, a PWH (with a regular 28-day cycle with ovulation on Day 14) taking modafinil may take it for 18 days starting on the first day of menstruation. By stopping it after Day 18, there is enough time (3 days) for it to clear their system by the end of Day 21, before the most likely date of implantation on Day 22. If pregnancy occurs, the embryo should never have been exposed to modafinil. If conception does not occur, menstruation will start and modafinil may be taken for another 18 days. In the case of early bleeding, one should wait until Day 1 of one’s next predicted menstrual cycle and then take a highly sensitive urine pregnancy test before deciding to restart one’s meds.

Irregular Menstruation
If the menstrual cycle is irregular, then ovulation and therefore fertilization and implantation cannot be predicted reliably. Therefore, it is safest to assume a very short cycle of 21 days, in which ovulation occurs around Day 7 and implantation 8 days later at Day 15 (as opposed to Day 22 for the table above). In this case, medications need to be eliminated by the end of Day 14.

Role for Maternal-Fetal Medicine

Maternal-fetal medicine (MFM) is a subspecialty of obstetrics, devoted to the monitoring and management of “high-risk” pregnancies. “High-risk” may be defined in a number of ways, but typically implies any maternal and/or fetal condition or complication requiring monitoring and care above and beyond the routine, or the comfort level of a generalist obstetrician/gynecologist. This may include: 

  • ultrasounds to document the entirety of fetal anatomy and identify any anatomical anomalies (“birth defects”)
  • predicting or diagnosing chromosomal or genetic abnormalities
  • following fetal growth and observation of fetal behavior as a means of assessing wellbeing
  • a variety of forms of fetal monitoring in the third trimester, especially for those pregnancies with an increased risk for stillbirth. 

Although PWH can experience uneventful (“low-risk”) pregnancies, the sonographic and fetal monitoring expertise provided by MFM can further increase the likelihood of good outcomes.

An MFM physician would also be able to provide counseling as soon as pregnancy is diagnosed or planned. They can help evaluate the potential risks of medications and medical conditions on pregnancy and human milk feeding, which may provide reassurance and/or guidance to the PWH and their prescribing doctor(s). MFM specialists can also perform an early ultrasound to establish a reliable due date, which allows for determining exact gestational age at any given point in time. 

Given the unclear association between the typical medications used to treat hypersomnias and birth defects, evaluating the fetal anatomy in a detailed fashion is important. This is also true for any pregnancy, as malformations can also occur in the absence of any medications. In other words, the routine evaluation for birth defects is just as relevant to the PWH as it is to any other. Being fully prepared for the birth of a newborn with a serious abnormality, such as a heart defect, provides a significant advantage to the family and pediatricians.

Similarly, and as mentioned earlier, fetal growth should also be monitored by ultrasound, typically every 4-6 weeks. Observing fetal behavior during these ultrasounds or by a fetal monitor is a means of evaluating blood flow and oxygen delivery to the fetus. As opposed to conditions such as obstructive sleep apnea, which can involve poor breathing efforts and jeopardized oxygenation to both pregnant person and fetus, this is not an issue for the fetal behavior of a PWH. Nonetheless, taking advantage of any scheduled ultrasound to ensure fetal well-being is prudent. However, observing fetal behavior does not allow for the diagnosis or prediction of withdrawal or abstinence syndrome from medications taken (or discontinued) during pregnancy.

In some cases, a generalist obstetrician/gynecologist may feel that a consultation with MFM is unnecessary, especially if they have experience with PWH or if the patient is otherwise healthy. Some generalists also perform ultrasounds, as well as fetal monitoring, in their offices, in which case referral would be furthermore unnecessary.

Delivery

Studies of obstetric outcomes have been conducted in people with narcolepsy in both the U.S. and Europe. In the U.S. study, there were no differences in route of delivery (spontaneous vs. induced vs. Cesarean), gestational age at delivery, or birth weight compared to a control population. In the European study, similar outcomes were noted, with the exception of route of delivery: people with narcolepsy with cataplexy were more likely to undergo Cesarean delivery.

Cataplexy during delivery is rare. Immediately following delivery, cataplexy may occur due to the heightened emotions typical of childbirth. Therefore, it may be prudent to take extra care when giving the baby to the PWH for the first time.

