Running head: AN INTEGRATIVE REVIEW 1

Breastfeeding Opiate-exposed Neonates

Ellen Sowder

Bon Secours Memorial College of Nursing

Arlene Holowaychuk, MSN

NUR 4122

October 30, 2017

I pledge.
AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to investigate literature regarding breastfeeding for

infants who were exposed to opiates in utero and born to mothers participating in Opiate

Maintenance Treatment (OMT). Neonatal Abstinence Syndrome (NAS) is a widespread problem

that is worsening with the increased prevalence of opiate addiction across the world.

Breastfeeding is recommended as the best nutritional source for newborn infants, but there is a

low rate of breastfeeding among the mothers in OMT. Research about the safety of newborn’s

exposure to OMT medications in breast milk is in its infancy, but it may reduce the severity of

NAS. PubMed was used to locate 94 research articles that apply to this topic. The results of these

articles show that the effects of NAS can be alleviated by breastfeeding. There are limitations to

this review including the researcher’s inexperience in conducting integrative reviews as well as

the inability to conduct experimental research on this topic. Additional research should be

focused on the long-term effects of OMT medication excreted in breast milk as well as if certain

medications are better choices than others for nursing mothers in OMT.
AN INTEGRATIVE REVIEW 3

Breastfeeding for Opiate-exposed Neonates

The purpose of this Integrative Review is to use information provided from research

studies to address if mothers undergoing opiate dependence treatment should be encouraged to

breastfeed their infants. The American Academy of Pediatrics (AAP) suggests that aside from a

very few exceptions, that infants should rely primarily on breast milk as their source for nutrition

until six months of age (“AAP Reaffirms Breastfeeding,” 2017). Due to a high number of

breastfeeding barriers, lack of support and minimal research on the safety of opiate maintenance

medication in infants, many of the mothers in opiate dependence programs choose not to

breastfeed. Infants born to mothers dealing with addiction are frequently premature and often

have other features that cause them to be at high-risk for illness and other health issues. The

high-risk nature of these couplets makes the benefits of breast milk an even more important

intervention. Infants exposed to opiate maintenance drugs in utero are likely to develop NAS,

which causes hyperirritability of the central nervous system, the gastrointestinal system, the

respiratory system and the autonomic nervous system (Welle-Strand, Skurtveit, Jansson,

Bakstad, Bjarko & Ravndal, 2013). Little research has been conducted to verify the validity of

using breastfeeding as an intervention to prevent or treat NAS, but the benefits of bonding, skin-

to-skin contact and nutrition associated with breastfeeding suggests that the act of breastfeeding

will provide comfort measures combating the symptoms of NAS. The researcher’s interest in this

topic came from having seen a high number of infants in the Neonatal Intensive Care Unit

(NICU) who were experiencing NAS symptoms but were being fed exclusively with formula.

Which led to the question, in opiate dependent neonates, does breastfeeding lessen the effects of

NAS compared to babies who are fed with formula alone?

AN INTEGRATIVE REVIEW 4

Design and Search Methods

The researcher used the search engine PubMed to search for articles directly related to the

question: In opiate dependent neonates, does breastfeeding lessen the effects of NAS compared

to babies who are fed with formula alone? The search was limited to articles published between

2013 and 2017 that were peer-reviewed and published in English. The articles needed to be

qualitative or quantitative studies and related to the question. The keywords used to search for

articles were ‘NAS’, ‘breastfeeding’, ‘Neonatal Abstinence Syndrome’, ‘opiate maintenance’,

‘breast’, ‘withdrawal’, ‘methadone’, and ‘Buprenorphine’. The search yielded 94 results

pertaining to the keywords. Other inclusion criteria were infants born to mothers undergoing

opiate maintenance treatment. Once the other inclusion criteria were included, five articles met

all the specifications needed. Four of these were quantitative research studies and one was a

qualitative research study.

