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Guideline Summary
Guideline Title
Guidelines for breastfeeding and the drug-dependent woman.
Bibliographic Source(s)
Academy of Breastfeeding Medicine Protocol Committee, Jansson LM. ABM clinical protocol #21: Guidelines for breastfeeding and the drug-dependent woman. Breastfeed Med. 2009 Dec;4(4):225-8. [29 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Academy of Breastfeeding Medicine (ABM) protocols expire 5 years from the date of publication. Evidence-based revisions are made within 5 years or sooner if there are significant changes in the evidence.

Scope

Disease/Condition(s)
  • Drug-dependence in women
  • Infant nutritional status and health
Guideline Category
Counseling
Evaluation
Management
Risk Assessment
Clinical Specialty
Family Practice
Nursing
Obstetrics and Gynecology
Pediatrics
Psychology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Substance Use Disorders Treatment Providers
Guideline Objective(s)

To provide evidence-based guidelines for the evaluation and management of the drug-dependent woman choosing to breastfeed

Target Population

Women of child-bearing age with a history of past or current drug abuse

Interventions and Practices Considered

Evaluation

  1. Obtain a maternal substance abuse history
  2. Assessment of the mother-infant dyad during the perinatal period

Counseling/Management

  1. Develop prenatal care plan
  2. Obtain maternal written consent for communication between abuse treatment providers and obstetrical and pediatric healthcare providers
  3. Refer drug-dependent women to substance abuse treatment programs
  4. Counsel drug-dependent women about the consequences of relapse to drug or alcohol use during lactation 
  5. Refer for psychiatric care when warranted
  6. Monitor drug-dependent women during the postpartum period
  7. Ongoing pediatric care and lactation support
Major Outcomes Considered
  • Concentrations of drug usage in human milk
  • Short-term and long-term effects of drugs on neurodevelopment
  • Prevalence of neonatal abstinence syndrome (NAS)

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

An initial search of relevant published articles written in English in the past 20 years in the fields of medicine, psychiatry, psychology, and basic biological science is undertaken for a particular topic. Once the articles are gathered, the papers are evaluated for scientific accuracy and significance.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

I - Evidence obtained from at least one properly randomized controlled trial

II-1 - Evidence obtained from well-designed controlled trials without randomization

II-2 - Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3 - Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

III - Opinions of respected authorities, based on clinical experience, descriptive studies and case reports; or reports of expert committees

Methods Used to Analyze the Evidence
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

An expert panel is identified and appointed to develop a draft protocol using evidence based methodology. An annotated bibliography (literature review), including salient gaps in the literature, are submitted by the expert panel to the Protocol Committee.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Draft protocol is peer reviewed by individuals outside of lead author/expert panel, including specific review for international applicability. Protocol Committee's sub-group of international experts recommends appropriate international reviewers. Chair (co-chairs) institutes and facilitates process. Reviews submitted to committee Chair (co-chairs).

Draft protocol is submitted to The Academy of Breastfeeding Medicine (ABM) Board for review and approval. Comments for revision will be accepted for three weeks following submission. Chair (co-chairs) and protocol author(s) amends protocol as needed.

Following all revisions, protocol has final review by original author(s) to make final suggestions and ascertain whether to maintain lead authorship.

Final protocol is submitted to the Board of Directors of ABM for approval.

Recommendations

Major Recommendations

Infants of drug-dependent women, at risk for multiple health and developmental difficulties, stand to benefit substantially from breastfeeding and human milk, as do their mothers. A prenatal plan preparing the mother for parenting, breastfeeding, and postpartum substance abuse treatment should be formulated for each woman. This care plan should include instruction in the consequences of relapse to drug or alcohol use during lactation, as well as teaching regarding formula preparation and bottle care should breastfeeding be contraindicated.

During the perinatal period each mother-infant dyad must be carefully and individually evaluated prior to the institution of breastfeeding. This evaluation must consider several factors, including maternal drug use and substance abuse treatment histories, medical and psychiatric status and medication needs, infant health status (to include ongoing evaluation for neonatal abstinence syndrome [NAS] and impact on breastfeeding), the presence or absence and adequacy of maternal family and community support systems and plans for postpartum health care, psychiatric care (if warranted) and substance abuse treatment for the mother, and pediatric care for the child. Optimally, the chemically dependent woman who presents a desire to breastfeed should be engaged in substance abuse treatment. Maternal written consent for communication between the substance abuse treatment providers and obstetrical and pediatric healthcare providers should ideally be obtained prior to delivery. However, if it was not, then consent for bidirectional communication should occur after delivery.

Please note that the following recommendations are based largely on expert opinion because of the sparse research base on these issues.

Women who meet all of the following criteria under the following circumstances should be supported in their decision to breastfeed their infants:

  • Women engaged in substance abuse treatment who have provided their consent to discuss progress in treatment and plans for postpartum treatment with substance abuse treatment counselor
  • Women whose counselors endorse that she has been able to achieve and maintain sobriety prenatally; counselor approves of client’s plan for breastfeeding
  • Women who plan to continue in substance abuse treatment in the postpartum period
  • Women who have been abstinent from illicit drug use or licit drug abuse for 90 days prior to delivery and have demonstrated the ability to maintain sobriety in an outpatient setting
  • Women who have a negative maternal urine toxicology testing at delivery except for prescribed medications
  • Women who received consistent prenatal care
  • Women who do not have medical contraindication to breastfeeding (such as HIV)
  • Women who are not taking a psychiatric medication that is contraindicated during lactation
  • Stable methadone-maintained women wishing to breastfeed should be encouraged to do so regardless of maternal methadone dose.

