Read time | 15 minutes

Trigger warning: Infant Death

Something you may not know about me: I was born to a drug-addicted mother.

My mother didn't struggle with drugs before getting pregnant with me; however, at some point in her pregnancy, she chose to give it a try.

Her drug of choice? Crack cocaine.

Her story is not mine to share, and because I love her dearly, I will end her account here. Still, it is an extremely important topic to discuss, especially in light of the recent news of another baby passing away due to drug overdose via breast milk.

I was not breastfed, and I doubt whether or not to breastfeed was even a consideration for my mom.

Yet, there are parents out there who set out to breastfeed their babies and continue a daily struggle of maintaining sobriety. Some of whom may relapse during their breastfeeding journey, and even fewer will unknowingly put their baby in harm's way due to a lack of resources or a lack of information surrounding breastfeeding and drug use or

One thing I've learned over the years, both personally and professionally, is that most parents are very concerned about the safety of their children. And even when tragedies like this happen, where babies die due to choices made by their parents, the parents operate within the circumstances of their environment and attempt to make the decisions they feel is best.

I will never judge a parent for doing what they thought was the best decision for themselves or their family. And I will never assume that I would have made a different choice given the same circumstances and the same level of knowledge or information.

I write this post in hopes that it provides information parents need to minimize the risk to their infants if they are struggling with addiction.

And if you're reading this as one of the parents who want to human milk feed but struggle with maintaining consistent sobriety to reach your breastfeeding goals, please do reach out. There are people out there, like myself, that are more than willing to provide judgment-free support and can help you, in conjunction with your health care team, ensure the safety of your baby and your breast health at any stage of your journey.

How drugs get into breast milk

The mechanisms behind transfer into breast milk for narcotic is similar to that of medications, which I've written about previously.

The main factors that determine milk transfer include

Maternal plasma concentrations: drugs that reach high plasma concentrations are more likely to transfer into human milk. Low plasma concentration has a milk/plasma ration of <1
Molecular weight: Drugs with low molecular weight (less than 500 Daltons) are more likely to transfer into human milk
Protein binding: Drugs that don't bind to protein well have an increased likelihood of passing into breast milk. 90% or higher is considered good protein binding.
Lipid Solubility: The more fat-soluble a drug is, the higher the chance of it transferring into breast milk
Central nervous system involvement: Drugs that actively involve the central nervous system and the brain, such as with illicit drugs, are uniquely capable of entering human milk

Lactation Risk Categories- A rating system for the safety of a drug/medication

A commonly used rating system for lactation risk is Dr. Hale's Lactation Risk categories. Drugs are rated from most safe (L1) to Hazardous (L5)

L1 (most safe) - Given to a drug when it's well established that there is no increase in adverse effects in breastfed infants when their parents have taken it, or the medication doesn't have the capability of being absorbed by the infant through oral intake via milk.

L2 ( safer) - A drug is labeled as L2 when there are studies that demonstrate no increase in adverse effects in breastfed babies when parents have taken it; however, the number of studies is limited. An L2 rating is also given when there is minimal risk of an adverse effect on the baby when used by a breastfeeding parent.

L3 (probably safe) - When there've been no controlled studies conducted with a drug, but the risk of unanticipated effects is possible or when controlled studies have only shown 'minimal non-life-threatening adverse effects' a drug is given an L3 rating. New drugs without published data are automatically assigned an L3 rating.

L4 (possibly hazardous) - L4 drugs have evidence to support a possible negative impact on the breastfed baby or milk production; however, the benefits form the medication's use outweigh the documented risks. As you might imagine, L4 drugs are rarely used, and when prescribed, are usually done so for life-threatening or severe diseases.

L5 (hazardous) - L5 drugs have a documented significant risk to the breastfed baby or have a high risk of causing substantial harm to the breastfed baby, thus it's risk outweighs any benefit of its use.