Because both hospitalization and anesthesia may affect hypersomnia symptoms and management strategies (including both medications and sleep schedules), it is also prudent to review the Hypersomnia Foundation’s Anesthesia, Hospitalization and IH Guide and to develop a personal Anesthesia/Hospital Care Plan well in advance of delivery or other hospitalization.   

Human Milk Feeding

Milk Production

There are many factors that can reduce milk production; these include:

  • Iron deficiency anemia.
  • Some birth control methods, especially those that contain estrogen (see La Leche League).
  • Leaving a sleepy baby to sleep for long periods.
  • Hypersomnias themselves may lead to reduced milk production if the sleep schedule of a PWH does not allow the frequent nursing or pumping required to establish a full milk supply. Any parent who is unable to establish their milk supply by removing milk via nursing or pumping at a minimum of 8 times in 24 hours will most likely have low milk supply. The more one nurses or pumps, the more milk one makes. Therefore, it is prudent to carefully track the number (aim for 10 and try to ensure 8 if that is possible). It can also be helpful to work toward full emptying, whether via direct feeding or pumping (pumping 5-10 minutes past the end of milk spraying can help ensure adequate emptying and promote higher supply).

Resources:

Regardless, many parents are highly motivated to give their milk and are encouraged and delighted to provide whatever milk they can produce. PWH may particularly benefit from talking with a lactation consultant for additional support, as there are numerous other helpful strategies and tools ​to aid and ease milk production. 

Formula and Donor Milk

For many reasons, including the potentially extra difficulties for PWH in milk production and the possible risks of infant exposure from medication use (see below), PWH may choose to feed with formula, either completely or as a supplement. If one can access pasteurized donor milk, this option may also be considered (see hmbana.org). PWH may also consider milk sharing, which has its own additional risks (read more HERE.) It is important for each individual to weigh the benefits of human milk feeding against the risks and difficulties. 

Medications and Human Milk

Many medications pass through to human milk, whether one is nursing or pumping. As is the case during pregnancy, data on medication safety and compatibility with human milk feeding is emerging. For all medications, it is important to weigh the potential risks of infant exposure via human milk against the known benefits to the infant of human milk feeding and the benefits of the medication for the parent’s symptom control. Each parent should make their own informed decision after discussion with their healthcare providers. The following medications are believed to be compatible based on very small studies:

  • When taken as directed, the relative infant dose is less than 10% and within a range that is generally accepted as being ‘safe’ in the short term. 
  • “A small study of four infants whose mothers were taking dextroamphetamine for ADHD found no problems in the health and growth of those infants up to 6-10 months of age. Babies that are born preterm and those under two months of age should be monitored for decreased appetite, sleeplessness, and irritability. … Some evidence suggests that large doses of dextroamphetamine could lower milk supply.” (Read more HERE.)
  • The relative infant dose is less than 1%, which is considered acceptably safe. 
  • However, antibiotics that are present in human milk may cause non-dose-related changes in bowel flora. Therefore, infants should be monitored for thrush, diarrhea, or other GI disturbances. 
  • “In addition, an increased risk for infantile hypertrophic pyloric stenosis (IHPS) may be present in infants who are exposed to macrolides [such as clarithromycin] via [human] milk, especially during the first two weeks of life … however, data are conflicting …”
  • (Clarithromycin Lexicomp, 2020.)
  • Studies of doses to treat depression (75-150 mg) find acceptably-low infant dosages. 
  • The typical dose of 10-50 mg used to treat cataplexy is substantially lower and would pass even less medicine to the infant. 
  • (Read more HERE.)
  • When taken as prescribed, methylphenidate, which passes into human milk at low levels, is not expected to cause problems. 
  • “Reports on five nursing infants, whose mothers were taking doses from 35-80mg per day, reported normal infant weight, sleeping and feeding habits.” (Read more HERE.)

A single case of a nursing parent taking modafinil showed that the infant received a weight-adjusted infant dosage of 5.3% of the parental dosage, which is considered acceptably safe.

