Opioid Abuse During Pregnancy And Breastfeeding

You’ve no doubt read or heard the news reports about the opioid crisis in the US, and pregnant women are not immune to this problem. From 1999 to 2014, the prevalence of opioid use disorder among pregnant women quadrupled in the US, going from 1.5 per 1,000 hospitalized deliveries to 6.5.1 Consequently, from 1999 to 2013, the prevalence of neonatal abstinence syndrome (the condition in which babies are born with symptoms of drug withdrawal) similarly increased from 1.5 per 1,000 hospital births to 6.0.2  So how do we treat these mothers and babies? The benefits of breastfeeding are well-known, but can these babies safely breastfeed? And if so, are there precautions to take?

Treatment of Opioid Use Disorder in Pregnant Women

As explained elsewhere on The Pulse, the worst thing for mothers and their fetuses is to completely stop the opioids during pregnancy. Usually, mothers are weaned off the offending drug (heroin or more commonly prescription opioids like oxycodone), and put on a maintenance drug. In the past, methadone was the drug most commonly used, but buprenorphine is used now, as well.

Support services are critical for pregnant women addicted to opioids, such as addiction counseling and nutrition counseling. In addition, special attention is given to treating pain in these women during and after birth. And health care providers need to prevent relapse and overdose in these mothers after giving birth.

Neonatal Abstinence Syndrome

Babies born to mothers who use opioids can exhibit neonatal abstinence syndrome (NAS). The symptoms of NAS can be variable, but can include:3

  • Fever
  • Frequent yawning
  • Sneezing
  • Sweating
  • Nasal congestion
  • Rapid breathing (respiratory rate>60 breaths/minute)
  • Vomiting
  • Diarrhea
  • Poor feeding
  • Weight loss
  • Excessive sucking
  • Irritability
  • Tremors
  • High-pitched crying
  • Sleep problems
  • Jerking of muscles
  • Microcephaly (small head)
  • Seizures

And there are long-term sequelae, too. Compared to infants born without NAS, those with NAS are more likely to have an educational disability and require special services in school.4

Treatment for NAS

Treatment for NAS is multidisciplinary and consists mostly of non-pharmacologic care. This means that physicians provide a lot of supportive measures and try to limit the medicines used. Such measures may include:3,5

  • Creating a soothing, gentle environment to calm the baby
  • Reduce stimulation as much as possible
  • Limit exposure to lights and noise
  • Encourage “clustering of care” to minimize handling of the baby
  • Promote rest for the infant
  • Swaddle and hold the infant as much as possible (often with volunteers whose only job is to cuddle with the baby)
  • Skin-to-skin contact
  • Provide opportunities for non-nutritive sucking
  • Provide adequate nutrition (these babies often have higher caloric needs) by giving more frequent feedings, and using high-calorie formula as a supplement
  • Massage therapy
  • Music therapy
  • Water-bed therapy

It is very important to include the mother in all of this. While that may sound obvious, in these cases, the baby is often transferred to a neonatal intensive care unit (NICU), and separated from the mother. However, this practice has been criticized by experts as short-sighted. The Canadian Pediatric Society issued a practice guideline recommending that doctors and hospitals consider non-drug measures first, and try to keep the mothers involved in the care in an effort to bolster bonding and attachment.5

As that guideline points out, the only non-medicine treatment that has been rigorously studied and been shown to help in this population is breastfeeding. And a prolonged NICU stay interferes with effective breastfeeding.

Multiple studies have shown that breastfeeding by infants with NAS is associated with many beneficial outcomes in these babies, including less severe symptoms of withdrawal, less need for medicines for withdrawal, and shorter hospital stays.6,7 Some researchers have suggested that the small amount of opioid in the breast milk accounts for these benefits, while others think the simple act of breastfeeding itself is the cause.6

The most common medicines used to treat NAS include morphine, methadone, and buprenorphine. These drugs are used to treat moderate to severe symptoms, such as seizures, fever, weight loss, and dehydration. Unfortunately, up to 60-80% of NAS infants will need medicines to treat their condition.3

So not only is breastfeeding by mothers with opioid use disorder safe, but it is beneficial, and a mainstay of treatment for NAS. However, the infant should be monitored closely by a healthcare provider, both in the hospital and afterwards, to ensure proper growth and to watch for signs of withdrawal. If you are on pregnant and on opioids, tell your doctor. And after the baby is born, advocate for yourself and your child by asking to room with the baby, breastfeeding your infant, and requesting to minimize the use of formula if possible.

References:

  1. Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM. Opioid use disorder documented at delivery hospitalization-United States, 1999-2014. MMRW. 2018 Aug 10;67(31):845-849.
  2. McCarthy M. Incidence of neonatal abstinence syndrome triples in US. BMJ. 2016 Aug 15;354:i4476.
  3. McQueen K, Murphy-Oikonen J. Neonatal abstinence syndrome. NEJM. 2016 Dec 22;375(25):2468-2479.
  4. Fill MA, et al. Educational disabilities among children born with neonatal abstinence syndrome. Pediatrics. 2018 Sept;142(3). pii: e20180562.
  5. Vogel L. Newborns exposed to opioids need mothers more than NICU, say pediatricians. CMAJ. 2018 Jan 29;190(4):E123-E124.
  6. Klaman SL, et al. Treating women who are pregnant and parenting for opioid use disorder and the concurrent care of their infants and children: literature review to support national guidance. J Addict Med. 2017 May/Jun;11(3):178-190.
  7. Wu D, Carre C. The impact of breastfeeding on health outcomes for infants diagnosed with neonatal abstinence syndrome: a review. Cureus. 2018 July;10(7):E3061.
Ruben Rucoba
Dr. Rucoba has over 25 years of experience as a primary care pediatrician after completing medical school at the University of California, San Francisco. His clinical areas of expertise include caring for children with special health care needs and assisting families with international adoption. He has been a freelance medical writer since 2010, writing for health websites, continuing medical education providers, and various print outlets. He currently works at Wheaton Pediatrics in the suburbs of Chicago, where he lives with his wife and four daughters, including a set of twins.

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