Breastfeeding Promotion in Infants of Substance Abusing Mothers

This article is intended to address the topic of infants born to mothers with a substance abuse condition, not a mother who was monitored as a patient on other medically necessary prescription medication throughout pregnancy.

While the occurrence of substance abuse in pregnant women has increased dramatically over the last several years, it is not new. Happel first published a report of neonatal withdrawal in 1900.1 Which substances are abused has changed from time to time with the most recent concerns centered around abuse of prescription drugs and heroin.

The 2013 National Survey on Drug Use and Health reported that 5.4% of all pregnant women were current illicit drug users.2  This included 14.6% of women between 15 and 17 years of age and 8.6% between 18 and 25 years of age, all pregnant. Rates of neonatal abstinence syndrome have increased from 2009 to 2012 from 3.4/1000 live births to 5.8/1000 hospital births.3  Rates for census regions are also available and range from 16.2/1000 live births in the East South Central states to 2.6 in the West South Central states. Notice that this reflects the incidence of neonatal abstinence syndrome (NAS) and not necessarily the rate of substance exposure.  Infants exposed to marijuana, for instance do not usually demonstrate the symptoms associated with NAS. Therefore, the actual rate of exposure is likely much higher. Many women are polysubstance abusers and frequently have alcohol and tobacco use during the pregnancy and limited or no prenatal care, all of which increase the risk of poor outcome.  A baby is now born every 25 minutes who is suffering from opioid withdrawal.3

This issue emotes strong emotional responses from caregivers. Comments from healthcare staff like “this mother doesn’t deserve this baby” and recommendations that these women be reported for child abuse demonstrate this attitude.4,5 However, today, we are encouraged to see substance abuse as a chronic health condition equal to type II diabetes, hypertension or asthma.6 One must understand that substance abuse is an illness that requires medical and social intervention and life-long support. These women have a substance abuse problem, in most cases, long before the pregnancy. Pregnancy rarely, if ever is the stimulus that results in substance abuse. Some women report using substances of abuse as self-medication for psychological conditions including post traumatic stress disorder, bipolar disease and depression. In order to stop the abuse, these underlying conditions must be treated. Prescription drugs are sometimes used after an injury in which opioids are legitimately prescribed but continued long after the injury-associated pain is gone. Prescribing practices have been targeted in efforts to decrease this type of abuse. Regardless of the underlying history of the abuse, it occurs in all races, cultures and populations but rates vary.

If mothers are receiving prenatal care, every attempt is made to transition her to methadone or buprenorphine treatment from heroin or other opioid abuse. This results in a known dose of drug during the pregnancy, regular screening to ensure this is the only drug being taken and continued prenatal care. However, methadone and buprenorphine cross the placenta and are found in the fetus. The infant may still have NAS even if the mother is properly managed on these replacement drugs during the pregnancy. The controlled dose given in a monitored program, however, leads to more predictable onset and course of withdrawal in the infant. Since these drugs cross the placenta, they are also found in breast milk, although in small quantities.

Patrick et al3 report length of stay at 2.1 days for infants without NAS and 16.9 days for infants with NAS.  Cost of care is estimated at $3500 for infants without NAS and $66,700 for infants with NAS. Infants with NAS are more likely to be born prematurely, have neonatal respiratory disease, feeding difficulty, seizures and low birth weight.3,7  These infants often have difficulty post-discharge as well including continued feeding difficulties and developmental and growth delay.8  As the number of infants with NAS increases, costs increase. Therefore, many facilities have protocols to manage NAS more efficiently and decrease length of stay. By decreasing length of stay and NICU admissions, cost of care is decreased as is separation from mothers. Providing breast milk or, more specifically direct breast feeding has been shown to result in a decrease in the need for pharmacotherapy for withdrawal as evidenced by a lower score on a standardized withdrawal scoring tool such as the Finnegan tool. 9,10

The benefits of breastfeeding are many and have been well documented for both the infant and mother (Table 1). These benefits are more important in NAS infants. A drug-abusing mother does not automatically exclude the possibility of breast feeding. The Academy of Breast feeding Medicine’s guidelines for breast feeding in this population states that each case must be evaluated individually.13  There are several advantages for mother and baby when breast feeding, some different than what is seen in non-substance abusing women. For instance, breastfeeding may increase the bond between mother and infant due to the release of oxytocin during breastfeeding which may also protect the mother against addiction relapse and stress.14,15 In some cases, the focus of providing for an infant, including breast feeding helps the mother stay in a treatment program, receive counseling and other support that aids in continued sober living. Besides the benefits of the infant receiving breast milk that contains a small amount of opiate, resulting in more gradual weaning of the drug rather than a sudden discontinuation upon delivery, infants who are direct breast fed also get other interventions that are helpful in supporting hyperactive, irritable infants. The skin to skin holding or swaddling during breast feeding and rooming-in may also result in a lesser need for withdrawal treatment.15

