1. Difficult conversations in the Neonatal Period
Opiate Use and Breastfeeding
Difficult conversations in the Neonatal Period

2. Disclosures
I have nothing to disclose and no conflicts of interest

3. A Common Scenario…..
You are called to do a prenatal consult with a pregnant mom
Mom is on methadone maintenance for a previous heroin addiction
You meet a well dressed young woman who is obviously nervous about this discussion
Her main question: Can I breastfeed?

4. Objectives
Provide an update on the prevalence and patterns of opiate use in breastfeeding women
Describe the passage of opiate medications into breast milk and the effects on the newborn
Discuss indications and contraindications to breastfeeding in women using opiates

5. Illicit Substance Use
Past Year Heroin Initiates among People Aged 12 or Older, by Age Group (in thousands):
(SAMSHA NSDUH 2014)
10.2% of Americans older than 12 are current illicit drug users
Non-medical use of prescription drugs is second only to Marijuana use
Primarily opioid class pain relievers
Use of Heroin has more than doubled since 2007
SAMSHA NSDUH 2014

6. Scope of the Problem: Among pregnant women:
5.9% report use of illicit drugs (Samsa-NSHUD 2013)
28% were prescribed at least one opioid pain reliever during pregnancy (Patrick 2015)
96% were non-maintenance prescription opioids
20% of women experience mood or anxiety disorders during pregnancy (Flynn 2006)

7. Substance Use Patterns
Prepared 3/3/2015 by Karina Atwell, MD UW‐Madison Preventive Medicine Resident

8. Opioids in Pregnancy
Opioids easily pass the placental and blood-brain barrier.
Fetus can develop physical addiction
Opioids inhibit release of norepinephrine from nerves in the brain
Tolerance develops and more norepinephrine is produced by the brain to overcome the inhibition
If opioids are suddenly taken away large amounts of norepinephrine are released and produce the physical signs of withdrawal
If the mother stops using opioids her fetus will experience withdrawal and will be at increased risk for distress and fetal loss

9. Neonatal Abstinence Syndrome (NAS)

10. Incidence of neonatal abstinence syndrome per 1000 hospital births in the United States, 2009 to 2012.
Patrick, J Perinatol 2015

11. NAS in Wisconsin !
Prepared 3/3/2015 by Karina Atwell, MD UW‐Madison Preventive Medicine Resident

12. Treatment of NAS Pharmacologic treatment with opiates
Restart the infant on morphine
Slowly wean
Non-pharmacologic treatment
Tight swaddling
Holding and rocking
Quiet dark room
Limit number of visitors
Feeding on demand
Small frequent feeds
Have pacifier available

13. Length of Stay
Prepared 3/3/2015 by Karina Atwell, MD UW‐Madison Preventive Medicine Resident

14. How do opiates work?

15. Passage of opiates into milk

16. What is baby getting? Depends on Size of molecule
Degree of protein binding
Lipid solubility
Ionization
Maternal factors
Infant factors

17. Estimating Infant Dose
Milk to Plasma Ratio
Ratio between the concentration of medication in the maternal plasma and milk at steady state
Estimate of the relative amount of drug in milk
Of limited value unless you know the maternal serum concentration
even if a medication has a milk to plasma ratio of greater than 1, the concentration in the breast milk may still be low if maternal plasma levels are low

18. Methadone Full opioid agonist
Will interact with the brain in the same way that morphine does.
Very long half life (mean half life is 22 hours)
Mothers must go to the methadone clinic every day to get their dose

19. Transfer of Methadone into Breastmilk
Variable but minimal transfer of methadone into breastmilk
Average amount transferred to infant mg/day
1-3% of maternal weight adjusted dose
Less than dosage used to treat NAS

20. Buprenorphine Subutex/Suboxone Semi-synthetic partial agonist
Binds opioid receptors in the brain but is not very active.
Can be prescribed to women who can pick up weeks worth of doses at one time
Popular choice for women in rural or remote areas.

