The problems associated with maternal substance use disorders (SUDs) and effects on the infant and child have expanded in the United States in the past two decades without precedent [1, 2]. Optimal care of the substance-exposed dyad is multidimensional, and breastfeeding is one strategy that can benefit both mother and baby. Breastmilk is optimal nutrition for the newborn, and it confers well-known short- and long-term health and developmental benefits for the infant. For a population of infants at elevated risk for medical, developmental, and emotional-behavioral concerns, this benefit stands to be substantial. Additionally, breastfed opioid-exposed infants have less severe neonatal abstinence syndrome (NAS) as compared to formula-fed infants . Breastfeeding confers similarly positive benefits for the mother, including health and self-regulatory benefits, improved attachment and communication with the infant, improved functioning via stress reduction, enhanced self-concept as a caregiver  and increased sensitivity to infant cues . Women with a history of SUD are a population of women at particular risk for medical concerns, poor dyadic communication patterns, deficits in parental functioning and poor self-regulation; breastfeeding promotion, applied to appropriate dyads, could be a cost-effective mechanism to improve the physical and psychological trajectory of substance-exposed dyads . Yet, despite the particularly salient benefits of lactation, breastfeeding rates in this expanding population are low, approximately 24 percent as compared to 79 percent of the general population [7, 8]. Reasons for these low rates of lactation are myriad, and can result from the mother, the infant, the dyad, the provider/institution/environment and shifting combinations of all.
Understanding and Treating the Lactating Mother with a Substance Use Disorder (SUD)
SUD and Lactation
The new mother with an SUD frequently presents with multiple challenges which can interfere with the initiation and continuation of breastfeeding. Idiosyncratic cultural norms among women with SUD may affect their decision to breastfeed. Multigenerational addiction, poor role models for lactation, or few peers breastfeeding their infants may have mothers seldom considering breastfeeding as a viable option. Breastfed newborns feed more frequently than formula-fed newborns and require maternal attention almost exclusively, and therefore provide more frequent cueing for maternal attention. Mothers with SUDs can find normally rewarding infant cues as stressful, and heightened levels of stress in a low reward environment increases craving for substances of abuse that will, by experience, bring relief from stress. Thus, the act of caring for an infant may be a trigger for relapse to substance use ; this risk may be heightened in breastfed infants. On the other hand, teaching relapse prevention skills and promoting breastfeeding concurrently can positively affect both behaviors, at least as related to cigarette smoking . Hallmarks of SUDs which can result from or precede chronic use of drugs, such as increased impulsivity and risk taking, poor attention, emotional dysregulation, and poor self-regulation may all impair the mother’s ability to initiate and sustain breastfeeding, and may additionally have implications for the safety of lactation. Individuals with SUDs frequently have low tolerance for pain or setbacks, putting them at risk for increased stress and consequent relapse to substance use. (i.e. “what if breastfeeding hurts/the baby fails to latch/doesn’t get enough milk/rejects my breast (i.e. me)”?) Other fears may include lack of family support for lactation, and the fear of passage of medications used to treat opioid use disorders or other substances taken by the mother into breastmilk. These fears should be addressed in counseling both prior to and after birth.
Active Maternal Addiction and Lactation
Ideally, the woman with an SUD who desires lactation is abstinent from substance use, stable on medication-assisted treatment for an opioid use disorder (if warranted) and in a comprehensive SUD treatment program, but this is not always the scenario that presents at the time of delivery. It cannot be presumed that women who desire lactation are abstinent from substance use/misuse as there is evidence that women who are in active addiction patterns do choose to breastfeed their infants . Lactation is contraindicated in women with active addiction patterns regardless of substance (including marijuana); however, the determination of active addiction vs. stable recovery is not always readily definable, particularly for a provider who is not familiar with addictions or the mother’s history, and reliance on biologic screening tests and maternal history can be problematic. Further, even women that are stable in their recovery are at heightened risk for relapse in the postpartum period , not infrequently due to the guilt associated with observing their infant experience NAS, thus care providers should focus on relapse prevention.