The Academy of Breastfeeding Medicine (ABM), the American Academy of Pediatrics and ACOG recommend breast feeding for mothers receiving opioid maintenance therapy during and after pregnancy provided there are no other contraindications to breast feeding.13,16,17  The ABM recommend that mothers who meet the following criteria be supported in their decision to breast feed their infant:

• Women already in a substance abuse treatment program who intend to continue the treatment program in the postpartum period
• Women whose substance abuse counselors confirm that the women are continuing in the treatment program
• Women who have been abstinent from the illicit drug for at least 90 days before delivery in an outpatient setting
• Women who have a negative drug screen at delivery except for prescribed medications and who have received consistent prenatal care
• Women who have stable methadone maintenance should be encouraged to do so regardless of maternal methadone dose

Historically, it was believed that a methadone dose of over 20 mg would contraindicate breast feeding.  However, many researchers have found that the amount of drug excreted into the breast milk is minimal for both methadone and buprenorphine, regardless of dosage that the mother receives.18,19,20,21 Furthermore, the dosage that the mother needs in order to prevent withdrawal symptoms during the pregnancy must be increased during the third trimester. Without this increase, she is more likely to relapse. Therefore, maintaining a lower dose in order to allow breast feeding is counterproductive, may result in relapse and does not make a significant difference in amount of exposure to drug in the breast milk.22

Liu and collegues14 evaluated the effect of mode and type of feeding on onset of NAS as well as need for pharmacologic management of NAS. They compared infants who were fed directly at the breast, those fed expressed breast milk and those fed formula. They found no difference in requirement for pharmacologic management based on mode/type of feeding in the first 2 days of life.  However, infants who were fed directly at the breast had a significantly delayed onset of NAS. It was not reported if these infants continued to be fed directly at the breast and the sample size was small so any effect of the mode of feeding may not have been seen in this sample. Malpas, Horwood & Darlow23 found that breast fed infants had a shorter stay by 8 days than infants who were formula fed due to lesser requirement for NAS treatment. Pritham, Paul & Hayes24 found infants who were breast fed as compared to formula fed were less likely to need treatment for NAS and had a significantly shorter stay by 9 days.

However, even if healthcare providers realize the benefit and encourage mothers to breastfeed, it has been found that breast feeding rates remain low in this population.25 Wachman, Byun & Philipp 25  published results of a retrospective chart review to determine how many substance-abusing mothers began breast feeding and how long the breast feeding continued. Their criteria for allowing substance abusing mothers to breast feed included a negative urine drug screen on admission, no illicit drug use in the third trimester and a negative HIV screen. They found that 68% of the mothers were eligible to breastfeed but only 24% actually breast fed in an environment they felt was supportive of breast feeding in these mothers. Sixty-percent of these mothers stopped breast feeding in less than 1 week. Tsai & Doan26 reported the results of a literature review in which studies were included that evaluated breast feeding in mothers receiving opioid maintenance treatment including either methadone or buprenorphine. They found 9 studies that met their inclusion criteria. There were 5 studies that reported breast feeding rates in the United States. The initiation of breast feeding in these studies ranged from 24% to 81% and duration, where reported 8% at discharge to 50% at 6-8 weeks postpartum.26  Most of the studies did not differentiate partial or exclusive breast feeding. These authors also undertook an analysis of type of medication used for opioid maintenance therapy (OMT), either methadone or buprenorphine and possible influences on initiation and duration of breast feeding.  No conclusions could be drawn about the effect of these drugs on breast feeding as not all reported the type of maintenance therapy, percentage of breast feeding and continuation based on this criteria.  We know that maintaining exclusive breast feeding for the recommended 6 months after delivery often requires encouragement and support for women who are not substance abusers.  It is logical that for these women, the support needed to initiate and maintain breast feeding for any length of time would be different than for women who are not substance abusers.

Measures to Support Breastfeeding

Various studies have reported the effect of various measurements on initiation and maintenance of breastfeeding. Two studies in the U.S. reported the effect of combined obstetric and addiction treatment.  The sites included in these two studies also practiced rooming in during the post-partum period.27,28  Combined obstetric and addiction treatment is likely to be valuable to these mothers since transportation and child care are often issues. Making multiple appointments after the infant’s discharge can result in insurmountable problems and loss to follow up. These two reports are from the same hospital in different time periods, all women were treated with buprenorphine and the hospital was designated Baby Friendly. The Baby Friendly designation, however, alone did not result in an increase in breast feeding rates. The one study that reported on breast feeding outcomes in a Baby Friendly hospital without other interventions showed one of the lowest rates of breast feeding for these women at 24.1%.25  While breast feeding support is part of the Baby Friendly designation, there is no specific education regarding the needs of women who are substance abusers. In another study, these women expressed guilt over having methadone in their breast milk, felt they were discouraged from breast feeding because of this and felt a lack of support for breast feeding from health care staff.15

