ABM Clinical Protocol #21: Guidelines for Breastfeeding and Substance Use or Substance Use Disorder, Revised 2015

Abstract

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

The choice of breastfeeding by a pregnant or newly postpartum woman with a history of past or current illegal/illicit drug abuse or legal substance use or misuse is challenging for many reasons. The purpose of this protocol is to provide literature-based guidelines for the evaluation and management of the woman with substance use or a substance use disorder who is considering breastfeeding.

Background

Illicit drug use and legal substance use/abuse remain a significant problem among women of childbearing age. The 2013 National Survey on Drug Use and Health revealed that among pregnant women 15–44 years of age in the United States, 5.2% had used illicit drugs in the past month, 9.4% reported current alcohol use, 2.3% reported binge drinking, 0.4% reported heavy drinking during the pregnancy, and 15.4% reported cigarette use in the past month.

The healthcare provider presented with a pregnant or recently postpartum woman with a history of current or past illegal drug abuse or legal drug use or misuse who desires to breastfeed often faces multiple significant challenges. Substance use disorders frequently engender behaviors or conditions that independently signify risk for the breastfed infant, in addition to the drug exposure per se. These mothers may have coexisting risk factors such as low socioeconomic status (although substance use crosses all socioeconomic lines), low levels of education, poor nutrition, and little to no prenatal care. Multiple drug use is common, in addition to the use of other harmful legal substances, including tobacco and alcohol. Illicit drugs are frequently mixed and extended with dangerous adulterants that can pose additional threats to the health of the mother and the infant. Drug users are at high risk for infections such as human immunodeficiency virus and/or hepatitis B and C. Psychiatric disorders that require pharmacotherapeutic intervention are more prevalent with substance use, making breastfeeding an even more complicated choice, as breastfeeding may not be recommended for women taking some psychotropic medications.

Despite the myriad factors that may make breastfeeding a difficult choice for women with substance use disorders, drug-exposed infants, who are at a high risk for an array of medical, psychological, and developmental issues, as well as their mothers, stand to benefit significantly from breastfeeding. Although many of the factors listed above may pose a risk to the infant, the documented benefits of human milk and breastfeeding must be carefully and thoughtfully weighed against the risks associated with the substance that the infant may be exposed to during lactation. Confounding many efforts to examine longer-term developmental outcomes in infants exposed to some substances is the lack of data evaluating infants who were not exposed during pregnancy but only during lactation.

Ideally, women with substance use disorders delivering an infant and desiring to breast feed are engaged incomprehensive healthcare and substance abuse treatment during pregnancy, but this is not always the case. Substance abuse treatment for these women is often not available, not gender specific, and not comprehensive, forcing the mother’s healthcare provider during and after pregnancy to rely on maternal self-report and a “best guess” at adequacy of services, compliance to treatment, length of “clean” time, community support systems, etc. In a recent retrospective study in the United Kingdom, significantly lower rates of breastfeeding initiation occurred in mothers who used illicit substances or opioid maintenance therapy during pregnancy (14% versus 50% of the general population). In Norway, among opioid-dependent women on opioid maintenance therapy, 77% (compared with 98% in the general population) initiated breastfeeding after delivery.

The specific terms used to describe use and misuse of various legal and illegal substances continue to evolve and may vary from country to country and among different organizations. The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders combines the previous categories of substance abuse and substance dependence into the category single substance use disorder, which is measured on a continuum from mild to severe. Of important note is that we would like to make it clear that drugs of any type should be avoided in pregnant and breastfeeding women, unless prescribed for specific medical conditions. The casual use of drugs—legal, illegal, illicit, dose appropriate or not—still may have ramifications for the developing fetus and infant that we have yet to determine, and hence, in general, drugs of all types should be avoided unless medically necessary.

Specific Substances

Perhaps the most critical challenge facing the healthcare provider for the woman with a substance use disorder who wishes to breastfeed is the lack of research leading to evidence-based guidelines. Table 1 gives two online Web sites, one in English and one in both English and Spanish, that are kept updated and are easily accessible for current information on drugs and breastfeeding. There have been several comprehensive reviews of breastfeeding among substance-using women, essentially concluding that breastfeeding is generally contraindicated in mothers who use illegal drugs. (III) (Quality of evidence [levels of evidence I, II-1, II-2, II-3, and III] is based on the U.S. Preventive Services Task Force Appendix A Task Force Ratings and is noted throughout this protocol in parentheses.) Yet, research on individual drugs of abuse remains lacking and difficult to perform. Pharmacokinetic data for most drugs of abuse in lactating women are sparse and based on small numbers of subjects and case reports. Most illicit drugs are found in human milk, with varying degrees of oral bioavailability. Phencyclidine hydrochloride has been detected in human milk in high concentrations, as has cocaine, leading to infant intoxication. There is little to no evidence to describe the effects of even small amounts of other drugs of abuse and/or their metabolites in human milk on infant development aside from those discussed further below.