Maternal active addiction can result in somnolence, altered sensoriums and/or responses to the infant and a chaotic or violent environment, all of which can portend risk to the infant’s development over the long term and their safety in the short term, and a more specific risk to the breastfed infant who must necessarily be in proximity to his mother. The breastfed infant may be at increased risk for smothering due to poor positioning while breastfeeding, or exposure to substances in breastmilk or via secondary exposures, which can be significant . Additionally, active addiction patterns often include drug seeking/taking activities that may place the woman and her infant in risky situations, including prostitution, unsafe locations, and potentially violent or chaotic environments.
All potential substances of misuse are transmitted into breastmilk and to the infant, and some have been documented to provide significant morbidity to the breastfeeding infant. Since most women with SUD are polysubstance using, a discussion of individual substance effects is somewhat artificial. Additionally, there is a dearth of information on individual substances in breastmilk, and that is likely to remain the case, since this research is ethically difficult to perform. However, a synopsis is included here for completeness’ sake:
Cocaine appears variably in breastmilk, and high concentrations are possible ; exposure has resulted in infant intoxication . Amphetamines frequently contain adulterants, may appear in breastmilk days after use [16, 17], are found in concentrations 2.8–7.5 times plasma concentrations, and can cause irritability and death . PCP can be highly concentrated in breastmilk . Alcohol can produce alterations in sleep cycles  and infant development . Benzodiazepines, when prescribed, are likely to present minimal risk to the breastfed infant, but drug-drug interactions may increase the risk for CNS depression . Irritability, lethargy, poor weight gain and apnea have been reported . Opioids such as oxycodone can cause CNS depression in 20 percent of infants  and codeine may cause a dose dependent CNS depression, particularly in ultrarapid metabolizers to morphine ; one death has been reported . Because of these risks among ultrarapid metabolizers, the US Food and Drug Administration recommends that breastfeeding women not be prescribed codeine or tramadol . Research on marijuana use and breastfeeding is several decades old, and marijuana today is approximately four times as potent as it was in most of these earlier studies . Marijuana delivered via breastmilk is absorbed and metabolized by the infant , may affect the ontogeny of various neurotransmitter systems, leading to changes in neurobiologic functioning , can cause sedation, weakness and poor feeding , significant health and other effects making it a potentially dangerous exposure via breastmilk . Women should be counseled that breastfeeding is not recommended with marijuana use, and that continued use of substances that can cause harm (even if legal) throughout pregnancy is strongly suggestive of having a substance use disorder.
Medical Conditions, Psychiatric Conditions, Medications and Lactation
Women with SUDs more often than not present with medical or psychiatric co-morbidities, which may deter the choice of lactation, rightfully or not. Concurrent HIV infection is a contraindication to lactation, but other infections, such as hepatitis B/C, not necessarily contraindications to lactation (hepatitis C is a contraindication if bleeding or cracked nipples present), or smoking cigarettes may deter women from breastfeeding due to lack of information or fears of compounding other exposures. Co-promotion of smoking cessation/relapse prevention and breastfeeding has shown benefit in these patients . Maternal psychiatric concerns in this population, most commonly depression and anxiety , can deter a mother from breastfeeding in several ways. These disorders can affect a mother’s self-confidence as a caregiver, her ability to read infant cues of hunger/satiation, her capacity for seeing her damaged self/body as “safe” to provide nutrition for her infant or her self-efficacy to advocate for lactation for herself and her infant. Psychiatric co-morbidities are often treated with medications during the perinatal period, as untreated maternal psychiatric illness may be harmful to both mother and infant. Medications used to treat these conditions are all transferred into human milk; most are compatible with breastfeeding, with some exceptions (i.e. Haldol), but these too may deter women from breastfeeding for fear of infant exposure via breastmilk compounding other prenatal and postnatal exposures. Medications used to treat maternal opioid use disorders during pregnancy and postpartum (i.e. methadone and buprenorphine) are transmitted into breastmilk in low concentrations and are not contraindications to lactation [33, 34]. However, mothers who need to access treatment programs daily to obtain these medications that do not accept the presence of the infant may find logistical barriers that hinder their ability to breastfeed the infant.
