According to the 2016 National Survey on Drug Use and Health, one in 10 people (28 million) over age 12 used an illicit drug in the past 30 days. For young adults aged 18 to 25, use ranges as high one in four for illicit drug use, one in 10 for heavy alcohol use, and two in five for binge alcohol use. Use is primarily driven by marijuana and misuse of opioid pain relievers. Of pregnant women, 6.3% used illicit drugs, 8.3% reported alcohol use, and 4.3% reported binge drinking in the last month.1 Breastfeeding is a major public health strategy because of the well-known benefits, including child spacing, and reduced rates of sudden infant death syndrome (SIDS), childhood infections, and postpartum depression. These benefits may be particularly important for families struggling with substance use. Both the American Academy of Pediatrics (AAP) and the World Health Organization (WHO) recommend exclusive feeding with breastmilk during the first 6 months of life.2,3 The Healthy People 2020 targets are 81.9% for ever breastfeeding and 60.5% for any breastfeeding in 6 months.4 In 2010, The Patient Protection and Affordable Care Act and Fair Labor Standards Act mandated that working mothers be given reasonable break time and a private place to pump that is not a bathroom for up to 1 year after childbirth.5 A woman with substance use (SU) or substance use disorder (SUD) has the same rights and desires as any other mother to receive unbiased counseling and make an informed decision about breastfeeding and is not immune to the medical and societal pressure that “breast is best,” as noted in official statements from organizations regarding breastfeeding and substance use (Table 1). Screening for drug use Hospital protocols vary widely in how hospitalized newborns are triaged to receive their mother’s breastmilk. Some rely on biological testing of urine or milk at delivery. Others do not use biological testing, do not initially withhold breastmilk, and provide education and supportive intervention first before deciding about ongoing breastfeeding recommendations. The latter better supports the ethical framework put forth by ACOG to discourage breastfeeding exclusion and separation of parents from their children solely based on suspected or confirmed SUD.8 Consequences of biologic screening for drug use Breastfeeding rates in women with SUD The perception of breastfeeding “contraindications” is important to mothers with SUD. In a 2003 cohort of 393 low-income inner-city women, 48% never initiated breastfeeding and 16% had a documented contraindication to breastfeeding. Of those who never initiated breastfeeding, 42% with a contraindication to breastfeeding cited “not wanting to pass dangerous things” as the reason for not breastfeeding. Of those with contraindications, 75% used cocaine, 28% had HIV infection, 5% used PCP, and 3% heroin or methadone.14 How ob/gyns can help Women with SUD may have fewer role models, lower self-esteem, and may make the assumption that successful breastfeeding is not achievable. A history of abuse may make it difficult. Breastfeeding may trigger flashbacks or shame, making trauma-informed counseling important. Information provided in a self-esteem-building manner about the potential harms of particular substances in the breastmilk may be enough to motivate a woman to stop using substances or practice responsible harm reduction while breastfeeding. Women with chronic drug use resulting in brain dysregulation may find breastfeeding overwhelming or impossible. Maternal behavior may become disrupted where stress becomes heightened by neonate behavior instead of what would normally be rewarding to mothers who do not have a SUD.15 As a result breastfeeding may be more harmful than helpful. The ideal situation for successful breastfeeding is for a mother to be abstinent from substance use, part of a comprehensive substance use treatment program (ideally gender specific), and if indicated, stable on medication-assisted treatment. If abstinence is not possible, but harm reduction strategies are reliably implemented, the benefits of breastfeeding can outweigh the risks. Harm reduction strategies include compliance with provider visits and, as needed, pumping and discarding milk, feeding with donor milk or formula, seeking an alternative childcare provider, and avoidance of co-sleeping with the baby when using drugs. For breastfeeding success, the provider approach and environment should be optimized. It is critical to treat SUD as a chronic relapsing disease, work to avoid mixed messages, and avoid pejorative language like “junkie,” “drug seeker,” and “addicted baby.” Assess the mother’s comfort level and exposure of breast and body. Ask permission before examination, respect boundaries, provide a breast pump and lactation consultation familiar with mother-infant SUD, and avoid encouraging discontinuation at the first sign of difficulty. Regardless of breastfeeding success, the mother’s progress in recovery is most important for the infant’s health and development.16 Table 2 summarizes how ob/gyns can help facilitate breastfeeding women with SU and SUD. Table 3 summarizes recommendations for specific substances and breastfeeding.17,18 Impact of specific substances on breastfeeding Methadone Buprenorphine Other prescription opioids Heroin Cocaine Methamphetamine or MDMA Marijuana Benzodiazepines Alcohol Tobacco Conclusion Disclosures:The authors report no potential conflicts of interest with regard to this article. References:
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