1. Rika Dombrowski PHN, MS, MA, IBCLC

2. Among pregnant women 15-44 years of age in U.S, -5.2% had used illicit drugs in the past month. -9.4% Alcohol use 2.3% binge drinking during pregnancy, 0.4% heavy drinking -15.4% cigarette use in past month

3. L1: Compatible A large number of breastfeeding mothers without any observed increase in adverse effects in the infant. L2: Probably compatible A limited number of breastfeeding mothers without any observed increase in adverse effects in the infant. L3: Probably compatible There are no control studies in breastfeeding women; may have some risk or only minimal non-threatening adverse effects. L4: Possibly Hazardous Evidence of risk to a breastfed infant or to breast milk production. But benefits from use in breastfeeding mothers may acceptable. L5: Hazardous Significant and documented risk to the infant. ( Source:Dr Hale Medications and Mother’s milk 2014)

4. Methadone is women with opioid dependence in treatment. Opiod Medications-hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), morphine (Kadian, Avinza), codeine, and related drugs. Significant data-The concentrations of methadone found in human milk are low, and all authors have concluded that women on stable doses of methadone maintenance should be encouraged to breastfeed if desired.

5. - Buprenorphine and Naloxone are opioid antagonist. -The amounts of Buprenorphine in human milk are small and there are no evidence that use of this drug will unlikely to have short-term negative effects on the developing infant.

6. Increase in incidence more than double from 2000-2009. -Information is lacking on the safety of breastfeeding when moderate to high doses of opioids are used for long periods of time. -There is also a lack of information available about transitioning mothers from short-acting opioids to opioid maintenance therapy while breastfeeding rather than during pregnancy. * Encourage stable methadone- or buprenorphine- maintained women to breastfeed regardless of dose.

7. Uniform guidelines regarding the varied use of marijuana by breastfeeding mothers are difficult to create and cannot to cover all situations. -Tetrahydrocannabinol (THC), the main compound in marijuana, is present in human milk up to 8x that of maternal plasma levels, and metabolites are found in infant feces, indicating that THC is absorbed and metabolized by the infant. It is rapidly distributed to the brain and adipose tissue and stored in fat tissues for weeks to months. -Exposure to second-hand marijuana smoke by infants has been 2x possible risk of sudden infant death syndrome(SIDS) because breastfeeding reduces risk of SIDS, this needs to be additionally considered.

8. *Breastfeeding mothers should be counseled to reduce or eliminate their use of marijuana to avoid exposing their infants to this substance and advised of the possible long-term neurobehavioral effects from continued use “Dr. Thomas Hale quoted “THC does enter milk easily, but due to low concentration in the maternal plasma, the absolute dose to the infant is low. If the mom smokes occasionally, she should expect that only small levels will be transferred to the infant, probably subclinical amounts, which is why the studies show no developmental abnormalities. The infant will show a positive drug screen, but it is not known for how long; probably correlates with the maternal dose ingested.”

9. Alcohol interferes with the milk ejection reflex, which may ultimately reduce milk production through inadequate breast emptying.  The AAP Section on breastfeeding: “ingestion of alcoholic beverages should be minimized and limited to an occasional intake but no more than 0.5 g alcohol per kg body weight. ( which for a 60 kg mother is approximately 2 oz liquor, 8 oz wine, or 2 beers).  Avoid breastfeeding until alcohol has completely cleared your breast milk. 2-3 hours for 12 ounces (355 milliliters) of 5 percent beer, 5 ounces (148 milliliters) of 11 percent wine or 1.5 ounces (44 milliliters) of 40 percent liquor, depending on your body weight - Possible long-term effects of alcohol in maternal milk remain unknown. * Waiting 2 hours( moderate drink) or longer after the alcohol intake to minimize. Or pump and dump within those time frame. *Pumping & dumping does not speed the elimination of alcohol from the milk.

10. Research…  Alcohol does not increase milk production. In fact, babies nurse more frequently but take in less milk in the 3-4 hours after mom has had a drink, and one study showed a 23% decrease in milk volume with one drink (Mennella &Beauchamp 1991, 1993; Mennella 1997, 1999).  2+ drinks may inhibit let-down (Coiro et al 1992; Cobo 1974).  One study showed changes in the infant’s sleep-wake patterning after short-term exposure to small amounts of alcohol in breast milk — infants whose mothers were light drinkers slept less (Mennella & Gerrish 1998).  Daily consumption of alcohol has been shown in the research to increase the risk for slow weight gain in the infant.  Daily consumption of alcohol (1+ drinks daily) has been associated with a decrease in gross motor development (Little et al 1989). Research…  Alcohol does not increase milk production. In fact, babies nurse more frequently but take in less milk in the 3-4 hours after mom has had a drink, and one study showed a 23% decrease in milk volume with one drink (Mennella &Beauchamp 1991, 1993; Mennella 1997, 1999).  2+ drinks may inhibit let-down (Coiro et al 1992; Cobo 1974).  One study showed changes in the infant’s sleep-wake patterning after short-term exposure to small amounts of alcohol in breast milk — infants whose mothers were light drinkers slept less (Mennella & Gerrish 1998).  Daily consumption of alcohol has been shown in the research to increase the risk for slow weight gain in the infant.  Daily consumption of alcohol (1+ drinks daily) has been associated with a decrease in gross motor development (Little et al 1989).

11. Decreasing numbers of women smoking as pregnancy progresses. But postpartum relapse is common. -Nicotine( L-2) and other compounds are transfer to the infant via milk. (or 2 nd hand smoke) -Increase in the incidence of respiratory allergy and in SIDs. -Smoking cessation modalities( nicotine patch, gum, and buproprion) are compatible with breastfeeding.

12. Optimally, the women with a substance use disorder who desire to breastfeed should be engaged in treatment pre- and postnatal.  Any discussion with mothers who use substances with sedating effects should include counseling on safely caring for her infant and instruction on safe sleep practices.

13.  Encourage women under the following circumstances to breastfeed their infants :  Engaged in substance abuse treatment; stable methadone or buprenorphine maintained  Plans to continue in substance abuse treatment in the postpartum period  Abstinence from drug use for 90 days prior to delivery; ability to maintain sobriety demonstrated in an outpatient setting  Toxicology testing of maternal urine negative at delivery  Engaged in prenatal care and compliant.

14. Not engaged in treatment Not in prenatal care Positive urine test at delivery (other than Marijuana) No plan for postpartum substance treatment Any indicators that the women is actively abusing substances. Chronic alcohol use

15.  Medications and Mother’s milk 2014  The 2013 National Survey on Drug Use and Health: Summary of National Findings http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf  The Academy of Breastfeeding Medicine -revised Clinical Protocol #21: Guidelines for Breastfeeding and Substance Use or Substance Use Disorder. http://online.liebertpub.com/doi/full/10.1089/bfm.2015.9992 http://online.liebertpub.com/doi/full/10.1089/bfm.2015.9992  Neonatal Abstinence Syndrome. Kocherlakota Pediatrics 2014; 134:2 e547-e561  Methadone Maintenance and Breastfeeding in the Neonatal Period. Jansson L, Choo R, Velez M, Harrow C, Schroeder J, Shakleya D, Huestis M. Pediatrics January 2008; 121:1 106-114