Mary asks:

"If there is evidence to suggest that mom may be using illegal substances (or legal substances obtained illegally) but she denies such use, and we have notified the social services, how do we approach breastfeeding for this mom?"

I work out in the community, making home visits with Public Health Nurses, and also have been brought into situations that caused real concern, in relation to this issue.

Of course if you believe the baby is in imminent danger (mom is actively using -  I have had dads bring in drugs for her) or states she plans to (yes, they DO) - or you are concerned - the report must be made to Child Protective Services - but that does not mean baby will be removed, as they usually have programs that try to keep families together. (It is possible to provide a pump for a mom whose baby is removed, and some have been able to keep their milk going while fighting the system to get their baby back.)

The "fuzzy" part is the hardest - and I have found that I need to be clear in my own mind what MY job is as an IBCLC.  I believe I need to understand that I cannot be there 24/7 and THIS baby will be.  I cannot prevent all bad things (from being dropped due to alcohol use, ignored due to drug use to burned due to ignorance about normal child exploration) whether breastfeeding or not. 

I carry Hale's book (sure is getting heavy, Tom - can it be a little bigger so it isn't so THICK?) with me at all times.  Whenever a nurse tells me this mom has a history of xx or YY - I pull it out and READ then explain and have her tell me back what she heard me say would be the risks to her baby if she gave her baby her milk laced with any one of the drugs she has a history of using. 

I do this in a collaborative way.  I know this sounds punitive as I write it out, but actually I sit NEXT to her, we talk about what brought her to this place now and then explain:  "Even though you tell me that aren't using right now... I need to provide you with the information so you have reasons why NOT to use TOMORROW".  I also explain that IF they "fall back" they can pump and dump and then go back to breastfeeding once they are clean.  We know that stopping the use of drugs is not a one-time decision, but a daily and even hourly decision...

I really don't know how many moms DID breastfeed while using drugs, even after my talking with them - but I have had moms call me to say "I used meth/heroin/alcohol this weekend, how long do I need to pump and dump?" and had another mom who INSISTED she wanted to pump for the baby that had been removed from her home for her history of drug use - we gave her a pump, but she never gave her milk to the foster mom.  Her NEXT baby was born "clean"...

We can't assure babies will be going to safe homes - and believe me, if you made home visits with me, you'd want to take them home with you!  We can't assure that moms will place their babies "back to sleep" or in safe locations, no matter how well we educate them.  We can't assure that the formula babies get has been mixed appropriately or that the bottles and nipples were washed...

Policies can make institutions (and their lawyers) think they are doing what is best - especially if they want to prevent ALL risk by refusing to allow a mother to breastfeed her baby if she has a history of drug use - but moms have spoken to our Breastfeeding Coalition who WERE users who reported that breastfeeding made them "not use TODAY"...and the next day...and the next...

If we believe we are releasing babies with complete assurance that there are no risks in the home by writing  policies and procedures that keep at-risk mothers from breastfeeding - we are fooling ourselves.  Breastfeeding is ONE way to reduce the risk of many things, including abuse and neglect.  And no, it is NOT a guarantee...  For this reason we also need to refer, refer, refer and collaborate with the agencies that WILL be her support system once discharged.  

Jeanette Panchula, BA-SW (Social Work), RN, PHN, IBCLC
California, USA

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