COMMENTARY |
Methadone and Breastfeeding: New Horizons
* Boston University School of Medicine, Boston Medical Center, Boston, MA 02118
The Breastfeeding Center, Boston Medical Center, Boston, MA 02118
The Birth Place, Boston Medical Center, Boston, MA 02118
Abbreviations: AAP, American Academy of Pediatrics • NAS, neonatal abstinence syndrome
For 18 years (from September 1983 until September 2001), the American Academy of Pediatrics (AAP) recommended that methadone was only compatible with breastfeeding at maternal doses 
20 mg per 24 hours.1–3 This effectively eliminated breastfeeding for the majority of US women on methadone maintenance therapy, because high doses are usually given in the third trimester to offset the apparent increase in methadone metabolism during pregnancy. In September 2001, with the release of the latest AAP statement,4 the dose restriction for methadone was eliminated, making methadone compatible with breastfeeding. With a national incidence of 1 to 3/1000,5 up to 120 000 newborns with neonatal abstinence syndrome (NAS) may be affected by this change. This new AAP recommendation requires us to reexamine our policies, create new guidelines for women on methadone maintenance who choose to breastfeed, and take a fresh look at our approach to the complex, disconcerting issue of drug-abusing mothers and NAS infants.
NAS attributable to methadone withdrawal has been well-described and does not occur immediately after birth for several reasons. In the early neonatal period, because of placental transfer of the drug, methadone levels in the infant are similar to in utero levels and then slowly decline because of the drug’s long half-life. Thus, withdrawal symptoms may not commence until 48 to 72 hours of life.
Since the publication of the last AAP statement in 1994, information has been added to the literature on methadone, human milk, and breastfeeding. Recent studies6–8 concur with older publications9,10 that the transfer of methadone into human milk is minimal. Begg et al11 examined the transfer of methadone into human milk for 8 women on medium to high doses of methadone (range: 40–105 mg; average dose: 80 mg) and found the mean relative infant dose to be 2.8% of the maternal dose. Much of the research in the field comes from New Zealand, where as many as 73% of mothers taking methadone leave the hospital setting breastfeeding.12 The New Zealand Ministry of Health protocol states the "the amount of methadone present in breast milk is minute" and that "breastfeeding is recommended" for women taking methadone.13
Despite the documented minimal transfer of methadone into human milk, many questions remain regarding methadone and breastfeeding. Although analyses conclude that methadone levels in human milk are "unlikely to be sufficient to prevent the neonatal abstinence syndrome,"11 some studies suggest that breastfeeding may be beneficial. A retrospective study from New Zealand reviewed 121 infants of women on methadone maintenance over a 7-year period, and found that infants who were treated for NAS and who were breastfed in the hospital went home an average of 8 days earlier than infants who were formula-fed. The authors concluded that "Breastfeeding reduces the duration of treatment length of hospital stay of infants with NAS," but they do not speculate on mechanism.12 One report described 2 infants who appeared to develop NAS after abrupt discontinuation of breastfeeding by mothers on methadone doses of 70 mg and 130 mg/day.14 Another study followed 16 infants of women on methadone doses from 30 to 100 mg and found that infants who simply breastfed and were not treated with opiates had lower NAS scores and went home from the hospital 8 to 29 days earlier than infants treated with morphine sulfate or methadone.15
Thus, an essential conflict exists between the apparently low levels of methadone found in human milk, and the reportedly mitigating effect of breastfeeding on the severity of NAS. This leads us to ask whether factors related to breastfeeding itself, other than or in addition to the passive transfer of methadone to the infant, may modify NAS scores. Breastfeeding has been shown to act as an analgesic to infants during the heel lance procedure. Crying, grimacing, and elevated heart rate, all of which are associated with the heel lance, were significantly reduced among infants who breastfed during this procedure.16
Perhaps the hormonal effect of oxytocin plays a role. Lvoff et al17 demonstrated that significantly fewer infants were abandoned by mothers who gave birth in a Russian Baby-Friendly hospital setting, with policies supporting breastfeeding in the first hour of life and continuous rooming-in, compared with Russian mothers in a more traditional hospital setting. In speculating a reason for these findings, the authors comment, "Researchers... observed... early suckling significantly increased the concentration of plasma and probably brain oxytocin in the mother. Increased brain oxytocin concentration is noted to result in slight sleepiness, euphoria, a raised pain threshold, and feelings of increased love for the infant." Thus, the role of breastfeeding in lowering NAS scores is worthy of additional investigation.
Regardless of whether future studies demonstrate a significant association between breastfeeding and reduced severity of NAS, the new and praiseworthy AAP recommendation means that these vulnerable mother/infant dyads will benefit from the known health and emotional benefits of breastfeeding. It is naïve, however, to expect that all health care providers will receive the recommendation enthusiastically. Breastfeeding is already an emotional topic about which clinicians are undereducated.18,19 To "allow," or more appropriately, to encourage this particular population group to breastfeed will bring unique challenges. An above average number of these women are likely to be human immunodeficiency virus-positive or abusers of other street drugs, both of which are contraindications to breastfeeding in the United States. Poly-drug abusers may be difficult to identify and may not admit to multiple use. Women on methadone who are eligible to breastfeed may need extra lactation support as infants undergoing withdrawal often feed poorly. How will we monitor these infants closely and encourage rooming-in, known to be essential to breastfeeding success? How will we support breastfeeding through the infant’s extended hospital stay that will inevitably mean some maternal/infant separation, especially if the mother is required to attend daily methadone maintenance clinic meetings for medication and counseling? Will breastfeeding affect or be affected by custody issues? How will we communicate these new recommendations to hospital staff and address their concerns?