Given sodium oxybate’s short half-life and limited time in human milk, the following precautions make it compatible with human milk feeding:

  • In the evening, nurse or pump just before taking the first dose.
  • Wait at least 5 hours after the final dose before nursing or saving pumped milk again. (Any milk pumped between the first dose and 5-6 hours after the final dose should be discarded. However, this pumping should serve to help improve overall milk supply. It is prudent to pre-label bottles used during this time as unsafe, so that the milk is definitely discarded.)
  • During the night, feed the baby with formula (or safely-pumped human milk).

For a summary of studies of sodium oxybate and human milk feeding, see the NIH’s Drugs & Lactation Database. The half-lives for both sodium and lower-sodium oxybate are reported for their metabolite (GHB). Therefore, it is likely that lower-sodium oxybate behaves similarly to sodium oxybate in human milk, but that has not yet been studied.

The following medications do not yet have data on presence in human milk. However, they are present in rat milk, making it likely that they will be present in human milk.

  • Pitolisant (e.g., Wakix)
  • Solriamfetol (e.g., Sunosi)

Infant Care

Most parents with a new baby are exhausted; a parent with a hypersomnia is usually even more so. In a European study of 249 mothers with narcolepsy, 60% reported that care of their baby was adversely affected by their symptoms. PWH should take advantage of any periods of infant sleep to sleep themselves. 

Others in the household may be required to respond to the infant when the PWH is sleeping, as the PWH may not awaken despite crying, especially if the PWH’s sleep is very deep or if they take an oxybate medication. The same can also be said during episodes of sleep drunkenness (i.e, severe sleep inertia), a common symptom of IH in which there is an extreme and prolonged difficulty fully awakening, associated with an uncontrollable desire to go back to sleep, which can be accompanied by automatic behavior (performing tasks without conscious self-control and with partial or total loss of memory), disorientation, confusion, irritability, and poor coordination. 

Depending on symptoms and whether one has decided to stop one’s medications or reduce their doses, a PWH may need significant help with the infant. Ultimately, a parent with IH or narcolepsy is best served by uninterrupted, restful sleep whenever possible, optimization of their treatment regimen, and familial and other help.

Familial support may be needed to help prevent injury, such as while ascending or descending stairs or while bathing, especially in people with cataplexy, sudden-onset sleep, or severe sleepiness that is not well-controlled. Guidelines for parents with epilepsy may be helpful to review, since many of the risks are similar.

Some PWH fear that they may fall asleep or experience cataplexy while nursing or bottle feeding. PWH and their doctors will need to consider the level of this risk, depending on how well symptoms are controlled. Some PWH may experience sudden unexpected lapses into sleep, but some are able to prepare for a sleep session when their sleepiness escalates. 

Potential ways to reduce these risks include:

  • Getting PWH symptoms as well-controlled as possible
  • Feeding while seated on the floor (perhaps on a very firm cushion or mattress)
  • Feeding while lying on a firm mattress (without any bedding ​other than a tight-fitting bottom sheet)
  • Having another alert adult in the room during the feeding 
  • Having a partner or another helper provide nourishment in the form of pumped milk, formula or pasteurized donor milk (see hmbana.org)

Some parents may choose to feed their child while wearing a sling or similar baby carrier. There is some risk, particularly if the wearer is not able to be awake/alert to movements their baby is making. (Read more HERE.)

According to safe co-sleeping guidelines, people “taking sedatives, medications or drugs, or intoxicated from alcohol or other substances, or otherwise excessively unable to arouse easily from sleep should not cosleep on the same surface with the infant.” SIDS research has documented the risk of infant entrapment on upholstered chairs, couches and on beds with extra pillows and bedding when adults fall asleep.

When the parent is sleeping normally the risk is less (parent is able to rouse), but when sleep is altered by any means, it is a greater risk. Although not specifically addressed in the co-sleeping guidelines, hypersomnias may increase the risk of co-sleeping because parents may be less able to rouse. After six months the risk of SIDS is greatly decreased, although the SIDS category still covers infant deaths in the first year of life. (Read more HERE.)

