THE ISSUES:
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Does methadone in breastmilk hurt the baby?
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Does the methadone in breastmilk help the baby go through withdrawal of the addiction from methadone during pregnancy more easily?
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Why should breastfeeding be encouraged for mothers on methadone maintenance therapy?
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Why is breastfeeding sometimes difficult for mothers on methadone maintenance therapy?
THE ANSWERS:
NO, it does not appear that the methadone excreted in breastmilk harms the baby. Research shows that methadone is excreted in breastmilk in quite small quantities and that breastfeeding is still the best way to feed the baby, even if mother is on oral methadone maintainance therapy.
BUT, it also doesn’t appear that there is enough methadone in the milk to treat the neonatal withdrawal syndrome the infant will likely experience due to his exposure to methadone during pregnancy. Funny thing though, methadone exposed babies who are breastfeed by their still methadone taking mothers have fewer withdrawal problems than addicted but formula fed babies. The breastfed babies go home from hospital on average 8 days earlier.
SO, breastfeeding as usual, should be encouraged, for all the usual reasons. The addicted baby benefits, as all babies benefit, from breastfeeding. Perhaps that wonderful bonding just helps him get through his early days of “welcome to the world and by the way, you are addicted to methadone!” better. Maybe it’s the hormones, that wonderful sedating and elating oxytocin response. Maybe it’s all the holding and the prolonged time suckling. Somehow, something … these babies do better breastfeeding despite the fact that they do not receive enough methadone through the milk to treat their withdrawal symptoms and still require medication for that. This doesn’t surprise me.
YES, there are difficulties, as in all worthwhile efforts. The baby is alternatively fussy and sedated with medically prescribed narcotics as he withdraws from his addiction. He can be difficult to wake, to soothe, to feed. Mom needs lots of help in learning to be a good parent and is often feeling quite awful herself. Negative voices may surround them; they are in a hospital and under legal and medical supervision. Other maternal behaviors MAY be dangerous to the mom and the infant. There may be other drugs involved which do preclude breastfeeding. There may be exposure to HIV or other diseases which preclude breastfeeding. There is the inevitable separation of mother and baby as mom goes to meeting after meeting involving treatment and supervision of her addiction(s).
But BREASTFEEDING IS NORMAL. Perhaps it is the only normal thing in this dyad's young life. It should be encouraged.
References:
These are by no means my original thoughts – I simply agree with and support them.
This w/u is largely a paraphrased summary of the wonderful commentary on page 1429/30 of the June, 2003 issue of Pediatrics.
Until 2001 when the AAP Policy Statement on The Transfer of Drugs and Other Chemicals Into Human Milk of Sept. 2001 Pediatrics removed methadone from all categories of concern Methadone had been considered safe with breastfeeding if only given in only very low doses. These doses were too low to maintain most addicted mothers through pregnancy when the doseage need increases because of pregnancy induced metabolic changes. (Earlier editions had allowed for only doses of 40mg per day or less as safe).
Research of note regarding this subject includes:
Treatment of neonatal abstinence syndrome with breast milk containing methadone by Ballard JL in the Journal of Perinatal Neonatal Nursing, 2002, March;15(4): 76 – 85 (basically states not enough methadone is present in breastmilk to treat withdrawal symptoms of perinatal addiction but that breastfeeding is still helpful for unknown (ha!) reasons)
Distribution of R- and S- methadone into human milk during multiple medium, to high oral dosing by Begg EG in Br J Clin Pharmacology. 2001 Dec;52 (6):681-5 (which states quite convincingly that even medium to high maternal doses of methadone appear to result in infant doses in the ‘safe’ range) (Not all drugs increase in breastmilk when the maternal dose increases although some do - reference Hale).
This w/u is written from the US perspective where a heroin addicted mother is encouraged to go onto methadone (at times VERY long term, she may have been clean from heroin for years and still be on methadone). The maintainance is administered via an established multidisciplinary program. The baby comes OUT addicted because mom is on methadone during pregnancy. The minute amount of methadone in the breastmilk is not enough to ease the baby through the withdrawal symptoms so they are given morphine typically for a few a weeks, in hospital under medical supervision, in fact usually in a
neonatal intensive care unit.