Substance use disorder

Should I breastfeed if I am using street drugs?

Drug use is complicated. Mothers who are breastfeeding and using illegal drugs or using excess amounts of legal ones should see their health-care providers. They will need to consider the benefits of breastfeeding, the impact of the drugs on the baby, and their ability to care for the baby. If mothers use PCP (phencyclidine) or cocaine, they should not breastfeed. Babies have been harmed by opioids. Using them during pregnancy can result in the baby having withdrawal symptoms (neonatal abstinence syndrome). Mothers in an opioid recovery program, using stable amounts of methadone and buprenorphine, are encouraged to breastfeed under certain conditions.

A) Breastfeeding with a substance use disorder

Substance use disorder is a complicated topic (Reece-Stremtan 2015; Sachs 2013). It can involve the use of illegal drugs or the abuse of legal ones. 

Mothers need to balance the benefits of breastfeeding for themselves and their babies against the impact of these substances on each. Considerations include:

  • The risks of exposing a baby to certain drugs during pregnancy and through breast milk.
  • The combined effect of multiple medications.
  • The risk of infecting a baby with dangerous viruses (HIV [the AIDS virus] or HTLV) through breast milk when a mother uses intravenous drugs.
  • The impact on the mother’s ability to care for her child.

B) When not to breastfeed

Street drugs can damage a baby’s brain development and health and even cause death (Reece-Stremtan 2015).

Street drugs can damage a baby’s brain development and health and even cause death (Reece-Stremtan 2015).Mothers who use PCP (phencyclidine) and cocaine should not breastfeed. Babies have been harmed by opioids. Even cannabis has the potential to harm the baby.

If you have a substance use disorder, please discuss this with your health-care providers and consider using additional resources for more information.

C) Controlled opioid use

Mothers using stable amounts of methadone and buprenorphine as part of a recovery program are encouraged to breastfeed because the concentration of each in breast milk is low. These mothers need to be (Reese-Stremtan 2015):

  • Otherwise well.
  • Free of HIV infection.
  • Stable on methadone or buprenorphine.
  • Not taking other substances that can harm the baby.
  • Receiving good support and monitoring.

D) Neonatal abstinence syndrome

1) Neonatal abstinence syndrome

If mothers are using opioids (legal and illegal) during pregnancy, their baby is exposed to the medication and becomes use to it.

After delivery, the baby no longer receives these medications and develops signs of withdrawal. This is called neonatal abstinence syndrome (NAS).  

2) Signs of neonatal abstinence syndrome

Babies with NAS may:

  • Show neurological abnormalities,including:
    • A high-pitched cry.
    • Jitteriness.
    • Tremors.
    • Generalized convulsions.
    • Excessive sucking or rooting.
    • Sleeping less.
    • Having tense muscles.
  • Have feeding and digestive problems,including:
    • Poor feeding.
    • Vomiting.
    • Diarrhea.
  • Sweat.
  • Have a fever.
  • Have several different shades of skin colour (mottled).
  • Breathe too fast.

NAS develops in 50% to 75% of babies born to mothers who use opioids (Casper 2014). It can start between 1 and 10 days after delivery and last up to several months (Kocherlakota 2014). The timing and severity of NAS depend on:

  • The type and amount of opioids
  • The time of the mother’s last use of opioids.
  • The number of opioids used.
  • How long opioids were used during the pregnancy.

3) Effects of neonatal abstinence syndrome

Over the longer term, babies who have had NAS are at an increased risk of sudden infant death syndrome (SIDS) and abnormalities in brain development.

4) Caring for babies with neonatal abstinence syndrome

Traditionally, babies born with NAS were cared for in a hospital neonatal intensive care unit (NICU). These units are generally high-stress environments that may limit a mother’s access to her baby.

More recently, babies who are full term or near term and are medically stable are cared for by their mothers in hospital but outside of the NICU (Lacaze-Masmonteil 2018). The benefits of this include the following (MacMillan 2018; MacVicar 2019; Wachman 2018):

  • Mothers and babies being in a less stressful environment
  • Higher rates of mothers starting to breastfeed
  • Babies spending more time skin-to-skin
  • Babies needing less medication to treat NAS
  • Babies requiring less time in hospital
  • Lower treatment costs for healthcare systems

5) Breastfeeding babies with neonatal abstinence syndrome

Mothers need to ensure that they meet the criteria for safe breastfeeding before proceeding. 

Breastfeeding babies with NAS (Favara 2019; Wu 2018):

  • Reduces the amount of time they spend in hospital.
  • Decreases the severity of NAS.
  • Decreases the amount of medication they need.

These benefits may come from (Bogen 2019):

  • The calming effect of breastfeeding.
  • The qualities of breast milk.
  • Healthier gut bacteria (microbiome).
  • The small amounts of opoids in breast milk that may help the baby to withdraw.

References

Bogen DL, Whalen BL. Breastmilk feeding for mothers and infants with opioid exposure: What is best? Semin Fetal Neonatal Med. 2019 Apr;24(2):95-104
 
Casper T, Arbour M. Evidence-based nurse-driven interventions for the care of newborns with neonatal abstinence syndrome. Adv Neonatal Care. 2014 Dec;14(6):376-80
 
Favara MT, Carola D, Jensen E, et al. Maternal breast milk feeding and length of treatment in infants with neonatal abstinence syndrome. J Perinatol. 2019 Jun;39(6):876-882
 
Lacaze-Masmonteil T, O'Flaherty P. Managing infants born to mothers who have used opioids during pregnancy. Paediatr Child Health. 2018 May;23(3):220-226
 
Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014 Aug;134(2):e547-61
 
MacMillan KDL, Rendon CP, Verma K, et al. Association of Rooming-in With Outcomes for Neonatal Abstinence Syndrome: A Systematic Review and Meta-analysis. JAMA Pediatr. 2018 Feb 5
 
MacVicar S, Kelly LE. Systematic mixed-study review of nonpharmacological management of neonatal abstinence syndrome. Birth. 2019 Apr 2
 
Reece-Stremtan S, Marinelli KA. ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med. 2015 Apr;10(3):135-41
 
Sachs HC and the Committee on Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics 2013;132(3)
 
Wachman EM, Schiff DM, Silverstein M. Neonatal Abstinence Syndrome: Advances in Diagnosis and Treatment. JAMA. 2018 Apr 3;319(13):1362-1374
 
Wu D, Carre C. The Impact of Breastfeeding on Health Outcomes for Infants Diagnosed with Neonatal Abstinence Syndrome: A Review. Cureus. 2018 Jul 28;10(7):e3061