My current patient (who gave me permission to ask about this here) is 35 weeks pregnant with her second child.  She has 2 ruptured disks in her back from a previous car accident.  Her doctor is just trying to "get her to 36 weeks" so he can deliver the baby by C-section.  She is taking many drugs for pain management and has been put on bed rest for hypertension.  Her OB and pain management Dr.s are telling her she cannot breastfeed because of her medication regimen. They did however say she could give the baby colostrum at first, but could not continue to breastfeed once her milk comes in.  The baby will be in the NICU to be weaned off of the opioids. 
She is taking Hydromorphone, Oxycodone, and BUTALBITAL COMPOUND (Firoicet) for occasional migraines.  She is also taking insulin, metformin, and a B-blocker.   She will also be weaning herself off of the opioids after childbirth.
 

I looked up these medications in Hale.  The opioids and the Firoicet are all L3 medications.  They have a high milk/plasma ration>1 (2.57 hydromorphone, 3.4 oxycodone, and unknown for Firoicet).  Still, there estimated infant doses are 0.67% for the hydromorphone and 8% of the maternal dose the the oxycodone.  

My main question is why can she not breastfeed this baby (especially if she was watching for signs of respiratory depression and sedation)? Am I missing something here?  The infant dosage for these medications is far more than the baby would be presumably receiving from the mother's milk.  Especially if the plan of care is to administer this medications postpartum to the infant so it can be weaned off of them.  Would the amount in the mother's milk not help the baby step down the intake he/she is receiving if the mother is also stepping down her dosage as well?  Please help!!! This mother is not willing to "pump-and-dump" until she is off the pain medications.    
 Thanks in advance,
Jen Light, IBCLC

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