Findings/Results

The results and findings of the research find a correlation between breastfeeding and a

decreased burden of NAS in infants of mothers receiving opiate maintenance therapies (Welle-

Strand et al., 2013). Along with symptom relief, these studies addressed the potential harm

caused by the excretion of methadone or buprenorphine into breast milk. Fortunately, the

research shows that regardless of the mothers’ dose, only a minimal amount is absorbed by the

infant and does not cause harm to the baby

(Jansson, Choo, Velez, Lowe & Huestis, 2013). The qualitative article studied the

phenomenology of new mothers in opiate maintenance treatment. Of the four quantitative

studies, two were non-experimental and two were quasi-experimental. The results are organized

by the following categories: maternal factors, severity of NAS, and well being of the infant.
AN INTEGRATIVE REVIEW 5

Maternal Factors

In the non-experimental studies, the decision to breastfeed was associated with a lower

incidence of drug use in late pregnancy and the first few months after delivery. In one study, the

rate of drug use among breastfeeding mothers in this cohort was lower than findings in previous

studies around the world (Welle-Strand et al., 2013). This study was a retrospective study using

questionnaires to address effects on breastfeeding for infants exposed to opiates. The mother’s

drug use was self-reported, but also verified by urine drug screen. Though breastfeeding

initiation rates were high, the number of mothers’ breastfeeding dropped significantly after four

weeks and by 50% after week twelve. The retrospective chart review from MaineGeneral

Medical center showed that babies who were formula fed were exposed to more illicit drugs in

the third trimester than breastfed babies (Oconnor, Collett, Alto & Obrien, 2013). In that sample,

76% of these women initiated breastfeeding and 66% were still breastfeeding after the post-

partum period. The breastfeeding success rate in this group is attributed to the integrative

medical model of their program, which provided education and support throughout the

pregnancy and beyond. A quasi-experimental study was done to analyze the plasma levels in

breast milk of mothers receiving methadone as well as concentration levels in their infants. The

participants in this study denied relapse during the lactation period. Of the patients receiving

methadone, only one required another medication--a selective serotonin reuptake inhibitor,

which was reflected in the results. Across the samples, regardless of methadone dosage, the

concentration of methadone in infant was calculated to be less that 1/3 mg per day. (Jansson, et

al., 2013). In a retrospective medical record review from Western Sydney, mother’s methadone

dose was the highest predictor for the infant’s need for pharmacological treatment for NAS.

Previous research had determined that cesarean section delivery increased the risk of NAS, but
AN INTEGRATIVE REVIEW 6

this study did not confirm that claims. Delivering the infant prematurely was found to increase

the risk of treatment needed for NAS (Liu, Juarez, Nair & Nanan, 2015).

Severity of NAS

In these research articles, the Finnegan scoring system determined the severity of NAS.

High scores on this scale required pharmacological intervention. The mean NAS scores of

breastfed infants were lower than those who were formula fed, and the formula fed infants were

more likely to require pharmacological treatment (Oconnor et al., 2013). In the first two days of

life, breastfeeding delayed the onset of NAS and decreased the need for medication by 37% (Liu

et al., 2015). The results of this quasi-experimental study found that even expressed breast milk

decreased the severity of NAS when compared to formula, but the sample size was too small to

confirm this (Liu et al., 2015). In the non-experimental retrospective study the breastfed infants

required less pharmacological treatment than formula fed babies, but compared to methadone

babies, those exposed to buprenorphine did not face a shorter duration of NAS (Welle-Strand et

al., 2013).

Well-being of infants

The benefits of breastfeeding are well researched and recommended to most new

mothers. The increased barriers to breastfeeding and stigma around addiction can make initiating

breastfeeding more difficult for mothers receiving OMT. Little research has been done on the

safety of infants exposed to these medications through breast milk. In the 2013, quasi-

experimental study analyzing plasma levels of OMT medication in breast milk a minute amount

was transferred to the infant through feeding. No developmental issues were noted in this group

of infants up to the six-month mark of exclusive breastfeeding. (Jansson et al., 2013). In a study

researching the effects of buprenorphine exposure to infants, mothers reported appropriate

AN INTEGRATIVE REVIEW 7

feeding and sleeping patterns in their infants. Up to four weeks into breastfeeding the infants

were gaining weight appropriately, had little or no color issues and were eliminating effectively.

(Gower, Bartu, Ilett, Doherty, McLaurin & Hamilton, 2014).

Discussion/Implications

The results of the research articles identify the benefits of breastfeeding in this unique

population of infants exposed to opiate maintenance therapy in utero. The positive relationship

between breastfeeding and decreased severity of Neonatal Abstinence Syndrome supports the

PICOT question set by the researcher. Not all medications used for opiate maintenance therapy

provided clear results shortening the duration of NAS when transmitted through breast milk, but

the decrease in symptom severity was clear. One of the article’s results showed that

breastfeeding delayed the onset of NAS (Liu et al., 2015) and two of the others found these

babies scored significantly lower on the Finnegan opiate withdrawal scoring system than those

who were formula fed. (Oconnor et al., 2013; Jansson et al., 2013). Other factors associated with

initiating breastfeeding may be the reason there are lower breastfeeding rates in this population.