It can also be quite challenging to breast feed an infant who is irritable and hyperactive. Maternal anxiety may be more pronounced in this population. Addressing anxiety related to breast before attempting to provide breast feeding may be helpful.29  Many of these mothers may suffer from anxiety disorders already and therefore, may need additional assistance in this area. In addition, smaller, more frequent feedings at breast may be helpful.29  Finally, infants should be put to the breast while still drowsy and swaddled to prevent symptoms of irritability which will make breast feeding more difficult.29  Measures that may be helpful in supporting breast feeding in these infants are listed in Table 2.

It is well known that health care providers’ attitudes impact rates of breast feeding for non-substance exposed infant/mother dyads. Attitudes about substance abuse in general and particularly in pregnancy as well as lack of knowledge about breast feeding safety can impact breast feeding rates in this population. Making judgments about a substance abusing mother after the baby is born is pointless and certainly not helpful to the baby. Kohsman6 discussed the three levels of prevention in NAS. Health care providers can intervene at the primary level of prevention by attempting to prevent exposure. Primary prevention occurs before pregnancy. Most neonatal providers will not have this opportunity but exposure for a future infant may be possible. As secondary prevention, women who present for prenatal care and who are substance abusers should be recognized and treatment provided in order to minimize exposure of this infant. Neonatal providers can intervene as part of tertiary prevention that seeks to minimize long-term consequences for both mother and infant. This would include mental health and social work referrals and supporting breastfeeding thus decreasing the signs of withdrawal in the infant.  An additional benefit is to impart many other advantages of breast feeding as has been found in studies involving infants not exposed to illicit substances. Studies not specific to the NAS infant have been shown to improve bonding with early continued contact and breast feeding, something that may be in jeopardy for these substance exposed infants due to separation (infants with extended inpatient stays or admission to the NICU) and social factors.

While substance abuse and addiction are issues fraught with morality, these are more common and especially in women of child-bearing age. As neonatal providers, making judgment against the abuser equals judgment against an innocent child. Encouraging breast feeding can impart advantages beyond decreasing withdrawal for these infants. Mothers should be supported in their role in the infant’s life, in spite of illicit drug exposure. For mothers maintained on methadone or buprenorphine, it appears that breast feeding is safe and should be supported. Pregnancy provides a window of opportunity to intervene and while not all abusers will take advantage of this opportunity, it does happen and is more likely to happen with appropriate referrals and support. In addition, we must recognize that substance abuse is often a sign of underlying mental health or social issues that must be addressed concurrently.

 

References:

1. Happel TJ. Morphinism from the standpoint of the general practitioner.    1900; 35:407-409.
2. Abuse, Substance. “Mental Health Services Administration (2014) Results from the 2013 national survey on drug use and health: summary of national findings.” NSDUH Series H-48, HHS Publication No.(SMA) (2014): 14-4863.
3. Patrick, S. W., et al. “Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012.” Journal of Perinatology8 (2015): 650-655.
4. Benoit, Cecilia, et al. “Providers’ constructions of pregnant and early parenting women who use substances.” Sociology of health & illness2 (2014): 252-263.
5. Abel, Ernest L., and Michael Kruger. “Physician attitudes concerning legal coercion of pregnant alcohol and drug abusers.” American journal of obstetrics and gynecology4 (2002): 768-772.
6. Kohsman, Mindy G. “Ethical Considerations for Perinatal Toxicology Screening.” Neonatal Network5 (2016): 268-276.
7. Marcellus L. Neonatal abstinence syndrome: reconstructing the evidence.  Neonatal Network.  2007;26(1):33-40.
8. Maguire, Taylor, Armstrong et al. (2016). Characteristics of maternal-infant interaction during treatment for opioid withdrawal.  Neonatal Network. 35(5): 297-304.
9. Welle‐Strand, Gabrielle K., et al. “Breastfeeding reduces the need for withdrawal treatment in opioid‐exposed infants.” Acta Paediatrica11 (2013): 1060-1066.
10. Cirillo, C & Francis, K. (2016). Does breast milk affect neonatal abstinence syndrome severity, the need for pharmacologic therapy and length of stay for infants of mothers on opioid maintenance therapy during pregnancy?  Advances in Neonatal Care.  16(5):369-378.
11. Godfrey, Jodi R., and Ruth A. Lawrence. “Toward optimal health: the maternal benefits of breastfeeding.” Journal of women’s Health9 (2010): 1597-1602.
12. Ross-Cowdery, M., Lewis, C. A., Papic, M., Corbelli, J., & Schwarz, E. B. (2016). Counseling About the Maternal Health Benefits of Breastfeeding and Mothers’ Intentions to Breastfeed. Maternal and Child Health Journal, 1-8.
13. Jansson, Lauren M. “ABM clinical protocol# 21: Guidelines for breastfeeding and the drug-dependent woman.” Breastfeeding Medicine4 (2009): 225-228.
14. Liu, Anthony, et al. “Feeding modalities and the onset of the neonatal abstinence syndrome.” Frontiers in pediatrics 3 (2015).
15. Pritham, Ursula A. “Breastfeeding promotion for management of neonatal abstinence syndrome.” Journal of Obstetric, Gynecologic, & Neonatal Nursing5 (2013): 517-526.
16. American Academy of Pediatrics (2012). Policy statement.  Breastfeeding and the use of human milk.  129(3), e827-e841.
17. American College of Obstetricians and Gynecologists. (2012).  Opioid abuse, dependence, and addiction in pregnancy. Committee opinion No. 524.  Obstetrics & Gynecology.  119, 1070-1076.
18. Jones, H. E., Dengler, E., Garrison, A., O’Grady, K. E., Seashore, C., Horton, E., … & Thorp, J. (2014). Neonatal outcomes and their relationship to maternal buprenorphine dose during pregnancy. Drug and alcohol dependence, 134, 414-417.
19. Jansson, L. M., Choo, R. E., Harrow, C., Velez, M., Schroeder, J. R., Lowe, R., & Huestis, M. A. (2007). Concentrations of methadone in breast milk and plasma in the immediate perinatal period. Journal of Human Lactation, 23(2), 184-190.
20. Jansson, L. M., Choo, R., Velez, M. L., Harrow, C., Schroeder, J. R., Shakleya, D. M., & Huestis, M. A. (2008). Methadone maintenance and breastfeeding in the neonatal period. Pediatrics, 121(1), 106-114.
21. Jansson, L. M., Choo, R., Velez, M. L., Lowe, R., & Huestis, M. A. (2008). Methadone maintenance and long-term lactation. Breastfeeding Medicine, 3(1), 34-37.
22. Lindemalm, Synnove, et al. “Transfer of buprenorphine into breast milk and calculation of infant drug dose.” Journal of Human Lactation2 (2009): 199-205.
23. Malpas, T. J., J. Horwood, and B. A. Darlow. “Breastfeeding reduces the severity of neonatal abstinence syndrome.” J Paediatr Child Health 33 (1997): A38.
24. Pritham, U. A., Paul, J. A., & Hayes, M. J. (2012). Opioid dependency in pregnancy and length of stay for neonatal abstinence syndrome. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41(2), 180-190.
25. Wachman, Elisha M., John Byun, and Barbara L. Philipp. “Breastfeeding rates among mothers of infants with neonatal abstinence syndrome.” Breastfeeding Medicine4 (2010): 159-164.
26. Tsai, Lillian C., and Therese Jung Doan. “Breastfeeding among Mothers on Opioid Maintenance Treatment A Literature Review.” Journal of Human Lactation (2016): 0890334416641909.
27. O’Connor, A., Alto, W., Musgrave, K., Gibbons, D., Llanto, L., Holden, S., & Karnes, J. (2011). Observational study of buprenorphine treatment of opioid-dependent pregnant women in a family medicine residency: reports on maternal and infant outcomes. The Journal of the American Board of Family Medicine, 24(2), 194-201.
28. O’Connor, A. B., Collett, A., Alto, W. A., & O’Brien, L. M. (2013). Breastfeeding rates and the relationship between breastfeeding and neonatal abstinence syndrome in women maintained on buprenorphine during pregnancy. Journal of midwifery & women’s health, 58(4), 383-388.

Table 1

With breast feeding, these conditions are seen less in the infant	With breastfeeding, these conditions are seen less in the mother
Respiratory illnesses	Breast cancer
Otitis media	Ovarian Cancer
Gastritis and diarrhea	Diabetes type II
UTIs	Hypertension
Asthma	Rheumatoid arthritis
Atopic dermatitis	Depression
Obesity	Cardiovascualar disease
Diabetes type I & II
Childhood leukemia & lymphoma
SIDS
15,16	11, 12

Table 2

Measures to support breast feeding in the infant with NAS

• Combined obstetric and addiction treatment
• Current knowledge regarding safety of breast feeding in the presence of OMT
• Rooming in
• Address maternal anxiety
• Smaller, more frequent feedings
• Put to breast while drowsy and swaddled

Jansson, Lauren M., Martha Velez, and Cheryl Harrow. “Methadone maintenance and lactation: a review of the literature and current management guidelines.” Journal of Human Lactation 20.1 (2004): 62-71.

This article appeared previously in the Winter 2017 issue of Neonatal Intensive Care.