I recently received an e-mail from Academy of Neonatal Nurses listing the top 10 neonatal articles accessed in 2015. Four of the 10 were on the topic of neonatal abstinence syndrome. Most neonatal clinicians are acutely aware of what a problem this poses and the increase in incidence. Various sources report an increase from 1.3/1000 births a decade ago to 19/1000 births (Kentucky)1, 7/1000 births in 2004 to 27/1000 in 2013 nationwide.2 So whatever the number might be for your state, numbers have increased dramatically.
The cost of care for these infants is quite high as many are admitted to the Neonatal ICU for withdrawal symptoms and associated care even if otherwise healthy and length of stay is reported at 16.4 days vs 3.3 days on average for healthy term infants.3 One report cites more frequent readmissions for these infants. They found these infants were 2.5 times more likely to be readmitted within 30 days than term, healthy infants. The longer they were initially hospitalized, the lower their risk of readmission.4 This may be due to withdrawal symptoms not being evident prior to usual 48 to 72 hour discharge.
In order to decrease healthcare costs and promote the best environment for the infant to grow and develop in, various studies have been undertaken to evaluate treatment protocols to decrease length of stay for these infants. While various medications are being evaluated to help in decreasing length of stay, one measure for these infants has shown promise and decreased length of stay in some studies. It is desirable to wean pregnant women from substances of abuse through the use of methadone or buprenorphine during pregnancy. These doses are controlled as compared to methamphetamine or heroin dosing, for instance, and avoids accidental overdose, diseases related to IV drug use, if not already present and perhaps aids in provision of prenatal care.
For mothers who are being maintained on methadone or buprenorphine during pregnancy, breastfeeding the newborn is recommended, provided the mother is HIV negative, and abstains from alcohol, illicit drugs, amphetamines and has no other contraindications to breastfeeding.5-7 The AAP had a previous recommendation that breastfeeding be encouraged and allowed for mothers who were receiving 20 mg or less of methadone in 24 hours. This has been changed and no dosing limits are mentioned.
O’Connor, Collett, Alto, O’Brien studied 85 mother-infant pairs, 65 of whom breastfed their infants after birth.8 The infants who were breastfed had a less severe NAS score and were less likely to need pharmacologic treatment than infants who were not breastfed. This did not, however reach statistical significance. Another group performed a retrospective chart review to determine effect of feeding mode, including direct breastfeeding, expressing breast milk and feeding or feeding formula to infants exposed to methadone or buprenorphine and the occurrence of NAS.9 They found no difference between groups but it was a small sample. Another small study found less NAS in infants who were predominantly breastfed.10 These mothers were managed with methadone. Pritham reviewed several studies and concluded that breast feeding can effectively decrease NAS.3
It has been found that little methadone or buprenorphine, either one, passes into the breast milk.11 Therefore, it may not be only continued exposure to the drug that prevents the withdrawal symptoms in the infant. Some benefits to breast feeding, particularly important in this population, are that it allows the mother to take an active role in managing the infant’s withdrawal symptoms, promotes bonding and provides the mother with continued motivation to avoid other drugs and alcohol.
Some strategies that are useful in promoting breast feeding but may need special attention for this population are rooming in, swaddling and skin-to-skin contact.3 Rooming in provides for more maternal-infant contact and provides the quiet environment that these infants need as compared to the NICU.12 However, if the infant needs additional medical management, including treatment for withdrawal symptoms that cannot be managed through breast feeding, a transfer to the NICU will be necessary.
Additional support by lactation consultants may be helpful in this situation. Direct breast feeding provides more skin to skin contact which is also an important measure to calm infants who may have some withdrawal symptoms and aids in bonding. A mother who is able to console her infant during the withdrawal will feel more successful and better prepared to manage the infant after discharge.
