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Recreational drugs
Breastfeeding mothers should avoid recreational drug use wherever possible. However, the value of breastfeeding to both mother and infant is such that it likely outweighs the risks associated with most maternal recreational drug use. The risks should be discussed on a case-by-case basis with the mother, with pragmatic advice given specific to her personal situation. Although there is evidence of deleterious short-term effects on the breastfed infant for a number of substances, there are few data relating to the long-term effects and the likely more significant exposure of the infant in utero , and the often-disadvantaged social background of women who use recreational drugs confound these. In general, breastfeeding is contraindicated in cases of persistent maternal use of heroin or stimulant drugs, such as amphetamine, cocaine and alcohol.
4.16.1
Alcohol
Alcohol transfers readily into breast milk leading to concentrations almost identical to those found in maternal blood. This results in the infant receiving about 10% of the mother’s weight-related amount of alcohol (survey in ). The activity of alcohol dehydrogenase, the main route of alcohol detoxification, in the neonatal period is reduced, leading to an elimination rate around half of that measured in adults, with greater attendant risks to the infants of mothers with alcohol intake.
Despite long-held claims that alcohol is a galactagogue, there is no scientific evidence to support this view. Indeed, to the contrary, there is evidence that even moderate maternal alcohol intake may decrease breast milk production and milk ejection ( ). Alcohol can also change the taste of the mother’s milk and may lead to feeding difficulties ( ). Consumption of more than two alcoholic drinks per day is associated with a significantly shortened duration of breastfeeding ( ).
Other adverse effects of alcohol on infants have been reported following moderate exposure: changes in sleep behavior ( ); potential alcohol-induced hypoglycemia ( ); mild sedation ( ); and possible mild delays in psychomotor development observed at 1 year of age ( ), although the same group was not able to replicate these findings in a similar cohort at 18 months.
It is conceivable that regular excessive maternal alcohol consumption during breastfeeding may lead to significant harm to the infant. A case report details a reversible pseudo-Cushing syndrome in a child, which was attributed to the mother’s massive intake of alcohol (survey in ).
Recommendation
Alcohol should be avoided when breastfeeding, although there is no hard evidence that occasional limited alcohol use (i.e. 1 unit of alcohol or 8 oz – equivalent to 100 mL champagne once or twice a week) causes harm to the infant. Furthermore, one drink should be consumed over a period of time (more than 30 minutes), and the mother should where possible, refrain from nursing for 2 hours thereafter to avoid any alcohol reaching the infant. With chronic or intermittent excessive alcohol consumption (binge drinking), breastfeeding should be discontinued. Alcohol use during breastfeeding also has adverse effects on the child. Babies have been found to drink less milk and to have a disturbed sleep–wake pattern for 3 hours after nursing mothers have consumed between one and two standard drinks.
4.16.2
Amphetamines
Amphetamines are transferred into the breast milk. After a regular intake of 20 mg daily, a milk to plasma (M/P) ratio of 2.8–7.5 was reported and amphetamines were detected in infant urine ( ). No clinical symptoms were observed among 103 infants whose mothers took various amounts of amphetamines ( ). However, irritability, poor sleeping and agitation have been described in infants breastfed by amphetamine users ( ). In four breastfeeding mothers treated with dexamphetamine for attention deficit hyperactivity disorder (ADHD), a M/P ratio was found to be maximally 5.3 with a relative infant dose of less than 10%. Normal development of the children was reported ( ). Methamphetamine is also excreted in milk ( ).
Recommendation
Amphetamine use during breastfeeding should be strongly discouraged. After an individual dose, an interruption of breastfeeding for at least 24 hours should be observed. In the event of regular amphetamine use, breastfeeding should be discontinued.
4.16.3
Caffeine
Methylxanthines , including theophylline , caffeine , theobromine and the metabolite paraxanthin , are considered part of the “normal” components of the milk, and arise from dietary sources as well as prescription and non-prescription medications ( ). The concentration in breast milk following maternal ingestion is very variable. Caffeine is metabolized by the hepatic cytochrome P450 oxidase system that is immature in the neonatal period. This results in a prolonged elimination half-life in the newborn of up to 90 hours as opposed to around 5 hours in adults. The amounts of caffeine arising in milk from usual social coffee consumption, with a milk to plasma ratio of approximately 0.6, appear to be well-tolerated by the infant. Even under controlled conditions, neither changes in heart frequency and sleep duration nor other symptoms could be detected. Regular intake of larger amounts of caffeine (daily more than four cups of coffee, eight cups of tea or relevant amounts of other caffeine-containing drinks), may lead to transitory irritability and restlessness especially in very young infants ( ).
Recommendation
“Normal” caffeine consumption, i.e. a maximum of three cups of coffee or six cups of tea or 300 mg of caffeine in 24 hours, is not considered to be harmful to the infant during breastfeeding. If this amount is regularly exceeded, symptoms of irritability may occur and consumption should be reduced.
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