Maternal Sexual Trauma and Lactation
Physical, emotional, and sexual abuse are common in women with SUD, in both past histories and current pregnancy . Histories of sexual abuse are frequently unrecognized, and can be a major factor in the inability for some women to consider or sustain lactation. Women with histories of sexual abuse often feel shame or self-blame for issues surrounding nudity, breasts, childbirth, or sensations related to breastfeeding an infant. Expressions including “my body in the baby’s mouth is disgusting,” or “breastfeeding is perverted” are common. Poor self-esteem or self-efficacy in women who have experienced sexual trauma often results in early cessation of breastfeeding. Women may feel mistrust or hostility related to the infant’s need for her body, particularly for older infants who may play at the breast, or infants demanding nighttime feedings. Psychiatric co-morbidities are common in women who have experienced sexual trauma, and range from depression to PTSD. The act of breastfeeding an infant combined with the process of childbirth may predispose this group of women to flashbacks, especially in the perinatal period, when strangers (i.e. medical staff, particularly men) have the need to expose and touch her body. Many women who have experienced violence can only give the infant pumped breastmilk, as the feeling or viewing of an infant suckling is intolerable, as is “forced” exposure of the body. Women who have been victims of sexual violence may experience pain out of proportion to clinical findings, and the pain associated with breastfeeding initiation can be a trigger for depression or PTSD . Sleep disorders are common among sexual assault survivors which can increase risk for depression, but the risk for these is lowered in breastfeeding as opposed to formula feeding mothers .
Treating the Lactating Mother with an SUD
Despite these challenges, many women with an SUD are willing to breastfeed and thus should be encouraged to do so. The only two absolute contraindications to breastfeeding in the United States are active substance use and HIV positivity. Ideally, the mother with an SUD who presents desiring to breastfeed her infant has been identified during the course of her prenatal care, and preparation for breastfeeding can be done. Issues related to trauma exposure, psychiatric co-morbidities and feelings that commonly arise when seeing the infant experience NAS at the breast can be preemptively addressed. Lactation support can be very helpful in the hospital and outpatient clinic to promote the maternal–infant dyad and address difficulties. By using trauma-informed and trauma-responsive care, the lactation support can address issues with previous abuse and use breastfeeding as relapse prevention. Available maternal treatment histories of active use and sobriety periods can be used to determine appropriate candidates for breastfeeding.
For women who lack prenatal care and in whom a thorough history is not known, a thorough assessment of the mother is warranted, to include: personal and drug use history, engagement (or not) in treatment for SUD, psychiatric co-morbidities, treatment (or not) and medication used to treat psychiatric co-morbidities, medical history and medications, violence/trauma exposure, family and community supports and plans for postpartum and SUD treatment and pediatric care.
When considering psychiatric medications and lactation, a multidisciplinary approach involving primary care, obstetric, psychiatric, and pediatric providers is warranted, as is using the safest effective medication (i.e. short as opposed to long-acting), carefully evaluating risk and benefits, and assuring careful and experienced monitoring of the infant. However, women who are stable on a specific psychiatric medication should not be switched to one with a shorter half-life solely for breastfeeding, as switching medication can increase relapse risk. Stable women on medication-assisted treatment with methadone or buprenorphine as part of SUD treatment who are candidates for lactation should be encouraged to do so regardless of dose. There is evidence that buprenorphine concentrations in breastmilk are dose-dependent , but buprenorphine is not substantially absorbed orally. Buprenorphine and metabolite concentrations in infants of buprenorphine maintained women at 2 weeks of age are low or non-detectable . Women are often under the misconception that she is “treating” the NAS by providing buprenorphine or methadone in breast milk. Gentle disabusing of this misconception can be helpful so that women remain on the most effective dose, without worrying about the infant’s treatment.
