Substance Use and Substance Use Disorder During Lactation

CQ #287 - October 30, 2023

by Anne Eglash MD, IBCLC, FABM

#LactFact

New parents who have discontinued nonprescribed substance use by the time of delivery should be supported in breastfeeding initiation and are advised to have close outpatient follow up.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder
Breastfeeding Med 18(10) 2023 p. 715- 733

What are guidelines for breastfeeding and feeding expressed milk in the setting of parental substance use or substance use disorder?

Pregnant or new birth parents with a history of nonprescribed substance use or substance use disorder (SUD) often experience lack of support to breastfeed. These individuals require education for shared decision-making regarding breastfeeding or provision of their milk, as both the parent and infant have the right to health equity afforded by breastfeeding and lactation. Unfortunately, pregnant and new birth parents are often faced with a variety of breastfeeding rules and limitations that are not evidence based.

The Academy of Breastfeeding Medicine (ABM) recently published their updated protocol #21 regarding guidelines on breastfeeding in the setting of substance use and SUD.

According to the 2021 US National Survey on Drug Use and Health data, 7.7%, 10.8%, and 9.8% of pregnant women reported past-month use of nonprescribed substance use, tobacco use, and alcohol use, respectively.

The protocol points out that interdisciplinary prenatal care that includes mental health and addiction treatment, along with social support services leads to improved OB and neonatal outcomes.

There is a great deal of valuable information in this protocol- Test yourself with this week’s question before reading the protocol!

What do you think are accurate statements regarding a history of nonprescribed substance use or SUD and lactation? Hint- 3 are NOT accurate statements:

Laws that criminalize substance use during pregnancy, or mandate reporting to child services deter pregnant women from seeking prenatal care and/or starting medications for their substance use disorder.
Individuals with SUD who are not engaged in prenatal care are more likely to be actively using nonprescribed substances at the time of delivery.
Nonprescribed fentanyl and its metabolites can possibly persist in urine for weeks after the last use.
Single use of cannabis, without chronic use, can cause a positive THC urine screen for up to 4 months.
The World Health Organization recommends routine urine toxicology screening for SUD for all pregnant individuals.
Positive urine drug testing at the time of delivery is strongly associated with ongoing nonprescribed substance use postpartum.
If a parent has evidence of recent nonprescribed substance use at the time of delivery and would like to breastfeed, they should be discouraged from establishing lactation because of the risk to the newborn.
Rooming-in and skin-to-skin decrease neonatal withdrawal syndrome among infants of lactating parents with chronic opioid use.
The half-life of cocaine is 1.5 hours.
Breastfeeding helps to decrease the negative infant effects from secondhand smoke exposure such as sudden unexpected infant death syndrome and respiratory illnesses.
Breastfeeding should be avoided during active use of nonprescribed opioids, nonprescribed hypnotics, and nonprescribed stimulants.

Click here to view the answer to this question.

Correct Answers: A, B, C, F, H, I, J, K (not D, E, G)

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder
Breastfeeding Med 18(10) 2023 p. 715- 733
Miriam Harris, Davida M. Schiff, Kelley Saia, Serra Muftu, Katherine R. Standish, and Elisha M. Wachman

Abstract

Background

The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments.

Key Information

Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are speciﬁc beneﬁts and risks for substance-exposed mother–infant dyads.

Recommendations

This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For speciﬁc breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

IABLE Comment by Anne Eglash MD, IBCLC, FABM

I won’t go into detailed comments regarding this protocol, as it is an important document for all stakeholders working in the birth and breastfeeding world, particularly for those establishing institutional policies and protocols regarding substance use. Please share this far and wide.

Breastfeeding rates among individuals with a history of substance use are low for several reasons, including not being well supported, and personal concern for how their SUD will affect their baby. The authors of the protocol recommend prenatal breastfeeding education that addresses SUD, including the lower risk of neonatal withdrawal syndrome, the safety of medication assisted therapy during lactation, etc.

The protocol recommends supporting breastfeeding among individuals with a history of SUD if their urine drug testing is negative at the time of delivery, as they have a lower risk of postpartum nonprescribed drug use.

Regarding the incorrect answers in the Clinical Question, after single use of cannabis, THC is no longer detected in urine by 6 weeks or less. The half-life of THC is 25-36 hours.

The World Health Organization and the American College of Obstetrics and Gynecology recommend universal screening for SUD during pregnancy using a validated screening tool, not routine urine testing.

Positive urine testing at the time of delivery is strongly associated with continued nonprescribed substance use postpartum. The protocol recommends that if a new birth parent is motivated to breastfeed but reports recent nonprescribed substance use or has positive substance screening, they should be supported in establishing lactation. A multidisciplinary team should work with the parent to determine when it is safe to provide the milk to the infant. Similarly, if a lactating parent returns to nonprescribed substance use they can be advised to express their milk and either save or discard based on their exposure, while evaluating their overall circumstances regarding ongoing substance use.

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Comments (2)

Cecile Tran

October 31, 2023 at 10:53 PM

Dear Dr. Eglash, thanks for updating us on the latest ABM protocol #21. I have a question concerning Cannabis. In terms of what are the actually route , type of cannabis product and potency and frequency we can inform clients that are considered the lowest risk to the baby and mother dyad? The protocol doesn’t give that info just tells us to discuss about that to mothers who wish to use cannabis while breastfeeding (perhaps it is beyond the scope of the article). But where can we get that info or if you can share what info you actually provide in your practice in that situation. Thank you !

IABLE

November 6, 2023 at 10:26 AM

Hi Cecile,
I don’t have that information. I would encourage you to contact the Infant Risk Center. Dr. Thomas Hale has done cannabis research and may be able to give better guidance on this. OVerall, though, the less cannabis use the better, and the lower the strength the better.