According to the American Academy of Pediatrics 2016 recommendations:

“The safest place for an infant to sleep is on a separate sleep surface designed for infants close to the parents’ bed. However, the AAP acknowledges that parents frequently fall asleep while feeding the infant. Evidence suggests that it is less hazardous to fall asleep with the infant in the adult bed than on a sofa or armchair, should the parent fall asleep. It is important to note that a large percentage of infants who die of SIDS are found with their head covered by bedding. Therefore, no pillows, sheets, blankets, or any other items that could obstruct infant breathing or cause overheating should be in the bed. Parents should also follow safe sleep recommendations outlined elsewhere in this statement. Because there is evidence that the risk of bed-sharing is higher with longer duration, if the parent falls asleep while feeding the infant in bed, the infant should be placed back on a separate sleep surface as soon as the parent awakens. …

There are specific circumstances that, in case-control studies and case series, have been shown to substantially increase the risk of SIDS or unintentional injury or death while bed-sharing, and these should be avoided at all times: …

[1] if parents choose to feed their infants younger than 4 months in bed, they should be especially vigilant to not fall asleep …

[2] Bed-sharing with someone who is impaired in his or her alertness or ability to arouse because of fatigue or use of sedating medications (eg, certain antidepressants, pain medications) or substances (eg, alcohol, illicit drugs). …”

Example Brand Names of Generic Antidepressants Used for Cataplexy or Depression
  • SSRI medications
    • Citalopram: Celexa
      • Escitalopram: Lexapro
    • Fluoxetine: Prozac, Sarafem
    • Paroxetine: Brisdelle, Paxil, Pexeva
    • Sertraline: Zoloft
  • SNRI medications
    • Duloxetine: Cymbalta, Drizalma Sprinkle, Irenka
    • Milnacipran: Savella
      • Levomilnacipran: Fetzima
    • Venlafaxine: Effexor, Effexor XR
      • Desvenlafaxine: Pristiq, Khedezla
  • Clomipramine: Anafranil

Acknowledgements

  • Based on the 2018 HF Conference Presentation by Isabelle Arnulf, MD, PhD, HF Medical Advisory Board Member
  • Maternal-Fetal Medicine review and vetting by Christopher T. Lang, MD
  • OB/GYN review and vetting by Elezabeth Young, MD
  • Sleep Medicine review and vetting by Lynn Marie Trotti, MD, MSc and Isabelle Arnulf, MD, PhD, Members, HF Medical Advisory Board
  • Pediatric review and vetting by Kiran Maski, MD, MPH, HF Medical Advisory Board Member
  • Lactation Consultant review and vetting and additional contributions by Valerie Vanderlip, IBCLC 
  • Lactation Consultant review and vetting by Sarah Briggs Williams RN, BSN, IBCLC
  • Contributions by Jodi Godfrey, PhD

Reviewed and approved by Hypersomnia Foundation’s Board of Directors and Medical Advisory Board.