Women under the following circumstances should be discouraged from breastfeeding:

  • Women who did not receive prenatal care
  • Women who relapsed into illicit drug use or licit substance misuse in the 30-day period prior to delivery
  • Women who are not willing to engage in substance abuse treatment or who are engaged in treatment but are not willing to provide consent for contact with the counselor
  • Women with positive maternal urine toxicology testing for drugs of abuse or misuse of licit drugs at delivery
  • Women who do not have confirmed plans for postpartum substance abuse treatment or pediatric care
  • Women who demonstrate behavioral qualities or other indicators of active drug use

Women under the following circumstances should be carefully evaluated, and a recommendation for suitability or lack of suitability for breastfeeding should be determined by coordinated care plans among perinatal providers and substance abuse treatment providers:

  • Women relapsing to illicit substance use or licit substance misuse in the 90–30-day period prior to delivery, but who maintained abstinence within the 30 days prior to delivery
  • Women with concomitant use of other prescription (i.e., psychotropic) medications
  • Women who engaged in prenatal care and/or substance abuse treatment during or after the second trimester
  • Women who attained sobriety only in an inpatient setting

While maternal prescription opioid use and buprenorphine maintenance may be safe for infants of some lactating women, the research literature is too sparse for recommendations to be made about these substances.

Women who have established breastfeeding and subsequently relapse to illicit drug use should be strongly discouraged from breastfeeding, even if milk is discarded during the time period surrounding relapse. There are no known pharmacokinetic data to establish the presence and/or concentrations of most illicit substances and/or their metabolites in human milk and effects on the infant, and this research is unlikely to occur given the ethical dilemmas it presents. The lack of pharmacokinetic data for most drugs of abuse in recently postpartum women precludes the establishment of a "safe" interval after use when breastfeeding can be reestablished for individual drugs of abuse. Additionally, women using illicit substances in the postnatal period may have impaired judgment, and secondary behavioral changes may interfere with the ability of the mother to care for or feed her infant adequately. Passive drug exposures may pose additional risks to the infant. Therefore, any woman relapsing to illicit drug use or licit substance misuse after the establishment of lactation should be provided formula. The aforementioned issues are relevant regardless of infant feeding choice, and all plans must include intensified drug treatment for the mother.

The drug-dependent woman who has successfully instituted breastfeeding should be carefully monitored, along with her infant, in the postpartum period. Ongoing substance abuse treatment, postpartum care, psychiatric care when warranted, and pediatric care are important for this group. Lactation support is particularly important for infants experiencing NAS. Communication between providers should provide an interactive network of supportive care for the dyad.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Please note that the recommendations are based largely on expert opinion because of the sparse research base on these issues.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate evaluation and management of the drug-dependent woman choosing to breastfeed
  • Despite the myriad of factors that may make breastfeeding a difficult choice for the drug-dependent woman, the population of drug-exposed infants, at high risk for an array of medical, psychological, and developmental problems, as well as their mothers, stands to benefit from breastfeeding.
Potential Harms

Not stated

Contraindications

Contraindications
  • There have been several comprehensive reviews of breastfeeding among chemically dependent women, with most concluding that breastfeeding is generally contraindicated in mothers who use illegal drugs.
  • Psychiatric medication may be contraindicated during lactation.
  • Human immunodeficiency virus (HIV) is a medical contraindication to breastfeeding.

Qualifying Statements

Qualifying Statements

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Academy of Breastfeeding Medicine Protocol Committee, Jansson LM. ABM clinical protocol #21: Guidelines for breastfeeding and the drug-dependent woman. Breastfeed Med. 2009 Dec;4(4):225-8. [29 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Dec
Guideline Developer(s)
Academy of Breastfeeding Medicine - Professional Association
Source(s) of Funding

Academy of Breastfeeding Medicine

This work supported in part by National Institute on Drug Abuse grant RO1 DA019934 awarded to L.M. Jansson.

Guideline Committee

Academy of Breastfeeding Medicine Protocol Committee

Composition of Group That Authored the Guideline

Lead author: Lauren M. Jansson, M.D.

Protocol Committee: Maya Bunik, M.D., MSPH, FABM; Caroline J. Chantry, M.D., FABM (Co-Chairperson); Cynthia R. Howard, M.D., MPH, FABM (Co-Chairperson); Ruth A. Lawrence, M.D., FABM; Kathleen A. Marinelli, M.D., FABM (Co-Chairperson); Nancy G. Powers, M.D., FABM

Financial Disclosures/Conflicts of Interest

None to report

Guideline Status

This is the current release of the guideline.

Academy of Breastfeeding Medicine (ABM) protocols expire 5 years from the date of publication. Evidence-based revisions are made within 5 years or sooner if there are significant changes in the evidence.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Academy of Breastfeeding Medicine Web site External Web Site Policy.

Print copies: Available from the Academy of Breastfeeding Medicine, 140 Huguenot Street, 3rd floor, New Rochelle, New York 10801.

Availability of Companion Documents

The following is available:

  • Procedure for protocol development and approval. Academy of Breastfeeding Medicine. 2007 Mar. 2 p.

The appendix of the original guideline document External Web Site Policy includes a sample hospital policy on illicit drug use and breastfeeding.

Print copies: Available from the Academy of Breastfeeding Medicine, 140 Huguenot Street, 3rd floor, New Rochelle, New York 10801.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on March 11, 2010. The information was verified by the guideline developer on April 21, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Single copies may be downloaded for personal use. Copyright permission to be requested for use of multiple copies by e-mailing requests to abm@bfmed.org. An official request form will be sent electronically to person requesting multiple copy use.

Disclaimer

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The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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