Swaddling is another measure that may help manage minor withdrawal symptoms. However, this too should be monitored as these infants are prone to overheating and have a higher incidence of SIDS, the risk of which is greater with overheating.13-15
There are many other benefits of breast feeding, not specific to drug-exposed infants. All of the advantages of breast feeding can only help these infants in every way and will hopefully help their mothers as well.
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- Bada, H. S., Sithisarn, T., Gibson, J., Garlitz, K., Caldwell, R., Capilouto, G., … & Breheny, P. (2015). Morphine Versus Clonidine for Neonatal Abstinence Syndrome. Pediatrics, 135(2), e383-e391.
- Tolia, V. N., Patrick, S. W., Bennett, M. M., Murthy, K., Sousa, J., Smith, P. B., … & Spitzer, A. R. (2015). Increasing Incidence of the Neonatal Abstinence Syndrome in US Neonatal ICUs. New England Journal of Medicine.
- Pritham, U. A. (2013). Breastfeeding promotion for management of neonatal abstinence syndrome. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42(5), 517-526.
- Patrick, S. W., Burke, J. F., Biel, T. J., Auger, K. A., Goyal, N. K., & Cooper, W. O. (2015). Risk of Hospital Readmission Among Infants With Neonatal Abstinence Syndrome. Hospital pediatrics, 5(10), 513-519.
- Sachs HC; American Academy of Pediatrics Committee on Drugs. The transfer of drugs and therapeutics into humanbreast milk: An update on selected topics. Pediatrics 2013;132:e796–e809.
- American College of Obstetricians and Gynecologists. Committee on Healthcare for Underserved Women and the American Society of Addiction Medicine. Opioid Abuse, Dependence, and Addiction in Pregnancy. Committee Opinion Number 524, May 2012, reaffirmed 2014.
- Reece-Stremtan, S., Marinelli, K.A., & The Academy of Breastfeeding Medicine. (2015). ABM Clinical Protocol #21: Guidelines for Breastfeeding and Substance Use or Substance Use Disorder, revised 2015. Breastfeeding Medicine. 10(3), 135-141.
- O’Connor, A. B., Collett, A., Alto, W. A., & O’Brien, L. M. (2013). Breastfeeding rates and the relationship between breastfeeding and neonatal abstinence syndrome in women maintained on buprenorphine during pregnancy. Journal of midwifery & women’s health, 58(4), 383-388.
- Liu, A., Juarez, J., Nair, A., & Nanan, R. (2015). Feeding modalities and the onset of the neonatal abstinence syndrome. Frontiers in pediatrics, 3.
- McQueen, K. A., Murphy-Oikonen, J., Gerlach, K., & Montelpare, W. (2011). The impact of infant feeding method on neonatal abstinence scores of methadone-exposed infants. Advances in Neonatal Care, 11(4), 282-290.
- Lindemalm S, Nydert P, Svensson JO, Stahle L, Sarman I. Transfer of buprenorphine into breast milk and calculation of infant drug dose. Journal of Human Lactation. 2009;25(2):199–205.
- Abrahams, R. R., Kelly, S. A., Payne, S., Thiessen, P. N., Mackintosh, J., & Janssen, P. A. (2007). Rooming-in compared with standard care for newborns of mothers using methadone or heroin. Canadian Family Physician, 53(10), 1722-1730.
- Binder, T., & Vavrinkova, B. (2008). Prospective randomised comparative study of the effect of buprenorphine, methadone and heroin on the course of pregnancy, birthweight of newborns, early postpartum adaptation and course of the neonatal abstinence syndrome (NAS) in women followed up in the outpatient department. Neuro endocrinology letters, 29(1), 80-86.
- Burns, L., Conroy, E., & Mattick, R. P. (2010). Infant mortality among women on a methadone program during pregnancy. Drug and alcohol review, 29(5), 551-556.
- Hauck, F. R., Thompson, J. M., Tanabe, K. O., Moon, R. Y., & Vennemann, M. M. (2011). Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis. Pediatrics, 128(1), 103-110.