Maternal somnolence in the postpartum period is not uncommon. Somnolence can be related to guilt and depression, the demands of the newborn, significant other, family and social services interventions or pressures or sleep disorders, which are common in women with SUDs. The dose of methadone for those women in maintenance therapy often requires a downward adjustment after delivery due to diminished volumes of distribution for the medication. For women with trauma histories, an evaluation for depression, guilt and issues surrounding victimization is necessary. For this population of women, revictimization is not uncommon and should be assessed. Feeding the infant only pumped breastmilk may be a red flag for sexual trauma, which if discovered during the postpartum period has implications for the sustainability of lactation and should be addressed by appropriate professionals. Women should never be forced to breastfeed or be made to feel guilty if they cannot or chose not to breastfeed.
Maternal education is an important component of successful lactation, and ideally this begins in the prenatal period. Teaching regarding NAS and maternal feelings surrounding the infant’s NAS display, and how NAS may affect the infant’s capacity for feeding at the breast are likely to positively influence the mother’s ability to initiate and sustain breastfeeding. Safe sleep is a particularly important topic, which should be reinforced at multiple points in the prenatal and postnatal periods.
The Substance-Exposed Infant
The substance-exposed infant may present their own independent problems that impair their ability to feed at the breast, and additionally may compound maternal lactation deterrents. These may include preterm birth, low birth weight, and other medical conditions. Medical interventions, such as medications, intravenous lines, monitor wires, gavage feedings, and NICU environments may also impair an infant’s ability to feed at the breast. Many substance-exposed newborns experience neurobehavioral dysregulation in the early neonatal period, which can be due to and potentiated by multiple substance exposures.
Neonatal Abstinence Syndrome (NAS) and Lactation
There are many nonmedical strategies to help promote breastfeeding and help prevent NAS that are addressed in Chapter 14. Rooming in, swaddling, kangaroo care, and nonNICU treatment have been shown to be helpful in preventing/ameliorating NAS. NAS is a group of signs and neurobehaviors that occur in the infant after discontinuation of exposure to substances taken by the mother. While typically associated with opioid exposures, other substances, such as nicotine, benzodiazepines, and SSRIs may cause an independent abstinence or toxidrome phenomenon, or may augment an opioid-induced NAS. Regardless of the antecedents of the NAS display in the infant, factors related to this disorder can and often do impair breastfeeding. Infants affected by NAS may display problems with motor control, such that they are hypertonic and/or jittery with uncontrolled and/or jerky movements. These infants are frequently difficult to position on the breast and often display head thrashing when approaching a nipple. Suck/swallow incoordination, another feature of NAS, may impair the ability of the breastfed infant to take in enough calories to offset his increased expenditures due to motor control issues, particularly in the early postnatal period when only colostrum is available. Regulatory problems, or the imbalance between the autonomic, motor, state control and attentional/interactive subsystems [38, 39], are also a hallmark of NAS.
