opioid dependence during breastfeeding

Last edited 08/2023 and last reviewed 08/2023

Opioid dependence during breastfeeding

Methadone is the preferred choice of treatment for opioid dependence during breastfeeding. Recommendations apply to full term and healthy infants only (1)

• methadone is the preferred choice during breastfeeding as there is more experience of its use, but infant monitoring is still required
  • infant monitoring
    • monitor infants for drowsiness, adequate weight gain, respiratory problems, constipation, looking pale, and developmental milestones, especially in infants up to one month old and exclusively breastfed infants.
  • is a moderate level of evidence and experience of use in breastfeeding, and small amounts pass through into breast milk
  • side effects are more likely to occur in infants not exposed to methadone during pregnancy or when the mother is receiving a high maintenance dose
    
    
• is less evidence and experience for the use of buprenorphine (including in combination with naloxone), or naltrexone.  However these are still considered compatible with breastfeeding
  
  
• infants exposed to methadone, buprenorphine, or naltrexone during pregnancy can breastfeed as normal after delivery
  
  
• breastfeeding has benefits to an infant who has been exposed to maternal opioids during pregnancy and may reduce any withdrawal symptoms in the infant (1)
  • infants exposed to opioids during pregnancy should be observed for withdrawal symptoms
    • neonatal abstinence syndrome (NAS)
      • all opioid dependent pregnant women should be counseled that infants chronically exposed to opioids in utero (elicit or prescribed opioids, illicit opioids or opioid maintenance therapy) are at risk for NAS
      • breastfeeding on opioid substitution is considered as safe and effective in reducing NAS (3)
        • is good evidence to support breastfeeding in women on opioid substitution therapy with methadone or buprenorphine
          
          
      • NAS is characterized by hyperactivity of the central and autonomic nervous systems (2)
        • NAS symptoms may present anytime in the first 2 weeks of life, but often occur within the first 3-4 days after birth.
        • symptoms such as:
          • excessive high-pitched cry,
          • reduced quality and length of sleep,
          • increased muscle tone and tremors
          • are often accompanied by:
            • autonomic dysregulation (e.g. sweating, yawning, and increased respiration) and
            • gastrointestinal manifestations (e.g. excessive sucking, poor feeding, vomiting and diarrhea)
              
              
  • breastfeeding is particularly important for chronically opioid-exposed newborns as it is the only intervention demonstrated to reduce NAS severity (2)
    • compared to formula fed infants
      • infants fed breastmilk are
        • less likely to need pharmacologic treatment for NAS and if treatment is required,
        • require lower doses of morphine
        • thus have shorter hospital lengths of stay
          
          
  • opioids present in breast milk may decrease withdrawal symptoms, but may be insufficient to allow dose reduction of any treatment of the infant
    
    
  • withdrawal symptoms in the infant may also occur during breastfeeding if the mother stops taking the medication suddenly or breastfeeding stops suddenly

Reference:

• NHS Specialist Pharmacy Service (August 2023). Treating opioid dependence during breastfeeding
• Krans EE, Cochran G, Bogen DL. Caring for Opioid-dependent Pregnant Women: Prenatal and Postpartum Care Considerations. Clin Obstet Gynecol. 2015 Jun;58(2):370-9. doi: 10.1097/GRF.0000000000000098. PMID: 25775440; PMCID: PMC4607033
• Graves LE, Turner S, Nader M, Sinha S. Breastfeeding and Opiate Substitution Therapy: Starting to Understand Infant Feeding Choices. Subst Abuse. 2016 Jul 12;10(Suppl 1):43-7. doi: 10.4137/SART.S34553. PMID: 27429549; PMCID: PMC4944830