  1. Ali, Mohsin, et al. “Idiopathic Hypersomnia: Clinical Features and Response to Treatment.” Journal of Clinical Sleep Medicine, vol. 05, no. 06, 2009, pp. 562–568, doi:10.5664/jcsm.27658. Free Full Text.
  2. Anderson, Kirstie N., et al. “Idiopathic Hypersomnia: A Study of 77 Cases.” Sleep, vol. 30, no. 10, 2007, pp. 1274–1281, doi:10.1093/sleep/30.10.1274. Free Full Text.
  3. “Anesthesia, Hospitalization & Emergency Planning.” Hypersomnia Foundation, 19 July. 2021, www.hypersomniafoundation.org/anesthesia-and-ih/.
  4. “Antidepressants: Safe during Pregnancy?” Mayo Clinic, Mayo Foundation for Medical Education and Research, 8 Jan. 2020, www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/antidepressants/art-20046420.
  5. Aurora, Sanjay, et al. “Evaluating Transfer of Modafinil Into Human Milk During Lactation: A Case Report.” Journal of Clinical Sleep Medicine, vol. 14, no. 12, 2018, pp. 2087–2089, doi:10.5664/jcsm.7546. Free Full Text.
  6. Barker, Emily C, et al. “GHB Levels in Breast Milk of Women with Narcolepsy with Cataplexy Treated with Sodium Oxybate.” Sleep Medicine, vol. 36, 2017, pp. 172–177, doi:10.1016/j.sleep.2017.05.008. Abstract & Request Full Text.
  7. Bassetti, C. “Idiopathic Hypersomnia. A Series of 42 Patients.” Brain, vol. 120, no. 8, 1997, pp. 1423–1435, doi:10.1093/brain/120.8.1423. Free Full Text.
  8. “Benefits of Breastfeeding: For Baby and Mom.” Cleveland Clinic, https://my.clevelandclinic.org/health/articles/15274-the-benefits-of-breastfeeding-for-baby–for-mom. Accessed February 17, 2021.
  9. “Birth Control.” La Leche League International, 6 Aug. 2020, www.llli.org/breastfeeding-info/birth-control/.
  10. Black, J, et al. “Medical Comorbidity in Narcolepsy: Findings from the Burden of Narcolepsy Disease (BOND) Study.” Sleep Medicine, vol. 33, 2017, pp. 13–18, doi:10.1016/j.sleep.2016.04.004. Abstract & Request Full Text.
  11. Busardò, Francesco Paolo, et al. “Determination of GHB Levels in Breast Milk and Correlation with Blood Concentrations.” Forensic Science International, vol. 265, 2016, pp. 172–181, doi:10.1016/j.forsciint.2016.02.020. Abstract & Request Full Text.
  12. Byatt, N, et al. “Antidepressant Use in Pregnancy: a Critical Review Focused on Risks and Controversies.” Acta Psychiatrica Scandinavica, vol. 127, no. 2, 2012, pp. 94–114, doi:10.1111/acps.12042. Free Full Text.
  13. “Can You Take Xyrem While Pregnant?” Drugs.com, www.drugs.com/medical-answers/you-xyrem-pregnant-3543658/. Accessed February 17, 2021.
  14. Cesta, Carolyn E, et al. “Incidence of Malformations After Early Pregnancy Exposure to Modafinil in Sweden and Norway.” Jama, vol. 324, no. 9, 2020, p. 895, doi:10.1001/jama.2020.9840. Abstract & Request Full Text.
  15. Clarithromycin (Pregnancy and Lactation, In-Depth). Lexicomp. Hudson, OH: Lexicomp, 2021. https://online.lexi.com/lco/action/doc/retrieve/docid/74/303804. Updated October 16, 2020. Accessed January 22, 2021.
  16. “Clomipramine (Anafranil) Use While Breastfeeding.” Drugs.com, www.drugs.com/breastfeeding/clomipramine.html. Accessed January 15, 2021.
  17. “Clomipramine” Bumps – Best Use of Medicine in Pregnancy, www.medicinesinpregnancy.org/Medicine–pregnancy/Use-of-clomipramine-in-pregnancy/. Accessed January 15, 2021.
  18. “Clomipramine.” Drugs and Lactation Database (LactMed) [Internet], U.S. National Library of Medicine, 31 Oct. 2018, www.ncbi.nlm.nih.gov/books/NBK501175/.
  19. Commissioner, Office of the. “Pregnancy Registries.” U.S. Food and Drug Administration, FDA, www.fda.gov/pregnancyregistries. Accessed June 5, 2020.
  20. Crat. “Centre De Référence Sur Les Agents Tératogènes Chez La Femme Enceinte.” CRAT, www.lecrat.fr/. Accessed June 5, 2020.