When an integrated medical model was implemented to provide support throughout pregnancy

and beyond, the rate of breastfeeding success increased significantly (Oconnor et al., 2013).

The safety of breastfeeding during opiate maintenance therapy is a question that has yet

to be studied long-term. According to these research articles, preliminary results show that the

amount of medication excreted into breast milk is enough to help alleviate symptoms, but not so

much that it hinders the infant’s development (Jansson et al., 2013). Even in self-reported

questionnaires mothers were reporting normal weight gain, feeding and sleeping habits, which

further show that breastfeeding during opiate maintenance therapy is not detrimental to the

infant. Some of the benefits of breastfeeding infants experiencing NAS include close physical
AN INTEGRATIVE REVIEW 8

contact and bonding with mother (Welle-Strand et al., 2013). Since there seems to be no danger

to the infant while breastfeeding during opiate maintenance therapy, these benefits are enough to

encourage breastfeeding regardless of breast milk’s effect on NAS.

Limitations/Conclusion

A limitation that was discussed in each of the articles was the small sample sizes. Due to

the specific population involved, it is hard to do studies with large groups. Another limitation

that was present in multiple articles was the retrospective nature of the studies. When studies are

done after the fact the researcher can only make hypotheses, not cause and effect deductions

(Oconnor et al., 2013). Retrospective studies depend on participants’ recall, which is another

limitation noted (Welle-Strand et al., 2013). In two of the studies, women self-reported other

illicit drug use (Liu et al., 2015; Welle-Strand et al., 2013). Even though there were urine drug

screens to validate, self-reported data is often unreliable. In one of the articles that began with a

small number of participants, there was a lab error rendering one sample unusable, which further

dwindled the sample size (Jansson et al., 2013). One study was conducted in Norway and

reflected a higher initiation of breastfeeding than other studies, but that is likely reflective of the

high rate of breastfeeding in that country (Welle-Strand et al., 2013). The researchers who

addressed the safety of infant exposure to buprenorphine admitted that the length of the study

was too short and further time was needed to verify the safety (Gower et al., 2014). Another

important limitation is that these studies show the positive relationship between breastfeeding

and treatment for NAS, not breast milk itself. Since the calming modalities involved with

breastfeeding cannot be separated from breast milk without using a bottle, the effectiveness of

breast milk alone is not being tested (Oconnor et al., 2013).

AN INTEGRATIVE REVIEW 9

Limitations associated with this integrative review include the researcher’s inexperience

with this research method. The search criteria was limited to articles published in English in the

last five years which further limited the resources available since many of the studies about NAS

were done years before breastfeeding became a variable of interest in mothers with opiate

maintenance therapy. Another limitation of this review is that conducting experimental research

studies on this topic would be unethical, so research is limited to quasi-experimental and non-

experimental studies.

The results of this integrative review are that the benefits of breastfeeding opiate-exposed

infants outweigh whatever risk they face. The initiation rate of breastfeeding is lower in the

mothers receiving treatment for opiate dependence than that of the overall public, but that is

likely because of the excess support needed for this group to successfully breastfeed. One if the

articles referenced in this integrative review had a high success rate of breastfeeding with the

mothers in the sample because of integrative care that provided extra support and education.

Developing more integrative medical programs can help increase the number of babies who

receive breast milk per the recommendations of the AAP. Results from these studies imply that

there is minimal or no harm inflicted on these neonates through the OMT medication transferred

by breast milk. Even though long-term research still needs to be done to conclude the effects of

these medications, initial findings have positive results and should encourage mothers in OMT to

breastfeed. Breastfeeding can reduce the symptoms of NAS and shorten the duration of treatment

needed. Mothers undergoing OMT should be provided support and education to help successful

breastfeeding and encouraged to breastfeed to provide the best nutrition while minimizing the

burden of NAS.
AN INTEGRATIVE REVIEW 10

References

Aap-reaffirms-breastfeeding-guideline. (n.d.). Retrieved November 07, 2017, from

www.aap.org/en-us/about-the-aap/aap-press-rrom/pages/aap-reaffirms-breastfeeding-

guidelines.aspx

Gower, S., Bartu, A., Ilett, K. F., Doherty, D., Mclaurin, R., & Hamilton, D. (2014). The

Wellbeing of infants exposed to buprenorphine via breast milk at 4 weeks of age. Journal

of Human Lactation, 30(2), 217-223. Doi:10.177/0890334413517748

Jansson, L.M., Choo, R., Velez, M. L., Lowe, R., & Huestis, M.A. (2013). Methadone

maintenance and long-term lactation. Breastfeeding Medicine, 3(1), 34-37.

