Breastfeeding in the Setting of Substance Use and Substance Use Disorder

Publication Date: October 16, 2023
Last Updated: November 14, 2023

General Recommendations

Those who have SUD or use substances during pregnancy or the postpartum period should engage in multidisciplinary prenatal and postpartum substance use care. (2, B)
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Individuals who discontinue nonprescribed substance use by the delivery hospitalization can be supported in breastfeeding initiation with appropriate follow-up. (2, B)
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Targeted perinatal dyadic lactation care such as prenatal education, inpatient and postpartum lactation support, and ongoing multidisciplinary SUD treatment can facilitate breastfeeding continuation. (2, B)
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Individual programs and institutions should establish breastfeeding guidelines to mitigate bias, facilitate consistency across providers, and empower individuals with SUD. (3, C)
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Setting of Nonprescribed Substance Use

Opioids

Breastfeeding should be avoided during the use of nonprescribed opioids. (2, B)
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Sedative hypnotics

Breastfeeding should be avoided during the use of nonprescribed sedative hypnotics. (3, C)
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Prescribed benzodiazepines

In breastfeeding mothers who stop nonprescribed use but remain on prescribed benzodiazepine tapers for the treatment of benzodiazepine use disorder, or for anxiety disorders, mothers may return to breastfeeding. (2, B)
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Stimulants

Breastfeeding should be avoided during the use of nonprescribed stimulants. (3, B)
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Alcohol

Breastfeeding should be avoided immediately after moderate-to-high alcohol consumption. Occasional intake of modest amounts of alcohol (two 150 mL glasses of wine or 1.5 pints of beer) during lactation and waiting for 2 hours per drink consumed to resume breastfeeding is likely safe. (1, A)
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Combustible tobacco and nicotine vaping

We recommend breastfeeding to be continued in those mothers who smoke or vape, given the documented benefits, but suggest they reduce their use as much as possible and avoid tobacco smoking and nicotine vaping product use around their infants. (1, A)
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Cannabis

We encourage cessation and/or reduction of cannabis use during breastfeeding. (2, B)
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For mothers who continue to use cannabis and wish to breastfeed, we recommend a shared decision-making process to discuss the risks and benefits of breastfeeding. Discussions may be guided by examining the route and type of cannabis product use, potency of product use, and frequency of use. (3, C)
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Setting of Substance Use Treatment

Methadone

Breastfeeding is compatible with methadone treatment, regardless of dose, and recommended in mothers taking methadone. During periods of titration, breastfeeding mothers should be counselled to monitor for infant sedation. (2, A)
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Buprenorphine sublingual

Breastfeeding is compatible with sublingual-buprenorphine formulations and is recommended in mothers taking sublingualbuprenorphine. (2, A)
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Buprenorphine injectable

Safety data for injectable extended-release buprenorphine formulations are lacking. Decisions around and treatment changes to support breastfeeding should be made in consultation with the patient and addiction provider given the risks associated with changes in OUD treatment. (3, C)
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Naltrexone

Breastfeeding is compatible with naltrexone and is recommended in mothers taking naltrexone. (3, B)
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Acamprosate

Breastfeeding appears compatible with acamprosate, but there is little evidence; thus, providers should pursue a risk–benefit discussion with patients to guide decision-making. (3, C)
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Disulfiram

Breastfeeding does not appear compatible with disulfiram given risk of infant exposure and risk of alcohol toxicity in the breastfeeding mother. Thus, other AUD treatments should be pursued over disulfiram in the setting of breastfeeding. (3, C)
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NRT

Breastfeeding is compatible with NRT and is recommended in mothers taking NRT. The type of NRT should be determined by the clinical needs of the breastfeeding mother. (2, B)
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Varenicline

Animal data suggest there may be some harms associated with varenicline exposure through breast milk, though clinical data are lacking. Providers should pursue a risk–benefit discussion with patients to guide decision-making based on the severity of tobacco use disorder and the clinical context. (3, C)
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Bupropion

Breastfeeding is compatible with bupropion, and bupropion is recommended in the setting of breastfeeding. (2, B)
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Recommendation Grading

Abbreviations

  • NRT: Nicotine Replacement Therapy
  • SUD: Substance Use Disorder

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Breastfeeding in the Setting of Substance Use and Substance Use Disorder

Authoring Organization

Academy of Breastfeeding Medicine

Publication Month/Year

October 16, 2023

Last Updated Month/Year

July 15, 2024

Supplemental Implementation Tools

Document Type

Guideline

Country of Publication

US

Document Objectives

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.

Target Patient Population

Breastfeeding mothers with substance use disorders

Target Provider Population

Clinicians caring for breastfeeding mothers with substance use disorders, including OBGYNs, psychiatrists, addictions specialists and similar

Inclusion Criteria

Female, Adolescent, Adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Addiction treatment specialist, nurse, nurse midwife, nurse practitioner, physician, physician assistant, social worker

Scope

Counseling, Management

Diseases/Conditions (MeSH)

D001942 - Breast Feeding, D019966 - Substance-Related Disorders

Keywords

Breastfeeding, Substance use disorders, substance use disorder, SUD in pregnancy

Source Citation

Miriam Harris, Davida M. Schiff, Kelley Saia, Serra Muftu, Katherine R. Standish, and Elisha M. Wachman. Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023). Breastfeeding Medicine.Oct 2023.715-733.http://doi.org/10.1089/bfm.2023.29256.abm