Despite the inevitable anxiety attached to this topic, and the difficulty in affecting change in the US hospital system, kudos to the AAP. We are now forced into action. This policy creates exciting possibilities for the most vulnerable of new mothers. Not only will their infants now benefit from human milk, but as breastfeeding mothers, they will be seen as essential to their infant’s care. Lvoff et al17 suggest that, "The first hours and days of life are a sensitive period for the mother when she is especially psychologically prepared to accept her infant as her own." The empowerment this brings may help inspire them—and us—to make the most of this sensitive window to start a new life with implications for generations to come.
 |
FOOTNOTES |
|---|
Received for publication Jul 2, 2002; Accepted Oct 22, 2002.
Reprint requests to (B.L.P.) Division of General Pediatrics, Maternity Building, 4th Floor, 91 E Concord St, Boston Medical Center, Boston, MA 02118. E-mail: bobbi.philipp{at}bmc.org
|
REFERENCES |
|---|
 TOP REFERENCES |
|---|
- American Academy of Pediatrics, Committee on Drugs. The transfer of drugs and other chemicals into human breast milk.
Pediatrics.1983; 72
:375
–383
[Abstract/Free Full Text] - American Academy of Pediatrics, Committee on Drugs. Transfer of drugs and other chemicals into human milk.
Pediatrics.1989; 84
:924
–936
[Abstract/Free Full Text] - American Academy of Pediatrics, Committee on Drugs. The transfer of drugs and other chemicals into human milk.
Pediatrics.1994; 93
:137
–150
[Abstract/Free Full Text] - American Academy of Pediatrics, Committee on Drugs. Transfer of drugs and other chemicals into human milk.
Pediatrics.2001; 108
:776
–789
[Abstract/Free Full Text] - Brown ER, Zuckerman B. The infant of the drug-abusing mother. Pediatr Ann.1991; 20 :555 –563[Web of Science][Medline]
- McCarthy JJ, Posey BL. Methadone levels in human milk.
J Hum Lact.2000; 16
:115
–120
[Abstract/Free Full Text] - Wojnar-Horton RE, Kristensen JH, Yapp P, Ilett KF, Dusci LJ, Hackett LP. Methadone distribution and excretion into breast milk of clients in a methadone maintenance programme. Br J Clin Pharmacol.1997; 44 :543 –547[CrossRef][Web of Science][Medline]
- Geraghty B, Graham EA, Loagan B, Weiss EL. Methadone levels in breast milk.
J Hum Lact.1997; 13
:227
–230
[Abstract/Free Full Text] - Blinick G, Inturrisi CE, Jerez E, Wallach RC. Methadone assays in pregnant women and progeny. Am J Obstet Gynecol.1975; 121 :617 –621[Web of Science][Medline]
- Blinick G, Wallach RC, Jerez E, Ackerman BD. Drug addiction in pregnancy and the neonate. Am J Obstet Gynecol.1976; 125 :135 –142[Web of Science][Medline]
- Begg EJ, Malpas TJ, Hackett LP, Ilett KF. Distribution of R- and S-methadone into human milk during multiple, medium and high oral dosing. Br J Clin Pharmacol.2001; 52 :681 –685[CrossRef][Web of Science][Medline]
- Malpas TJ, Horwood J, Darlow BA. Breastfeeding reduces the severity of neonatal abstinence syndrome [abstract]. J Paediatr Child Health.1997; 33 :A38
- Ministry of Health, New Zealand. National Protocol for Methadone Treatment in New Zealand. New Zealand: Ministry of Health, New Zealand; 1996
- Malpas TJ, Darlow BA. Neonatal abstinence syndrome following abrupt cessation of breastfeeding. N Z Med J.1999; 112 :12 –13[Web of Science][Medline]
- Ballard J Shortened length of stay for neonatal abstinence syndrome. Academy of Breastfeeding Medicine Annual Meeting; November 2001; Washington, DC
- Gray L, Miller LW, Philipp BL, Blass EM. Breastfeeding is analgesic in healthy newborns.
Pediatrics.2002; 109
:590
–593
[Abstract/Free Full Text] - Lvoff NM, Lvoff V, Klaus MH. Effect of the Baby-Friendly Initiative on infant abandonment in a Russian hospital.
Arch Pediatr Adolesc Med.2000; 154
:474
–477
[Abstract/Free Full Text] - Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians’ practices and attitudes regarding breastfeeding promotion. Pediatrics.1999; 103(3) . Available at: http://www.pediatrics.org/cgi/content/full/103/3/e35
- Freed GL, Clark SJ, Lohr JA, Sorenson JR. Pediatrician involvement in breastfeeding promotion: a national study of residents and practitioners.
Pediatrics.1995; 96
:490
–494
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
This article has been cited by other articles:
|
|
 |
|
  M. M. Glatstein, F. Garcia-Bournissen, Y. Finkelstein, and G. Koren Methadone exposure during lactation Can Fam Physician, December 1, 2008; 54(12): 1689 - 1690. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Merewood and B. L. Philipp Promoting Breastfeeding in an Inner-City Hospital: How to Address the Concerns of the Maternity Staff Regarding Illicit Drug Use J Hum Lact, November 1, 2003; 19(4): 418 - 420. [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