Doi:10.1089/bfm.2013.0032

Liu, A., Juarez, J., Nair, A., & Nanan, R. (2015). Feeding modalities and the onset of the

Neonatal Abstinence Syndrome. Frontiers in Pediatrics, 3. Doi:10.3389/fped.2015.00014

Oconnor, A. B., Collett, A., Alto, W.A., & Obrien, L. M. (2013). Breastfeeding rates and the

relationship between breastfeeding and Neonatal Abstinence Syndrome in women

maintained on buprenorphine during pregnancy. Journal of Midwifery & Womens Health.

58(4), 383-388. doi;10.1111/jmwh.12009

Welle-Strand, G. K., Skurtveit, S., Jansson, L. M., Bakstad, B., Bjarkø, L., & Ravndal, E. (2013).

Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta

Paediatrica. doi:10.1111/apa.12378
Running head: AN INTEGRATIVE REVIEW 1

Table 1- Qualitative and Quantitative Article Evaluation

Author Anthony Liu, Neonatoligist, 2015

(Year)/Qual
ifications

Introductio Breast milk is thought to relieve the symptoms of Neonatal Abstinence Syndrome (NAS), but the levels of opiate
n/ dependence treatment drug transmitted through breast milk is unlikely to be the reason. This article compares feeding
Background modalities in NAS. The aim of this study is to differentiate the effect of breastfeeding versus human breast milk for
/Problem treatment of NAS.
Statement

Conceptual/ The theoretical framework is that methadone in breast milk does not have a pharmacological effect on NAS, and that
Theoretical breastfeeding itself is the factor that alleviates symptoms.
Framework

Design/Rese This study is a retrospective medical record review of infants born to mothers in opiate dependence treatment
arch programs in two birthing unit in Western Sydney. History of drug use was self-reported by the mothers in the study.
Methods/Sa The Institutional Ethics Committee approved this study. The sample was 194 mother/baby couplets and was
mple/ classified by primary feeding methods for the first two days of life. Infant’s withdrawal symptoms were scored on an
Setting/Ethi objective Finnegan scoring system. Statistical analyses were performed by SPSS version 20.0 software. Multiple
cal logistic regression analysis was used to evaluate correlations.
Considerati
ons/
Major
Variable
Studied/
Measureme
nt
Tool/Data
Collection
Tool/Data
Analysis
AN INTEGRATIVE REVIEW 2

Findings/Re Higher maternal methadone dose was the biggest indicator for need for pharmacological treatment of NAS. Unlike
sults previous studies, cesarean section was not determined to adjust the need for NAS treatment, but prematurity
decreased the likelihood of pharmacological intervention. In the first two days of life, breastfeeding delayed the onset
of and decreased the need for NAS treatment by 37%. Data seemed to favor formula to expressed breast milk in
relieving NAS symptoms, but the sample group was too small to prove that finding.

Discussion/ Fetuses exposed to methadone are at risk for NAS. Breastfeeding is associated with delaying the onset and reducing
Implications the effects of NAS. Expressed breast milk is still a healthy choice for babies, but the act of breastfeeding seems to
provide more benefits to opiate exposed neonates than the milk alone.

Limitations/ The expressed breast milk group was too small. Further randomized studied need to be conducted, but ethical issues
Conclusions limit the possibilities for this. Substance abuse was self-reported, so it is unlikely to be completely accurate.
Breastfed infants are no less likely to develop NAS than formula fed babies, but there is a significantly delayed onset
for these babies. This indicates a need for closer monitoring in their first 5-7 days, so they are not prematurely
discharged from the hospital.

