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.