These subsystems interact with each other and the environment in a continuous fashion, such that an infant with NAS expending any additional effort in any one subsystem, i.e. motor control, may not have sufficient energy to achieve homeostasis and balance in the others, i.e. attentional/interactional subsystems. The inability of the NAS-affected infant who is exhibiting problems with regulation to achieve a quiet alert state which is necessary for breastfeeding can easily derail lactation in its early phases. Difficulties with state control, and tendency to be easily overstimulated, common features of infants with NAS, can also impair breastfeeding. These infants often go from sleep to an insulated crying state without reaching the quiet alert state that is necessary for feeding at the breast. Infants with NAS are often irritable and transmit poorly interpretable cues to their mothers, which may prompt the mother to soothe the infant with her breast if she interprets all crying as hunger. This can result in the infant at the breast for most or all of the day, never taking a full feeding and disrupting wake/sleep cycles. Medication for NAS, typically morphine or methadone, can also impair breastfeeding capabilities in infants who are sedated after medication, or overstimulated prior to medication to latch at the breast without medication. For infants that require prolonged hospitalization, prolonged separation may inhibit the mother’s ability to pump breastmilk for her infant. These difficulties can be further compounded by a mother that experiences guilt, easy frustration, or poor tolerance for her inability to feed or soothe the infant. Lastly, infants who are breastfed tend to have shorter sleep/wake cycles, which can negatively affect their NAS scoring. It is prudent to adapt NAS scoring to the breastfed infant by disallowing increased NAS scores for physiologic sleep cycles that are less than 3 hours.
Treating the Breastfeeding Infant of a Mother with an SUD
When considering lactation for the substance-exposed infant, a thorough understanding of their longitudinal health status, medications, environment, and NAS display is warranted, as these factors are likely to change and evolve with time. Understanding the infant’s dyadic communication pattern and triggers for dysregulation or overstimulation requires careful observation of the infant with his mother during breastfeedings, routine cares, and other interactions. Evaluation of the infant’s response to external stimuli, such as auditory, visual, or tactile stimuli will provide a mechanism to assess his triggers for dysregulatory behaviors that will impact breastfeeding. Similar assessment of the infant’s response to internal stimuli, such as bowel movements or hunger, will allow interpretation of his capacity to cue his caregivers for necessary interventions. Promoting the mother’s capacity for recognizing and interpreting signs of infant hunger, discomfort, fatigue, or dysregulation will assist her ability to provide contingent and sensitive responses. These responses can be learned and should be adaptable to the infant’s changing condition over time. All infant crying is not hunger, and constant breastfeeding or using the maternal breast as a pacifier to soothe an irritable infant should be avoided, as in these cases the infant never receives a full feed and the maternal breast is never completely emptied, and it may additionally predispose the nipples to cracking/bleeding which may present risk for women with HCV infection.
Observation of the breastfeeding infant will allow the provider to assess factors that can impair lactation, such as factors related to NAS including hypertonicity, suck swallow incoordination or overstimulation, and simultaneously allow the modification of handling and/or the environment to overcome these difficulties (see Figure 15.1). It is important to note that the feeding capacity of some infants is affected by the timing of medication administration delivered coincident with each feeding. Some infants cannot be positioned on the breast without medication, some may require medication during or after a feed, or a split dose of medication delivered before and after a feed to be able to breastfeed successfully.
|Infant NAS sign||Breastfeeding intervention|
|Avoid infant positioning on the breast in any position that promotes back arching or hypertonia; i.e. one infant arm behind the mother’s back. Swaddle the infant to reduce tremors, bring arms and legs forward and curve the infant’s body in a C position. Apply gentle pressure to the occiput if tolerated.|
|Identify interactional and environmental interventions (i.e. avoiding eye contact, rocking, dim light, pacifier) that help the newborn to achieve a drowsy or quiet alert state to start the breastfeeding. Decrease any visual, auditory, tactile stimuli that may dysregulate the infant. When medication is needed avoid sedation if present by administering the medicine in the middle or after feeding; consider splitting the dose.|
|Identify autonomic signs that may indicate sensory stress and avoid their external or internal triggers: (visual/auditory), tactile (blankets, pressure points, monitor wires), excessive gas due to limited burping. Swaddling; may need to restrict to extremities if fever present. Small frequent breastfeedings on demand, modifying the Finnegan score to reflect this intervention (i.e. do not score for sleeping less than 3 hours for breastfed infants who feed more frequently).|
|Chin support if helpful. Avoid gavage feedings, which will worsen other symptoms of NAS, when possible. Monitor infant weight. May require OT consultation.|