>The first is about a mother on methadone who is partially >breastfeeding.
>Mom stopped using heroin when she realized she was pregnant and has >been
>on methadone since.  Baby was born fine & is now fed a >combination of
>artificial baby milk and breastmilk at 4 weeks of age.  >Dr. has
>recommendedshe give baby bottles of water to help flush her >baby's system
>out.  I am wondering if the recommendation is to nurse >less when on
>methadone?  What if she should go back to >injecting...what is the
>recommended wait time for
>heroin to exit the body and breastfeeding be OK again?

Breastfeeding is contraindicated if the mother goes back to using heroin.
Hales book and the AAP guidelines clearly state this.  In order for her to
breastfeed she must be stable on a methodone program and not using any othe
illicit substances. There are varying opinions if the mother is on a very
high dose of methone particularly above 80 mg per day.  Baby's rarely go
through withdrawal if the dose is <20 mg day. The dose and purity and
regularity of heroin cannot be guaranteed and it is not considered safe to
breastfeed.

I don't believe there is any basis for this treatment of giving water to
flush out the baby's system. I have nursed numerous babies who are
withdrawing from methodone in my nursing career and I have never read or
heard of this treatment although I have read numerous articles on the
subject of nenatal drug withdrawal. Breast milk and the formula baby is
receiving are mainly water anyway. These babies, if they are going through
withdrawal, have a higher caloric need and need more calories not less. This
is becaue of the caloric expenditure caused by increased activity, crying
and decreased sleeep as well as calories that may be lost through vomiing,
drooling and diarrhea. If the baby is absolutely fine with no symptoms of
withdrawal it is more likely the mother was on a low dose of methodone.

In my experience I am used to mothers fully breastfeeding on methodone.
Full breast feeding is prefereable to partial because the amount of
methodone in the breast milk remains relatively stable and is fairly
constant at each feed (rather than none in formula and then some at the next
BF). This is another reason why giving water seems inappropriate.

Many of these babies need pharmocological support to help them over the
withdrawal they are going though and many go home on reducing doses of
medication (usually either morphine or phenobarb). Although this does not
seem to be the case with this baby.  However although most of these babies
who are going to go through withdrawal commencing  within the first 7 to 10
days (usaually about 3 to 5), in some methodone babies this withdrawal can
be delayed until day 14 to 28 long after they have gone home.

These mothers need lots of support and health care professionals need to be
very up front and honest about the benefits of breastfeeding and the risks
of polydrug use (taking other illicit substances as well) at the very
beginning. Ideally this should have been first discussed antenatally.  This
should be handled compassionately and factually.  Most of these mothers feel
guilty enough about the situation they have got themselves into and usually
genuinely want to do what is best for their baby.  The mother does need to
be committed and up front with what she is actually taking.  The fact that
this mother has sought the services of a lactation counsellor demonstrates
she is keen to do what is best for her baby.
I suggest you read "Neonatal Abstinence Syndrome" at the RPA website
http://www.cs.nsw.au/rpa/neonatal/html/newprot/nas.htm
and also "Neonatal Drug Withdrawal"  by the Americal Academy of Pediatrics
in Pediatrics Volume 101 Number 6 June 1998.  You can access the Pediatrics
article through a free 10 day trial of mdconsult  at
http://www.mdconsult. com
Although they are medically orientated and focused mainly on the initial
treatment they should give you some understanding of the issues.
There are numerous other articles, that are appropriate to the topic, you
can access in mdconsult by doing a search
good luck
Marian Rigney RN and IBCLC candidate

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