Options for opioid dependent parents

According to ABM protocol #21 "Guidelines for Breastfeeding and Substance Use or Substance Use Disorder” :

Methadone treatment for opioid addiction poses little risk to the breastfed infant as methadone transfer into breast milk is low. Parents on stable doses of methadone should be encouraged to breastfeed.
Breastfeeding on Buprenorphine appears to pose little risk to breastfed infants, as the amount transferred into human milk is low.
Short courses of most low-dose prescription opioids can be safely used while breastfeeding with specific caution paid to codeine, as some people are ultra metabolizers of codeine and may end up with an excessive amount of morphine in their system-including breastmilk.

Breastfeeding Recommendations for the most commonly abused drugs

Heroin

Overview

L5
Molecular weight of 369 daltons
protein binding: 35%
milk/plasma ratio: 2.45

Heroin is rapidly converted into the metabolite 6-acetlymorphine, followed by a slower conversion to morphine. Morphine, in normal dose ranges, is considered probably safe (L3) for breastfeeding and is the most commonly prescribed pain med post-cesarean; however, due to the large volume of heroin users generally take, the amount of converted morphine exceeds safe ranges.

High doses of morphine over an extended period may lead to adverse effects such as sedation and respiratory problems, especially babies under two months of age, who have a decreased clearance of morphine and a prolonged elimination half-life. It's for this reason that highly dependent heroin users are urged to wean and provide donor milk or formula to their babies.

Those who use heroin recreationally have the potential of preserving their breastfeeding relationship given they do not breastfeed or provide expressed milk while under the influence and under the close guidance of an IBCLC and health care team who have a deep understanding of morphine pharmacokinetics, specifically metabolism & clearance.

Hydrocodone (Vicodin)

Overview

L3
molecular weight: 299

Vicodin is commonly prescribed for postpartum pain and is considered probably safe during breastfeeding despite being a widely abused opiate. In the case of Hydrocodone, the volume taken is the critical factor for whether or not there will be adverse effects on the breastfed baby.

Vicodin dosages should not exceed 30 mg per day, as sedation and apnea have been recorded with higher doses. Doses over 40 mg per day should be avoided.

Due to its relatively short half-life, complete weaning may not be necessary unless one is a highly-dependent, daily user of an excessive amount of Vicodin, in which donor milk or formula would be preferred. Recreational users, once again, should receive close monitoring by an IBCLC and health care team if they continue to sustain lactation and should not breastfeed or feed expressed milk when taking dosages over 30 mg/day.

Snorted and injected hydrocodone intake impacts many factors- bioavailability, half-life, and time to peak levels, etc.- making it a critical consideration in guidance plans.

Oxycodone

L3
molecular weight: 315
Milk/plasma ratio: 3.4

Similar to hydrocodone, Oxycodone is considered 'probably safe' in doses not exceeding 40 mg/day and is occasionally prescribed in the postpartum period.

When compared to other medications, such as codeine or hydrocodone, Oxycodone is not considered a safer alternative, and may, in fact, be riskier.

diazepam

Overview

L3
molecular weight: 285
Protein binding: 99%
M/P ratio: 0.2-2.7

Despite the low level of transfer of diazepam into breast milk, it is not an ideal medication for breastfeeding parents. Prolonged usage or high doses may lead to significant accumulation, which presents the risk of adverse effects on breastfeeding babies. Additionally, as typical of benzodiazepines, it has a long half-life ( 43 hours), which means it takes that long for half of the dose to clear from the system.

Lethargy, sedation, and poor suckling have been reported with its use, and diazepam should not be used during the first-week post-delivery, as the rate of transfer is higher and babies are more susceptible to the effects.

Alprazolam (Xanax)

Overview

L3
molecular weight: 309
Plasma binding: 80%
milk/plasma ratio: 0.36

Withdrawal symptoms in breastfed babies have been reported with long term use in breastfeeding parents, despite the low transferability of Xanax in breast milk. Similar to the above medications, short-term, low dose, intermittent use is acceptable during breastfeeding.

Those relying on Xanax for long term therapy must decide, with the guidance of their health care team, if the benefits of its use outweigh the potential risk. Because withdrawal symptoms have been reported from breastfeeding alone, we know that the accumulation of medication in breastmilk of prolonged usage is high enough to cause dependency. There doesn't appear to be any reports of adverse effects in the breastfed infant outside of those reported with abrupt weaning from the medication.

