BREASTFEEDING MEDICINE Volume 10, Number 3, 2015 ABM Protocol ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2015.9992 ABM Clinical Protocol #21: Guidelines for Breastfeeding and Substance Use or Substance Use Disorder, Revised 2015 Sarah Reece-Stremtan,1,2 Kathleen A. Marinelli,3,4 and The Academy of Breastfeeding Medicine A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. Purpose use of other harmful legal substances, including tobacco and alcohol. Illicit drugs are frequently mixed and extended with he choice of breastfeeding by a pregnant or newly dangerous adulterants that can pose additional threats to the postpartum woman with a history of past or current T health of the mother and the infant. Drug users are at high risk illegal/illicit drug abuse or legal substance use or misuse is for infections such as human immunodeficiency virus and/or challenging for many reasons. The purpose of this protocol is hepatitis B and C. Psychiatric disorders that require phar- to provide literature-based guidelines for the evaluation and macotherapeutic intervention are more prevalent with sub- management of the woman with substance use or a substance stance use, making breastfeeding an even more complicated use disorder who is considering breastfeeding. choice, as breastfeeding may not be recommended for wo- men taking some psychotropic medications. Background Despite the myriad factors that may make breastfeeding a Illicit drug use and legal substance use/abuse remain a difficult choice for women with substance use disorders, significant problem among women of childbearing age. The drug-exposed infants, who are at a high risk for an array of 2013 National Survey on Drug Use and Health revealed that medical, psychological, and developmental issues, as well as among pregnant women 15–44 years of age in the United their mothers, stand to benefit significantly from breastfeed- States, 5.2% had used illicit drugs in the past month, 9.4% ing. Although many of the factors listed above may pose a reported current alcohol use, 2.3% reported binge drinking, risk to the infant, the documented benefits of human milk and 0.4% reported heavy drinking during the pregnancy, and breastfeeding must be carefully and thoughtfully weighed 15.4% reported cigarette use in the past month.1 against the risks associated with the substance that the infant The healthcare provider presented with a pregnant or re- may be exposed to during lactation. Confounding many ef- cently postpartum woman with a history of current or past forts to examine longer-term developmental outcomes in illegal drug abuse or legal drug use or misuse who desires to infants exposed to some substances is the lack of data eval- breastfeed often faces multiple significant challenges. Sub- uating infants who were not exposed during pregnancy but stance use disorders frequently engender behaviors or con- only during lactation. ditions that independently signify risk for the breastfed Ideally, women with substance use disorders delivering an infant, in addition to the drug exposure per se. These mothers infant and desiring to breastfeed are engaged in comprehensive may have coexisting risk factors such as low socioeconomic healthcare and substance abuse treatment during pregnancy, status (although substance use crosses all socioeconomic but this is not always the case. Substance abuse treatment for lines), low levels of education, poor nutrition, and little to no these women is often not available, not gender specific, and prenatal care. Multiple drug use is common, in addition to the not comprehensive, forcing the mother’s healthcare provider 1Divisions of Pain Medicine and of Anesthesiology, Sedation, and Perioperative Medicine, Children’s National Health System, Washington, D.C. 2The George Washington University, Washington, D.C. 3Division of Neonatology and The Connecticut Human Milk Research Center, Connecticut Children’s Medical Center, Hartford, Connecticut. 4University of Connecticut School of Medicine, Farmington, Connecticut. 135 136 ABM PROTOCOL during and after pregnancy to rely on maternal self-report and a detected in human milk in high concentrations,10 as has co- ‘‘best guess’’ at adequacy of services, compliance to treatment, caine,11 leading to infant intoxication.12 There is little to no length of ‘‘clean’’ time, community support systems, etc. In a evidence to describe the effects of even small amounts of other recent retrospective study in the United Kingdom, significantly drugs of abuse and/or their metabolites in human milk on infant lower rates of breastfeeding initiation occurred in mothers who development aside from those discussed further below. used illicit substances or opioid maintenance therapy during pregnancy (14% versus 50% of the general population).2 In Methadone Norway, among opioid-dependent women on opioid mainte- For pregnant and postpartum women with opioid depen- nance therapy, 77% (compared with 98% in the general pop- dence in treatment, methadone maintenance has been the ulation) initiated breastfeeding after delivery.3 treatment of choice in the United States, Canada,13 and many The specific terms used to describe use and misuse of other countries. In contrast to other substances, concentra- various legal and illegal substances continue to evolve and tions of methadone in human milk and the effects on the may vary from country to country and among different or- infant have been studied. The concentrations of methadone ganizations. The 5th edition of the Diagnostic and Statistical found in human milk are low, and all authors have concluded Manual of Mental Disorders combines the previous cate- that women on stable doses of methadone maintenance gories of substance abuse and substance dependence into the should be encouraged to breastfeed if desired, irrespective of category single substance use disorder, which is measured on maternal methadone dose.3,14–22 (II-1, II-2, II-3) Previously, a continuum from mild to severe.4 no apparent effects of methadone exposure prenatally and in Of important note is that we would like to make it clear that human milk were reported on infant neurobehavior at 30 drugs of any type should be avoided in pregnant and days.19 Recently an ongoing longitudinal follow-up study of breastfeeding women, unless prescribed for specific medical methadone-exposed infants with 200 methadone-exposed and conditions. The casual use of drugs—legal, illegal, illicit, nonexposed, demographically matched families has shown dose appropriate or not—still may have ramifications for the neurocognitive delays in methadone-exposed 1-month-old developing fetus and infant that we have yet to determine, infants compared with nonexposed infants. When retested at 7 and hence, in general, drugs of all types should be avoided months, methadone-exposed infants were similar to nonex- unless medically necessary. posed, comparison infants. At 9 months of age, 37.5% of this sample of methadone-exposed infants showed clinically sig- Specific Substances nificant motor delays ( ‡ 1.5 standard deviation) compared Perhaps the most critical challenge facing the healthcare with low but typical development in the comparison group.21 provider for the woman with a substance use disorder who Exposed infants typically have high environmental risk wishes to breastfeed is the lack of research leading to evidence- profiles, which continue at birth, posing ongoing risk to the based guidelines. Table 1 gives two online Web sites, one in developing child. English and one in both English and Spanish, that are kept The current thought is that environmental risk factors com- updated and are easily accessible for current information on bine with prenatal exposures to promote epigenetic changes in drugs and breastfeeding. There have been several compre- gene expression and methylation patterns that have both im- hensive reviews of breastfeeding among substance-using mediate and long-term implications related to developmental women, essentially concluding that breastfeeding is generally programming.22 Note that these findings relate to infants ex- contraindicated in mothers who use illegal drugs.5–8 (III) posed to methadone both prenatally and after birth via breast- (Quality of evidence [levels of evidence I, II-1, II-2, II-3, and feeding, and there is little information available on infants with III] is based on the U.S. Preventive Services Task Force Ap- chronic methadone exposure via breastfeeding alone. pendix A Task Force Ratings9 and is noted throughout this In addition, about 70% of infants born to women pre- protocol in parentheses.) Yet, research on individual drugs of scribed methadone during pregnancy will experience neo- abuse remains lacking and difficult to perform. Pharmacoki- natal abstinence syndrome (NAS),23 the constellation of netic data for most drugs of abuse in lactating women are sparse signs and symptoms often presenting following in utero and based on small numbers of subjects and case reports.7 Most opioid exposure. Infants with significant NAS can experience illicit drugs are found in human milk, with varying degrees of difficulties with attaching and sucking/swallowing during oral