  21. “DailyMed – BIAXIN- Clarithromycin Tablet, Film Coated BIAXIN- Clarithromycin Tablet, Film Coated, Extended Release BIAXIN- Clarithromycin Granule, for Suspension.” U.S. National Library of Medicine, National Institutes of Health, dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2e899f4a-a2e9-445c-a0ed-6ad811e997e6. Accessed June 5, 2020.
  22. “DailyMed – DEXTROAMPHETAMINE…” U.S. National Library of Medicine, National Institutes of Health, dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c907301d-e24d-9609-5529-fed14f94549f. Accessed June 5, 2020.
  23. “DailyMed – Methylphenidate…” U.S. National Library of Medicine, National Institutes of Health, dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=6281ca7c-2aec-4f14-b7e4-82401a701c96. Accessed June 5, 2020.
  24. “DailyMed – MODAFINIL Tablet.” U.S. National Library of Medicine, National Institutes of Health, dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0c634b7a-cce6-4c3d-9c49-63593755f49c. Accessed June 5, 2020.
  25. “DailyMed – SUNOSI- Solriamfetol Tablet, Film Coated.” U.S. National Library of Medicine, National Institutes of Health, dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2f30ab12-20e1-4391-9359-24b23a21578d. Accessed March 9, 2021.
  26. “DailyMed – WAKIX- Pitolisant Hydrochloride Tablet, Film Coated.” U.S. National Library of Medicine, National Institutes of Health, dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8daa5562-824e-476c-9652-26ceef3d4b0e. Accessed June 5, 2020.
  27. “DailyMed – XYREM- Sodium Oxybate Solution.” U.S. National Library of Medicine, National Institutes of Health, dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=926eb076-a4a8-45e4-91ef-411f0aa4f3ca. Accessed June 5, 2020.
  28. “DailyMed – XYWAV (Calcium, Magnesium, Potassium, and Sodium Oxybates Solution.” U.S. National Library of Medicine, National Institutes of Health, dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1e0ae43a-037f-42af-8e23-a0e51d75abe8. Accessed Sept. 27, 2021.
  29. Daly, David D., and Robert E. Yoss. “A Family With Narcolepsy.” Staff Meetings of the Mayo Clinic, vol. 34, no. 12, 1959, pp. 313-319.
  30. Damkier, Per, and Anne Broe. “First-Trimester Pregnancy Exposure to Modafinil and Risk of Congenital Malformations.” Jama, vol. 323, no. 4, 2020, p. 374, doi:10.1001/jama.2019.20008. Free Full Text.
  31. “Dextroamphetamine.” MotherToBaby, 29 May 2020, mothertobaby.org/fact-sheets/methamphetaminedextroamphetamine-pregnancy/. Accessed January 15, 2021.
  32. Fan, Heng et al. “Associations between macrolide antibiotics prescribing during pregnancy and adverse child outcomes in the UK: population based cohort study.” BMJ, 2020;368:m331. doi: https://doi.org/10.1136/bmj.m331. Free Full Text.
  33. “Fluoxetine.” Drugs and Lactation Database (LactMed) [Internet], U.S. National Library of Medicine, 16 Mar. 2020, www.ncbi.nlm.nih.gov/books/NBK501186/.
  34. Gashlin, Lauren Z., et al. “Treatment of Narcolepsy with Sodium Oxybate While Breastfeeding: A Case Report.” Breastfeeding Medicine, vol. 11, no. 5, 2016, pp. 261–263, doi:10.1089/bfm.2016.0025. Free Full Text.
  35. Government of Canada, Health Canada. “ALERTEC (Modafinil) and the Risk of Congenital Anomalies.” Recalls and Safety Alerts, 20 June 2019, healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2019/70201a-eng.php.
  36. Huybrechts, Krista F, et al. “Association Between Methylphenidate and Amphetamine Use in Pregnancy and Risk of Congenital Malformations.” JAMA Psychiatry, vol. 75, no. 2, 2018, p. 167, doi:10.1001/jamapsychiatry.2017.3644. Free Full Text.
  37. Hypersomniafoundation. “Dr. Isabelle Arnulf: Women and IH.” YouTube, 14 Apr. 2019, www.youtube.com/watch?v=L7TG5Z5rf3s.
  38. IBCLC, Author By Philippa Pearson-Glaze. “Reasons for Low Milk Supply.” Breastfeeding Support, 2 Sept. 2020, breastfeeding.support/reasons-low-milk-supply/.
  39. Johnson, Traci C. “Anemia in Pregnancy: Causes, Symptoms, and Treatment.” WebMD, 12 June 2020, www.webmd.com/baby/guide/anemia-in-pregnancy#1.