For those who are dependent on Xanax and have decided to continue to breastfeed, close follow up and guidance with the healthcare team is essential, especially during the weaning process, which should be slow and prolonged. Abrupt weaning poses an increased risk to the breastfed baby.

flunitrazepam (Rohypnol)

Overview

L3
Molecular weight: 313
Protein binding 80%

Flunitrazepam, known colloquially as the "date-rape drug", is not a commonly abused medication, as it induces rapid sedation and amnesia. The most significant risk with its usage would be the inability to care for a baby, and breastfeeding would be considered physically unsafe.

With that said, occasional usage (be it for insomnia or unknowingly ingesting it) does not necessitate weaning. Breastfed babies should be watched for signs of sedation, and an unmedicated adult should be present to take care of the infant.

Breast health and milk supply should be considered before its use, as typical effects last for 8 hours- well over the recommended time between milk expression. Completely draining the breast immediately prior to ingesting it, and again once awake, would be recommended. The half-life is 20-30 hours, and should not be used regularly during lactation.

clonazepam (Klonopin)

Overview

L3
molecular weight: 316
Protein binding: 50-86%
Maternal plasma ratio: 0.33

The current, but limited studies conducted, suggest a low incidence of toxicity of this medication. Extended usage should be followed closely by the health care team, and breastfed babies should be watched for apnea and cyanosis (turning blue).

Similar to Rohypnol, Klonopin is a sedative and poses a risk to infant safety when the sole child care provider is medicated, especially on large dosage. Direct breastfeeding, when experiencing any wobbliness, tiredness, or hallucinations, should be avoided, and the baby should be under the care of a sober adult. The half-life of Klonopin is 18-50 hours making it less than ideal to use during lactation, and prolonged usage should be avoided.

If Clonazepam is prescribed to combat debilitating anxiety, the decision to breastfeed while taking the medication should be made in conjunction with the healthcare team after determining if the benefits outweigh the risk.

LORAZEPAM (Ativan)

Overview

L3
Molecular weight: 33
Protein binding: 85%
milk plasma ratio: 0.15-0.26

Lorazepam, when used intermittently, in low doses, and after the first week of life, is the preferred benzodiazepine, due to its relatively short half-life of 12 hours.

As with all of the other benzodiazepines, extended use or high dosages pose an increased risk to the breastfeeding infant, though complete weaning may not be necessary except for those who use daily or take high dosages regularly in which donor milk or formula may be recommended.

Methamphetamine

Overview

L5
Molecular weight: 185.7
Potent CNS stimulant

Methamphetamine is a commonly abused stimulant, which poses an extreme risk to breastfed babies when ingested via breastmilk. There are many reported cases of infant deaths due to infant methamphetamine overdose via breastmilk.

Because methamphetamine readily affects the central nervous system, it makes it highly able to transfer into breast milk in high amounts.

Heavily dependent parents should wean and provide donor human milk or formula. Recreational users should pump and dump for at least 48 hours, and a sober adult should be in charge of infant care while under the influence.

Cocaine

Overview

L5
Molecular weight: 303
Protein binding: 91%
Powerful Central Nervous System stimulant

Cocaine is an especially dangerous drug for the breastfed infant, as though the effects of cocaine are short-lasting, it is slowly metabolized and excreted for an extended period.

Cocaine has a wide range of ingestion methods, to include intranasally, smoking, and topical application. all of which are contraindicated. Cocaine application to the nipple, especially, poses significant risks to the breastfed infant.

A minimum pump and dump duration of 24 hours are required to allow for complete clearance from breastmilk, however, due to the inactive metabolite of cocaine excreted in breastmilk for the days following, babies will test positive on drug screens.

Gamma Hydroxybutyric Acid (GHB)

Overview

L5
Molecular weight: 126

Pump and dump for at least 12-24 hours, with higher or multiple dosages requiring more time of pumping and dumping. Heavily dependent users should wean and provide donor milk or formula.

