Revision of Breastfeeding Guidelines in the Setting of Maternal Opioid Use Disorder

Abstract

Breastfeeding is recommended for women with opioid use disorder who are treated with methadone or buprenorphine. Infants with neonatal abstinence syndrome (NAS) secondary to in-utero opioid exposure have unique challenges related to breastfeeding but also have significant benefits including improved NAS symptoms with a decreased need for pharmacotherapy. Poor understanding of substance use disorder and treatment, lack of evidence-based recommendations, and vague guidelines from national academies create controversy about breastfeeding eligibility for these women. Defining breastfeeding guidelines is often difficult, particularly in large institutions with multiple providers caring for the mother-infant dyad. Based on the available evidence and review of our institutional data, we revised our breastfeeding guidelines for mothers with opioid use disorder. The aims of our new guidelines are (a) to safely promote breastfeeding in all mothers with opioid use disorder who are in recovery, (b) to improve NAS outcomes through use of breastfeeding as a key nonpharmacologic treatment modality, and (c) to improve staff communication and consistency on the subject of breastfeeding in this patient population.

Breastfeeding in Women on Opioid Maintenance Therapy: A Review of Policy and Practice

“…Two studies examined the use of treatment programs that included breastfeeding education, and one additional study examined breastfeeding education alone . Three studies compared the implementation of new, breastfeeding‐friendly policies with prior policies, and one study described the management of NAS, including breastfeeding recommendations, in Canadian neonatal intensive care units (NICUs) . Finally, one of the studies evaluated multiple daily dosing of methadone in pregnancy and included breastfeeding as an outcome of interest .…”

“…Finally, one of the studies evaluated multiple daily dosing of methadone in pregnancy and included breastfeeding as an outcome of interest . All of the studies were retrospective chart reviews, except one study that used a survey to describe the array of NAS management practices in Canada …”

“…Policies can influence whether a woman receiving opioid maintenance therapy will breastfeed. Four studies examined institutional policies for obstetric and neonatal management of opioid exposure and included breastfeeding as a result of interest . Two retrospective chart reviews were conducted at the Boston Medical Center in 2016 and 2018 that examined breastfeeding outcomes before and after the implementation of a hospital policy that was more supportive of breastfeeding by women receiving opioid maintenance therapy .…”

“…Four studies examined institutional policies for obstetric and neonatal management of opioid exposure and included breastfeeding as a result of interest . Two retrospective chart reviews were conducted at the Boston Medical Center in 2016 and 2018 that examined breastfeeding outcomes before and after the implementation of a hospital policy that was more supportive of breastfeeding by women receiving opioid maintenance therapy . The change in hospital policy led to the formation of an NAS quality improvement team and the provision of breastfeeding education to women on opioid maintenance therapy .…”

“…The impact of the mandatory online education module on breastfeeding outcomes was not examined as an independent variable . Both studies, however, found that breastfeeding rates in women on opioid maintenance therapy improved under the new supportive guidelines . Schiff et al found a statistically significant increase between 2006 and 2016 in initiation (38% vs 56%; P < .001) and continuation of breastfeeding (8% vs 34%; P = .001) as the hospital policy became more supportive of breastfeeding for women using opioid maintenance therapy .…”