21. Buprenorphine and breastfeeding
Buprenorphine has low oral bioavailability (31%)
Very low levels in breastmilk
0.38% of maternal buprenorphine dose
0.18% of maternal norbuprenorphine dose
Assumed to be safe – more studies needed
Ilett et al. Breastfeed Med 2012

22. Other Opiates Hydrocodone, oxycodone and fentanyl
Usual doses for pain relief have minimal to no effect on infant
When used as a drug of abuse mothers should be transitioned to maintenance opiate
Caution with codeine

23. Polydrug Exposure
NAS complicated by the interplay between opioid withdrawal and withdrawal from other substances
SSRIs (7-8%) and Tobacco (85%) are common co-exposures
Symptoms are similar to NAS and may exacerbate NAS
Benzodiazepines, barbiturates and alcohol are also known to cause withdrawal signs in infants.

24. Polydrug Exposure
Fetuses exposed to methadone + polysubstances in utero had:
Decreased fetal heart rate
Decreased fetal movement
Delivered 1 week earlier than fetuses exposed to methadone only or no methadone
Required treatment for NAS twice as often
Jannson, Drug and Alcohol Dependence 2012

25. Breastfeeding and opiates

26. Breastfeeding and NAS Challenges Lack of evidence based guidelines
Polydrug use
Infectious disease risk
Poor nutrition
Comorbid psychiatric disorders
Lack of evidence based guidelines
Jansson. Breastfeeding Medicine 2009

27. Evidence Based Web Sites
LactMed
E-Lactancia
English and spanish

28. Screening for opiate use
Based on risk?
Universal screening?
Universal Drug Testing in a High-Prevalence Region for Opiate Abuse
2995 pregnant women, 96 + for opiates
77/96 had risk factors that would have triggered screening
19/96 had no risk factors that would have triggered screen
Wexelblatt et al. Journal of Pediatrics 2015

29. Breastfeeding Initiation Rates
UK – 14% in women using opiates vs 50% in general population (Goel 2011)
Norway – 77% in women using opiates vs 98% in general population (Welle-Strand 2013)
US women using opiate with no contraindications to breastfeeding
66% did not initiate BF
24% did initiate BF: 40% still BF at time of discharge (Wachman 2010)

30. Barriers to Breastfeeding
Low SES
High prevalence of mental health issues
Lack of knowledge about specific benefits of breastfeeding
Prejudice
Need for urine drug screening

31. Advantages of breastfeeding
Breastfeeding is recommended for women compliant with treatment and on maintenance medications regardless of dose
Shorter length of hospital stay
Lower Finnegan scores
Less likely to require pharmacologic treatment
If treatment is needed: lower doses of medication and shorter duration of treatment
Abdel-Letiff, Pediatrics 2006

32. Breastfeeding and Incidence of NAS Requiring Pharmacologic Treatment
Breastfed
Formula Fed
Welle-Strand
57% (n=58)
69% (n=20)
Wachman
50% (n=38)
77% (n=48)
Abdel-Latif
52.9% (n=85)
79% (n=105)
O’Connor
23.1%
30%

33. Breastfeeding and Length of Treatment
Formula Feeding
Abdel Latif
85 days (n=85)
108 days (n=105)
Welle-Strand
31 days (n=58)
49 days (n=20)
Wachman
15.8 days (n=38)
27.4 days (n=48)

34. Why? Dosage of opioids in breastmilk low
Known benefits of breastfeeding:
Skin to skin
Holding and soothing
Bonding
Enhanced confidence
Increased maternal participation in care of the infant

35. Breastfeeding and SIDS
Protective effect of Breastfeeding against SIDS (AAP 2005)
Infants exposed to opiates at higher risk for SIDS (Burns et al 2010)

36. Encourage breastfeeding
Women in treatment
Consent for communication
No illicit substance use in last 90 days
Negative urine tox screens
Consistent prenatal care
No medical contraindications
Reece-Stremtan Breastfeeding Medicine 2015

37. Consider breastfeeding
Relapse in days before delivery but not within 30 days of delivery
Other prescription medications
Prenatal care or substance abuse treatment after the second trimester
Custody or sobriety as motivators
Lack of family and community support systems
Reece-Stremtan Breastfeeding Medicine 2015