Lysergic Acid Diethylamide- LSD

Overview

L5
Molecular weight 268

Unlike the other drugs listed so far, there's no data on the amount of LSD that transfers into breastmilk. LSD a powerful hallucinogen due to its ease of crossing the blood-brain barrier & it's highly likely to pass into the breastmilk. Therefore, breastfeeding under its effects is contraindicated. It has a short half-life of 3 hours, but urine is positive for LSD up to 120 hours after taking.

Using this data, for occasional users, pumping and dumping for at least 14 hours (5 half-lives) is recommended, and heavy users should wean and provide donor milk or formula to their baby.

MDMA (Ecstacy)

Overview

L5
Molecular Weight: 193.2

MDMA is concentrated in breast milk, meaning it reaches higher levels in breastmilk than in the parent's blood. Elimination Half-life is 7 hours, though it can be as high as 31 hours depending on the PH level of the urine.

According to Drug abuse.com, once a day, users should breastfeed before ingesting and wait at least 3 hours after the dose to breastfeed again, and more frequent users wait at least 48 hours before resuming breastfeeding.

Infant risk, however, suggests waiting for five half-lives or 1.5 - 6 days after a single use before resuming breastfeeding.

With such a long wait after a single-use, it's reasonable to suggest that highly dependent users should wean and switch to donor milk or formula.

ketamine

Overview

L3
Molecular weight: 237
Protein binding: 47%

There is no data available regarding the transfer of Ketamine into human milk; however, due to the short half-life (2.5 hours) and the fact that its redistribution half-life out of the plasma is more concise (4.68 minutes), milk levels of Ketamine are likely low.

phencyclidine (PCP)

Overview

L5
molecular weight: 243
Protein binding: 65%
Milk plasma Ratio: >10

High concentrations of PCP are transferred into human milk, and prolonged transfer happens over an extended period due to its storage in fat tissues.

As such, breastfeeding is contraindicated with any PCP use, including PCP use prior to delivery.

This is extremely important to note as many drugs, especially marijuana, may be laced with PCP, posing a significant risk to the breastfed infant long after PCP ingestion.

DXM (dextromethorphan)

Overview

L1
Molecular weight 271

DXM is the main component of many cough medicines, and in standard dosages (10-20 mg every 4 hours) poses a minimal risk as not enough DXM transfer into human milk occurs to pose a danger to a breastfed baby.

The DEA has four tiers of DXM abuse, with tier1 being 100 mg and 200 mg and tier 4 being 600 mg or more.

It is unclear the impact such high doses have on drug transfer into milk. A tier 4 dosage of 600 mg would reach a "typical" dose of less than 20 mg roughly 20 hours after ingesting it.

However, a dosage that high leads to other concerns, such as the ability to care for an infant, therefore, even if milk transfer is low, breastfeeding should be avoided while under the influence of high doses of DXM.

Dextroamphetamine (amphetamine)

Overview

L3/L5
Molecular weight 368
Protein binding 16-20%
Milk plasma ratio 2-2.5
Powerful CNS stimulant

Amphetamine has two ratings: L3 for typical therapeutic doses and L5 for excessive intake, as is frequent with amphetamine abuse.

In typical doses of 20 mg daily, the amount of amphetamine is most likely minimal (subclinical). Pumping and dumping for 24 hours is recommended for high doses of the medication, as it's long-acting.

DRUGS NOT LISTED

Naturally, this list doesn't contain all the possible drugs a parent may take. There is not a lot of research for many of the illicit drugs regarding breastfeeding as drug use while breastfeeding should be avoided.

For the medications listed, I hope it's reassuring that the occasional relapse while breastfeeding doesn't automatically necessitate full weaning and that with the assistance of the health care team, recovering parents can get the support they deserve.

I’ve referenced Dr Hale’s Medication and Mother’s milk (2012) for information regarding specific drugs. For more information on specific drugs or medications, you can reference Lactmed (a free phone app on android and apple), HSDB on Pubchem (Formerly TOXNET), or call infant risk at (806) 352-2519.

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