Appraisal/ Methadone-maintained women should be encouraged to breastfeed their infants and provided support to increase the
Worth to likelihood of her success.
practice
AN INTEGRATIVE REVIEW 3

Author Alane B,. O’Connor, Doctor of Nursing Practice with a focus on substance abuse 2013
(Year)/Qualif
ications

Introduction/ The aim of this study is to determine the rate of breastfeeding among women using buprenorphine to treat opioid
Background/ dependence and to determine if breastfeeding in this population lessens the effects of Neonatal Abstinence
Problem Syndrome (NAS). The duration, severity, and pharmacological treatment of neonates experiencing NAS was
Statement assessed compared to non-breastfed infants with NAS.

Conceptual/ Theoretical Framework is not addressed in this article, most likely because of the scarcity of previous research
Theoretical available about this topic.
Framework

Design/Resea The design was a retrospective chart review for women being treated for opioid dependence during pregnancy with
rch specific inclusion and exclusion criteria explained. The sample was 85 maternal-infant pairs from MaineGeneral
Methods/Sam Medical Center participating in an integrated medical and behavioral addiction treatment program. This study was
ple/ approved by the institutional review board of MaineGeneral Medical Center. The major variables studied were the
Setting/Ethic rate of breastfeeding among couplets receiving postpartum opioid dependence treatment and the effects of
al breastfeeding on NAS for neonates of mothers receiving Buprenorphine. Categorical data were tested using Fisher’s
Consideratio exact tests as well as t tests and Mann-Whitney U tests. The analysis software used was Stata software version 11.
ns/
Major
Variable
Studied/
Measurement
Tool/Data
Collection
Tool/Data
Analysis

Findings/Res 76% of the mothers chose to initiate breastfeeding in their hospitalization. At the 6-8 week postpartum mark 66% of
ults those were still breastfeeding. Breastfed infants were less likely to have been exposed to illicit drugs in the third
trimester than those who were not breastfed. The mean NAS score of breastfed infants was lower than those who
AN INTEGRATIVE REVIEW 4

were bottle-fed. The breastfed babies were also less likely to require pharmacological treatment for symptoms and
their symptoms resolved quicker.

Discussion/ This article reports a much higher number of women in opioid dependence treatment programs initiating
Implications breastfeeding than previous research. This is likely due to the integrated medical and behavioral treatment program
provided. The treatment was all provided at one location, which decreases a major barrier to breastfeeding noted in
previous research. The group also participated in discussion groups, which provided support as well as education
from professionals. Nonbreastfed infants were exposed to more illicit drugs during the third trimester, which
excluded participants from breastfeeding in previous research, so that accounts for another possible cause of the
higher breastfeeding rate in this study. The infant-friendly design of the medical center in this study provided optima
care for infants, which likely led to higher breastfeeding rates. Further research needs to be done to determine if the
association between NAS symptoms and breastfeeding is statistically significant, but the researchers suggest that it
is. Women treated with Buprenorphine were able to wean abruptly as opposed to women on methadone whose
neonates experienced acute withdrawal symptoms upon abrupt withdrawal of breastfeeding.

Limitations/ The retrospective nature of this study allows for hypotheses to be made, but not cause and effect deductions.
Conclusions Reasons women chose whether or not to initiate breastfeeding was not available. Other nonpharmacological NAS
interventions are provided during breastfeeding, so it is impossible to determine if breastfeeding alone is what
alleviates the symptoms. Exposure to other substances in utero may affect the withdrawal of the infant.

Providing integrated medical and behavioral treatment for opiate dependent mothers throughout pregnancy and after
birth may increase the rates of breastfeeding and the symptoms of NAS may be alleviated or lessened with
breastfeeding, but more research is necessary.

Appraisal/W Providing an integrated model of care can ensure better outcomes for mothers and babies involved in addiction
orth to treatment during childbearing years.
practice
AN INTEGRATIVE REVIEW 5

Author The authors from this 2013 study are healthcare professionals and college professors associated with the Norwegian
(Year)/Qualif Center for Addiction Research, University of Oslo, Norwegian Institute of Public Health’s Department of
ications Epidemiology, Johns Hopkins University School of Medicine’s Department of Pediatrics and Oslo University
Hospital’s Department of Pediatrics.

Introduction/ Opiate maintenance treatment (OMT) is given to pregnant mothers struggling with addiction. Their neonates then
Background/ suffer from Neonatal Abstinence Syndrome, which is associated with poor health outcomes. Breast milk is the most
Problem beneficial source of nutrition for neonates, but women participating in OMT have low rates of breastfeeding. This
Statement study looks at the reduction in need for withdrawal treatment of NAS based on the rate and duration of
breastfeeding.