38. Counsel women not to breastfeed:
Not in substance abuse treatment
No prenatal care
Relapse into illicit substance use within 30 days of delivery
Unwillingness to seek treatment or allow communication
Positive urine tox screen at delivery
Women with active drug use
Chronic alcohol use
Other contraindication for breastfeeding
Reece-Stremtan Breastfeeding Medicine 2015

39. No easy answers….. Trauma informed care
Family centered care of the newborn
Prenatal counseling and education

40. References
CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers and Other Drugs Among Women — United States, 1999– Morbidity & Mortality Weekly Report. 2013, July 5:62(26);
Chisholm MS et al. Relationship between cigarette use and mood/anxiety disorders among pregnant and methadone maintained patients. Am J of Addiction. 2009;18:
Finnegan LP et al. Neonatal Abstinence Syndrome: Assessment and Management. Addictive Diseases. 1975;2(1):
Flynn HA, Blow FC, Marcus SM. Rates and predictors of depression treatment among pregnant women in hospital- affiliated obstetrics practices. General Hospital Psychiatry, Vol, 28, No. 4, July-August 2006, pp
Hudak ML et al. Neonatal Drug Withdrawal. Pediatrics. 2012;129(2):e540-e561
Jansson LM et al. The opioid exposed newborn: Assessment and pharmacologic management. Journal of Opioid Management. 2009;5(1):47-55
Johnston A. Neonatal Abstinence Syndrome Scoring: Guidelines for treatment with methadone. Scoring Tool Training MOTHER study 2006
Jones HE et al. Neonatal Abstinence Syndrome after methadone or buprenorphine exposure. NEJM ;363(24):
King JC. Substance Abuse in Pregnancy. A bigger problem than you think. Postgrad Medicine. 1997;102(3):
Lambers DS and Clark KE. The maternal and fetal physiologic effects of nicotine. Semin Perinatol. 1996;20(2):115-26
Patrick SW et al. Prescription Opioid Epidemic and Infant Outcomes. Pediatrics (5)
Patrick SW et al. Incidence and Geographic distribution of NAS: United States 2009 to J Perinatol 2015
Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use and Health: Vol 1: Summary of National Findings 2010

41. References
Reese-Stremtan S. ABM Clinical Protocol #21: Guidelines for Breastfeeding and Substance Abuse or Substance Use Disorder, Revised 2015 Breastfeeding Medicine 2015: 10(3)
Welle-Strand GK, Skurtveit S, Jansson LM, et al. Breast- feeding reduces the need for withdrawal treatment in opioid- exposed infants. Acta Paediatr 2013;102:1060–1066.
Abdel-Latif ME, Pinner J, Clews S, et al. Effects of breast milk on the severity and outcome of NAS among infants of drug-dependent mothers. Pediatrics 2006;117:1163–1169.
Jansson LM, Choo R, Velez ML, et al. Methadone main- tenance and breastfeeding in the neonatal period. Pediatrics 2008;121:106–114.
Jansson LM, Choo R, Velez ML, et al. Methadone main- tenance and long-term lactation. Breastfeed Med 2008;3: 34–37.
Kocherlakota P. Neonatal abstinence syndrome. Pediatrics 2014;134:e547–e561.
Wachman EM, Byun J, Philipp BL. Breastfeeding rates among mothers of infants with neonatal abstinence syn- drome. Breastfeed Med 2010;5:159–164.
D’Apolito K. Breastfeeding and substance abuse. Obstet
Clin Gynecol 2013;56:202–211.
Jannson et al. Pregnancies exposed to methadone, methadone and other illicit substances, and poly-drugs without methadone: A comparison of fetal neurobehaviors and infant outcomes. Drug and Alcohol Dependence (3):

42. Department of Pediatrics University of Wisconsin – Madison
Questions
Elizabeth Goetz MD MPH
Department of Pediatrics
University of Wisconsin – Madison
Meriter Hospital