  40. Kaplan, Sigal, et al. “Pregnancy and Fetal Outcomes Following Exposure to Modafinil and Armodafinil During Pregnancy.” JAMA Internal Medicine, 2020, doi:10.1001/jamainternmed.2020.4009. Abstract & Request Full Text.
  41. Kay-Stacey, Margaret, and Hrayr P. Attarian. “Managing Sleep Disorders during Pregnancy.” Gender and the Genome, vol. 1, no. 1, 2017, pp. 34–45, doi:10.1089/gg.2016.0006. Abstract & Request Full Text.
  42. Pien, Grace W., and Richard J. Schwab. “Sleep Disorders During Pregnancy.” Sleep, vol. 27, no. 7, 2004, pp. 1405–1417., doi:10.1093/sleep/27.7.1405. Free Full Text.
  43. Kuczkowski, K. M. “Liquid Ecstasy during Pregnancy.” Anaesthesia, vol. 59, no. 9, 2004, pp. 926–926, doi:10.1111/j.1365-2044.2004.03925.x. Free Full Text.
  44. Leke, Aminkeng Zawuo, et al. “Macrolide and Lincosamide Antibiotic Exposure in the First Trimester of Pregnancy and Risk of Congenital Anomaly: A European Case-Control Study.” Reproductive Toxicology, vol. 100, 2021, pp. 101–108, doi:10.1016/j.reprotox.2021.01.006. Abstract & Request Full Text.
  45. “Link Between Depression Treatments and Birth Defects.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 16 July 2020, www.cdc.gov/pregnancy/meds/treatingfortwo/features/ssrisandbirthdefects.html.
  46. Masri, Tony J., et al. “Idiopathic Hypersomnia.” Sleep Medicine Clinics, vol. 7, no. 2, 2012, pp. 283–289., doi:10.1016/j.jsmc.2012.03.012. Request Full Text.
  47. Maurovich-Horvat, Eszter, et al. “Narcolepsy and Pregnancy: a Retrospective European Evaluation of 249 Pregnancies.” Journal of Sleep Research, vol. 22, no. 5, 2013, pp. 496–512, doi:10.1111/jsr.12047. Free Full Text.
  48. Mechelen, Jc Van, et al. “Severe Illicit Gamma-Hydroxybutyric Acid Withdrawal in a Pregnant Woman: What to Do?” BMJ Case Reports, vol. 12, no. 12, 2019, doi:10.1136/bcr-2019-230997. Free Full Text.
  49. “Medications and Pregnancy.” American Pregnancy Association, 13 Oct. 2019, americanpregnancy.org/medication/medication-and-pregnancy/.
  50. “Methylphenidate (Ritalin®, Concerta®).” MotherToBaby, 26 June 2020, mothertobaby.org/fact-sheets/methylphenidate/.
  51. Mignot, Emmanuel J. M. “A Practical Guide to the Therapy of Narcolepsy and Hypersomnia Syndromes.” Neurotherapeutics, vol. 9, no. 4, 2012, pp. 739–752, doi:10.1007/s13311-012-0150-9. Free Full Text.
  52. Mignot, E. “Genetic and Familial Aspects of Narcolepsy.” Neurology, vol. 50, no. Issue 2, Supplement 1, 1998, doi:10.1212/wnl.50.2_suppl_1.s16. Request Full Text.
  53. “Modafinil.” Drugs and Lactation Database (LactMed) [Internet], U.S. National Library of Medicine, 7 Jan. 2019, www.ncbi.nlm.nih.gov/books/NBK513058/.
  54. “New (But Still Not Enough) Data on Modafinil and Pregnancy.” MGH Center for Women’s Mental Health, 17 Nov. 2020, womensmentalhealth.org/posts/modafinil-pregnancy/.
  55. “New FDA Pregnancy Categories Explained.” Drugs.com, www.drugs.com/pregnancy-categories.html. Accessed June 5, 2020.
  56. “New Mothers With Epilepsy: Breastfeeding, Effects of Epilepsy Drugs on Baby, and More.” WebMD, www.webmd.com/epilepsy/guide/parenting-concerns-women-epilepsy. Accessed February 20, 2021.
  57. Ohayon, M. M., et al. “Frequency of Narcolepsy Symptoms and Other Sleep Disorders in Narcoleptic Patients and Their First-Degree Relatives.” Journal of Sleep Research, vol. 14, no. 4, 2005, pp. 437–445, doi:10.1111/j.1365-2869.2005.00476.x. Free Full Text.
  58. “Safe Breast and Bottle Feeding in a Sling.” Carrying Matters, 16 Oct. 2020, www.carryingmatters.co.uk/breast-and-bottle-feeding-safely-in-a-sling-3/.
  59. “Safe Breastmilk Sharing.” Eats on Feets, https://www.eatsonfeets.org/safeMilkSharing. Accessed February 20, 2021.
  60. “Safe Cosleeping Guidelines.” Safe Cosleeping Guidelines // Mother-Baby Behavioral Sleep Laboratory // University of Notre Dame, cosleeping.nd.edu/safe-co-sleeping-guidelines/. Accessed February 17, 2021.
