October 23, 2023
By Kristen Ampig, MS4, Drexel University College of Medicine

Postpartum women with opioid use disorder may ask their provider if they would need to stop taking buprenorphine or methadone while breastfeeding their newborns. Taking any medication while breastfeeding warrants inquiry into the costs and benefits to the mother, baby and lactation. There is growing evidence demonstrating the safety and benefits of breastfeeding while taking medications for opioid use disorder (MOUD), especially for infants with neonatal abstinence syndrome (NAS). Despite the growing evidence, only 19.6% to 31.4% mothers with opioid use disorders on maintenance therapies initiate breastfeeding compared to the national average of 83.2% in 2018^{1, 2}. This discrepancy highlights the importance of increasing awareness and education for patients and providers.

Infants born with in-utero exposure to illicit opioids, misused prescribed opioids, or MOUD are at risk for NAS. They may present with a spectrum of opioid withdrawal symptoms, including nervous, gastrointestinal and respiratory symptoms³. Nevertheless, breastfed babies of methadone- or buprenorphine-maintained mothers have been studied to have less severe NAS, decreased need for pharmacotherapy with morphine, and shorter hospital stays. Methadone and buprenorphine have been shown to exist at low serum levels in breastfed infants^{4, 6}. A small study of infants showed no adverse effects, which are potentially lethargy, respiratory difficulty or poor weight gain⁵. If any adverse effects are noted, mothers are advised to notify their providers.

In general, breastfeeding is known to strengthen maternal-infant bonding, psychological well-being, nutrition, digestive health and immunity of the infant. Additionally, breastfeeding has analgesic properties that reduce symptoms from NAS and duration of pharmacotherapy (i.e., morphine)⁷. The well-known benefits of breastfeeding and the evidence supporting the benefits and safety of breastfeeding with MOUD highlight the importance of advocating for babies to receive the best nourishment for them. Mothers stable on MOUD should be encouraged to breastfeed as long as they continue to meet eligibility criteria. Eligibility includes receiving treatment from a substance use disorder counselor, being in recovery since 90 days before delivery, maintaining recovery in an outpatient setting, having a negative urine drug screening at delivery, testing negative for HIV and not taking medications contraindicated in breastfeeding^{7, 8, 9}. We must prevent misinformation and stigma from discouraging moms from bonding with their infants and providing essential nourishment through breastfeeding.

Sources/Resources:

• Yonke N, Maston R, Weitzen S, Leeman L. Breastfeeding Intention Compared With Breastfeeding Postpartum Among Women Receiving Medication-Assisted Treatment. J Hum Lact. 2019 Feb;35(1):71-79. doi: 10.1177/0890334418769637. Epub 2018 May 3. PMID: 29723483
• Clark RRS. Breastfeeding in Women on Opioid Maintenance Therapy: A Review of Policy and Practice. J Midwifery Womens Health. 2019 Sep;64(5):545-558. doi: 10.1111/jmwh.12982. Epub 2019 Jul 11. PMID: 31294522
• Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med 2010; 363:2320
• Welle-Strand GK, Skurtveit S, Jansson LM, et al. Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr 2013; 102:1060
• Gower S, Bartu A, Ilett KF, et al. The wellbeing of infants exposed to buprenorphine via breast milk at 4 weeks of age. J Hum Lact 2014; 30:217
• Jansson LM, Choo R, Velez ML, et al. Methadone maintenance and breastfeeding in the neonatal period. Pediatrics 2008; 121:106
• Meek JY, Noble L, Section on Breastfeeding. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2022; 150
• Sachs HC, Committee On Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics 2013; 132:e796. Modified from: Centers for Disease Control and Prevention. Breastfeeding: Contraindications to Breastfeeding or Feeding Expressed Breast Milk to Infants. Available at: https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/contraindications-to-breastfeeding.html (Accessed on April 10, 2023)
• Reece-Stremtan S, Marinelli KA. ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med. 2015 Apr;10(3):135-41. doi: 10.1089/bfm.2015.9992. PMID: 25836677; PMCID: PMC4378642.5