Why we are recommending this best practice
Illicit or Inappropriate Drug Use: According to the AAP “maternal substance abuse is not a categorical contraindication to breastfeeding” and therefore well-nourished narcotic dependent mothers being treated for OUD with pharmacotherapy are encouraged to breastfeed in the absence of illicit drug use. Breastfeeding is contraindicated if “relapse” occurs, or a return to any illicit drug use or frequent legal substance misuse, especially if relapse has occurred in the 30-day period prior to delivery. Infrequent substance use, especially if outside of the 30-day window before delivery, may not necessarily be a contraindication to breastfeeding, but each woman must be carefully and individually evaluated for type of substance used, length of time since last use, and other risk factors. Refer to ABM Clinical Protocol #21 in the References section of this Best Practice for more detailed guidelines.
Strategies for implementation
- Develop breastfeeding protocol for women with OUD. Create a multidisciplinary team ideally including obstetricians, midwives, family physicians, pediatricians, nurses, lactation specialists, pain/addiction specialists, pharmacists, and social workers to create a facility-specific protocol addressing the following topic areas:
- Information for women with OUD and clinicians caring for them: Create user-friendly resources on the benefits of breastfeeding for women with OUD and their newborns and include important contraindications.
- Develop a protocol for identification of women with OUD and mobilization of required resources to support breastfeeding, emphasizing best practices such as early skin-to-skin care.
- Develop a plan for outpatient breastfeeding and newborn nutritional support. Develop a workflow to ensure pregnant patients with OUD are discharged with a plan to support breastfeeding and the overall nutrition for their newborns; this plan should include appropriate short interval pediatric follow-up, access to advice on lactation continuation, and access to local or online breastfeeding support resources.
- Train the workforce on breastfeeding for women with OUD. Educate physicians, nurses, and other care team members on the benefits of breastfeeding for women with OUD and institute multimodal strategies for implementation of developed protocols.
- Educate clinical staff on the strength of evidence and criteria for safety of breastfeeding for women with OUD. Determine appropriate avenues through which to educate hospital staff (e.g., emails, physical bulletin boards, staff meetings) and mitigate discrimination and bias toward patients with OUD.
- Train providers on OUD treatment protocols. Create standards for providers caring for pregnant patients to provide information relevant to breastfeeding decisions and ask questions about the mother’s concerns and barriers surrounding breastfeeding.
- Implement quality improvement strategies to improve breastfeeding in women with OUD: Create process metrics that allow for regular evaluation of facility-based breastfeeding support protocols.
- Define target metrics for breastfeeding in OUD. Develop facility-specific metrics for tracking implementation and effectiveness of the breastfeeding program for women with OUD, including measurement of initiation and continuation of breastfeeding.
- Delineate role(s) for OUD treatment assessment and improvement. Designate either an individual or a team to take accountability for ongoing facility-level assessment and improvement of metrics for breastfeeding in women with OUD.
- SB-402 Breastfeeding. California Legislative Information. https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml? bill_id=201320140SB402. Accessed December 19, 2019.
- Feldman-Winter L, Goldsmith JP; Committee on Fetus and Newborn, Task Force on Sudden Infant Death Syndrome. Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns. Pediatrics. 2016; 138(3), e20161889. doi: 10.1542/peds.2016-1889.
- 9 Steps to Breastfeeding Friendly: Guidelines for Community Health Centers and Outpatient Care Settings. California Department of Public Health . https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/NEOPB/CDPH Document Library/PPPDS_9StepGuide_ADA.pdf. Published 2015. Accessed December 19, 2019.
- Protecting, Promoting, and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services: The Revised Baby-Friendly Hospital Initiative 2018. World Health Organization. https://www.who.int/nutrition/publications/infantfeeding/bfhi-implementation/en/. Published 2018. Accessed December 19, 2019.
- ACOG committee opinion no. 736: optimizing postpartum care. Obstet Gynecol. 2018; 131(5): e140-e150. doi: 10.1097/AOG.0000000000002633.
- A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorder. SAMHSA. https://store.samhsa.gov//system/files/sma16-4978.pdf. Accessed December 19, 2019.
- Breastfeeding and the use of human milk. Pediatrics. 2012; 129(3): e827-41. doi:10.1542/peds.2011-3552.
- ACOG committee opinion no. 756 summary: optimizing support for breastfeeding as part of obstetric practice. Obstet Gynecol. 2018;132(4):1086-1088. doi: 10.1097/AOG.0000000000002891.
- Breastfeeding and Special Circumstances. Centers for Disease Control. https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/index.html. Updated June 2, 2020.
- Reece-Stremtan S, Marinelli KA. ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder. Breastfeed Med. 2015;10(3):135-141. doi: 10.1089/bfm.2015.9992.