  61. “Safe Sleep Recommendations.” AAP.org, www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/safe-sleep/Pages/Safe-Sleep-Recommendations.aspx. Accessed February 20, 2021.
  62. “SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment.” Pediatrics, vol. 138, no. 5, 2016, doi:10.1542/peds.2016-2938. Free Full Text.
  63. Silvestri, Rosalia, and Irene Aricò. “Sleep Disorders in Pregnancy.” Sleep Science, vol. 12, no. 3, 2019, doi:10.5935/1984-0063.20190098. Free Full Text.
  64. “Sodium Oxybate.” Drugs and Lactation Database (LactMed) [Internet], U.S. National Library of Medicine, 3 Dec. 2018, www.ncbi.nlm.nih.gov/books/NBK500802/.
  65. Sodium Oxybate (Briggs Drugs in Pregnancy and Lactation). Lexicomp. Hudson, OH: Lexicomp, 2021. https://online.lexi.com. Updated November 15, 2017. Accessed January 29, 2021.
  66. Sodium Oxybate (Lexi-Drugs). Lexicomp. Hudson, OH: Lexicomp, 2021. https://online.lexi.com. Updated January 22, 2021. Accessed January 29, 2021.
  67. Swick, Todd J. “Postnatal Treatment of Women with Narcolepsy Who Choose to Breastfeed-Time for a Reappraisal?” Sleep Medicine, vol. 36, 2017, pp. 178–179, doi:10.1016/j.sleep.2017.05.011. Request Full Text.
  68. Team, Pregnancy and Childbirth. “Breastfeeding: How to Establish a Good Milk Supply.” Health Essentials from Cleveland Clinic, Health Essentials from Cleveland Clinic, 15 Oct. 2020, health.clevelandclinic.org/breastfeeding-how-to-establish-a-good-milk-supply-infographic/.
  69. Thorpy, Michael, et al. “Management of Narcolepsy during Pregnancy.” Sleep Medicine, vol. 14, no. 4, 2013, pp. 367–376, doi:10.1016/j.sleep.2012.11.021. Abstract & Request Full Text.
  70. “Use of ADHD Medicine Is Increasing among Pregnant Women.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 8 Nov. 2019, www.cdc.gov/pregnancy/meds/treatingfortwo/features/keyfinding-ADHD-med-increase.html.
  71. UpToDate, www.uptodate.com/contents/safety-of-infant-exposure-to-antidepressants-and-benzodiazepines-through-breastfeeding. Accessed February 21, 2021.
  72. UpToDate, www.uptodate.com/contents/treatment-of-narcolepsy-in-adults. Accessed Mar. 16, 2021.
  73. “Venlafaxine.” Drugs and Lactation Database (LactMed) [Internet], U.S. National Library of Medicine, 16 Nov. 2020, www.ncbi.nlm.nih.gov/books/NBK501192/.
  74. Vernet, Cyrille, et al. “Subjective Symptoms in Idiopathic Hypersomnia: beyond Excessive Sleepiness.” Journal of Sleep Research, vol. 19, no. 4, 2010, pp. 525–534, doi:10.1111/j.1365-2869.2010.00824.x. Free Full Text.
  75. “Wakix: Highlights of Prescribing Information” U.S. FDA, https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/211150s000lbl.pdf. Accessed June 5, 2020.
Disclaimer

The contents of this website, including text, graphics and other material, are for informational purposes only. This website is not intended to be a substitute for professional legal or medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Always consult your own attorney or other legal advisor with any legal questions you may have. The Hypersomnia Foundation does not recommend or endorse any specific tests, physicians, lawyers, legal advisors, products, procedures, opinions or other information referenced on this website. Reliance on any information on this website is solely at your own risk.

The Hypersomnia Foundation makes no representations or warranties about the satisfaction of any government regulations requiring disclosure of information on prescription drug products. In no event shall The Hypersomnia Foundation be liable for any damages (including without limitation incidental and consequential damages) or costs (including without limitation attorney’s fees) based on any claim arising from the use of this website and/or its content.