Conceptual/ Theoretical framework was not addressed, probably because very little research has been done on this topic to date.
Theoretical
Framework

Design/Resea The study was a three part retrospective study. Standardized questionnaires were given to treatment facilities, which
rch produced a Cohort of 124 women who delivered their first child between 1999 and 2009 while in OMT. The data
Methods/Sam was self-reported but confirmed with hospital records and urine drug screens. The study was approved by the
ple/ National Committee for Research Ethics and the Data Inspectorate in Norway. All the women who participated gave
Setting/Ethic written consent. The major variables studied were breastfeeding rates, duration, participant demographic and affect
al on NAS symptoms. Multivariate linear regression analyses were used to control variables and adjust for covariates.
Consideratio
ns/
Major
Variable
Studied/
Measurement
Tool/Data
Collection
Tool/Data
Analysis

Findings/Res There was a shorter duration of NAS for methadone-exposed infants who were breastfed versus those who were not.
AN INTEGRATIVE REVIEW 6

ults Breastfed infants also required less pharmacological intervention. The initiation rate for breastfeeding in the OMT
group is lower than the national average. There was also a low rate of drug use in the sample a month before
delivery, which is different than the findings from other countries. The rates of breastfeeding dropped by almost
50% after the 12 week, but the highest drop was in the first four weeks of life. This might be due to neonates being
inpatient for NAS treatment. Small frequent feeds, close physical contact and maternal response to infant cueing are
some of the possible reasons the symptoms of NAS are lessened by breastfeeding. Buprenorphine-exposed infants
did not have a shorter duration of NAS, but they still showed benefit from breastfeeding.

Discussion/ Increasing the rate of breastfeeding for women in OMT will benefit both mother and baby. They need more support
Implications to effective breastfeed because of environmental stressors and the effects of NAS. Specific advantages of
breastfeeding for this population should be provided to these women and lactation education and support should be
provided from the beginning of pregnancy.

Limitations/ The high rates of breastfeeding initiation in this cohort of women might be reflective of the high breastfeeding rates
Conclusions in Norway and not actually an accurate representation of breastfeeding rates of women in OMT. This study looks at
a few different variables, and even though the covariates were adjusted for accuracy, conclusions are difficult to
make when many variable are addressed at ones. The retrospective designs relies on participant recall which is a
flawed design study. The extent of breastfeeding was not addressed in the questionnaire so whether or not these
babies were supplemented in formula is not considered in this information.

Women in OMT should be supported and encouraged to breastfeed to the benefit of the baby as well as the mother.
Methadone seems to be the preferred method of treatment of NAS symptoms with breast milk, but breastfeeding on
Buprenorphine is still beneficial.

Appraisal/W Women in OMT have a lower rate of breastfeeding initiation and duration. However, the benefits to the dyad
orth to outweigh the potential difficulties associated with breastfeeding during OMT. Extra support should be provided to
practice these mothers to increase the rates of breastfeeding in this group.
AN INTEGRATIVE REVIEW 7

Author Shelley Gower, Faculty of Curtin University School of Nursing, Midwifery and Paramedicine
(Year)/Qualif
ications

Introduction/ Buprenorphrine is an alternative to Methadone available for opiate dependence treatment. Little research has been
Background/ done to study the effects of Buprenorphrine exposure on breastfed infants following discharge from the hospital.
Problem This study examines Buprenorphrine exposed infants after four weeks of breastfeeding.
Statement

Conceptual/ Babies exposed to Buprenorphrine may have less effects of Neonatal Abstinence Syndrome than those exposed to
Theoretical Methadone due to lower excretion of the medication into the breastmilk.
Framework

Design/Resea This study was approved by the Women and Newborn Services Ethics Committee of King Edward Memorial
rch Hospital. Around four weeks after birth, information about feeding, sleeping, hydration elimination and other
Methods/Sam determinants of health were collected by observation and previous documentation. The participants were recruited
ple/ from an antenatal clinic dealing with substance abuse. The sample size was 7 women and infant couplets. Each
Setting/Ethic participant gave informed consent before participating, and were chosen based on their intention of breastfeeding
al while receiving Buprenorphrine before being approached about the study. All babies were weighed with the same
Consideratio brand and model of scale, each mother reported specific information, and a uniform NAS scale was used to assess
ns/ symptoms. Major variables studied were sleeping patterns, feeding habits, sleeping patterns, color, elimination and
Major NAS symptoms. The small sample size led to descriptive data for each participant, which was put into tables for
Variable analysis.
Studied/
Measurement
Tool/Data
Collection
Tool/Data
Analysis

Findings/Res Weight gain was appropriate for these infants. Mothers recorded healthy sleeping patterns, the only abnormal
ults coloring noted was one infant’s mottling, One baby experienced loose stools while one experienced constipation.
None of the infants required referral for increased healthcare.
AN INTEGRATIVE REVIEW 8

Discussion/ The study concluded that the infants being breastfed by mothers treated with Buprenorphrine did not experience
Implications adverse effects associated with the medication. NAS scored were very low for all but one infant in the study, but the
highest score did not even require readmittance for treatment. Constipation reported by one participant was likely
because of introduction of formula into the infants diet. The breastfeeding rate in this group was lower on average
than the national mean, but over half of the participants required support from professionals for breastfeeding.

Limitations/ Small sample size is a limitation of this study. The exact amount of breast milk consumed is unknown. Although this
Conclusions new research is helpful, it is done in a short period and required further study to conclusive decide if Buprenorphrine
is harmful to infants. Buprenorphrine exposure from breastfeeding seems to be safe for infants, but further studies
need to be conducted.

Appraisal/W Opiate dependence is a worldwide epidemic, especially in adults who are childbearing age. Research addressing the
orth to safety of interventions provided to pregnant and lactating mothers needs to be studied to provide knowledgeable
practice choices to people in need of treatment.
AN INTEGRATIVE REVIEW 9

Author Lauren M. Jansson, MD Director of Pediatrics, Center for Addiction and Pregnancy at John’s Hopkins Medical
(Year)/Qualif Center (2013)
ications

Introduction/ The American Academy for Pediatrics encourages breastfeeding as the primary source of nutrition for most infants.
Background/ Infants exposed to methadone in utero are some of those most likely to benefit from breastfeeding. There are many
Problem barriers that contribute to the low number of methadone dependent women initiating breastfeeding, but preliminary
Statement studies show that breast milk does not transmit significant levels of methadone. This study aims to show if long-term
lactation will help or harm and infant past the withdrawal phase.

Conceptual/ Addressing the unknown if breastfeeding during methadone treatment should be continued past the Neonatal
Theoretical abstinence period.
Framework

Design/Resea The sample size was five, methadone maintained lactating women, for up to six months of breastfeeding. They
rch provided monthly plasma samples as long as breast milk was still a daily part of their infants’ diets. For milk and
Methods/Sam hind milk were collected from the same breast at a pediatric visit as close to exactly one moth after the last sample.
ple/ Plasma samples were taken from each infant at this time. Maximal concentrations of methadone were calculated and
Setting/Ethic compared to the mean infant ingestible dose. Informed consent was gained from each participants and the research
al was approved by local governing IRBs. The major variable studied was the concentration of methadone in breast
Consideratio milk compared to plasma levels in each infant. Samples were stored at an appropriate temperature and extracts were
ns/ analyzed by validated liquid chromatography atmospheric pressure ionization tandem mass spectrometry.
Major
Variable
Studied/
Measurement
Tool/Data
Collection
Tool/Data
Analysis

Findings/Res One patient was receiving a SSRI throughout the study period, but no other participant required medication other
ults than methadone. Each participant denied relapse or use of other illicit substances. None of the infants exhibited signs
AN INTEGRATIVE REVIEW 10

of developmental concern during this period. The maximum concentration of methadone in the infants was
calculated to be less than 1/3 mg per day regardless of dosage of the mother’s methadone.

Discussion/ Beyond the neonatal period, concentration of methadone in breast milk remains low and poses little or no risk to
Implications infants. Therefore, methadone maintained mothers should be encouraged to continue breastfeeding without
limitations.

Limitations/ Limitations were a small sample size and a lab error in one of the specimens rendering it unusable. The authors
Conclusions suggest that future research is focused on opiate exposed infants who are breastfed past the neonatal period.
Methadone should be considered compatible with breastfeeding.

Appraisal/W Methadone should be considered a compatible medication for breastfeeding barring new research proving otherwise.
orth to
practice