I do not for a minute think this is an easy topic for us, as IBCLCs, to
ponder.
So what are we to do with the cocaine addict who walks into the unit and
delivers a baby?
Our professional responsibility radiates in three directions: to the
mother, to the baby and to the *relationship* of breastfeeding. Take a
quick buzz through the ILCA Standards of Practice, the IBLCE Code of Ethics,
the IBLCE Scope of Practice for IBCLCs -- heck, even the Int'l Code of
Marketing of Breast-milk Substitutes -- and you will see this duty mentioned
over and over again. We cannot write off a mother, her baby, and her
breastfeeding relationship just because cocaine is in the picture at the
time of delivery. Measuring just how much is in the baby's system is
inexact. Infant urine will show traces of cocaine *longer* than the 7 days,
post-exposure, of adults. "Even after the clinical effects of cocaine have
subsided, the breastmilk will still probably contain significant quantities
of ... the inactive metabolite of cocaine." Hale 2008 at p 233.
So what are we to do with the cocaine addict who walks into the unit and
delivers a baby?
Looking at the VERY short term, and doing the VERY least we can, we at know
this: YES, without a doubt, cocaine is a horrid drug, dangerous to both
mother and baby. When Crack Mom delivers we will have to rely on her oral
report of how much cocaine she took, and when. But how ever much it was, we
know baby got 100% of the maternal dose while in utero. Now baby has been
delivered. Presumably, security measures in the hospital are in place (the
original inquiry was about policies for a hospital ...) that will prevent
mom from snorting/injecting/smoking while on the premises ... so at least
for 24 or 48 hours, we know that we will not have more cocaine entering the
picture. Whatever residual cocaine the baby ingests from the mother's milk
will be very small in comparison to that third trimester. Baby will only
get what small amounts cross over into the colostrum ... and the colostrum
itself is ingested in small amounts in Days 1-3. Indeed, because Baby will
probably be showing signs of withdrawal, the small amounts of cocaine in the
colostrum may actually help to ease the symptoms, as research
involving methadone withdrawal suggests.
Meanwhile, back at the ranch, mom and baby are skin-to-skin (we hope). If
not (perhaps Baby is in the NICU), we health care providers [should be]
cheer-leading Crack Mom to pump-express-pump her colostrum because it is so
important for her baby's survival ... just as we tell every mother of a NICU
baby, right? Even if the mother ONLY pumps for two days, and turns right
around and goes on a bender the minute she is discharged, that is two days'
worth of colostrum baby would never otherwise have got. Baby will get the
anti-bacterial and anti-viral properties of human milk as soon as oral feeds
occur; the gut will close properly; the brain will get natural oxytocin ...
all that cool stuff we know about human milk. With any luck, feeding will
be done directly at breast ... and, just as with the encouragement and
cheer-leading we give every mother feeding her baby at breast, we will be
doing the same for Crack Mom. And fer cryin' out loud ... the baby is in a
hospital. Skilled clincians are there around the clock, monitoring the
baby. If they see that things are "going south," they can move on to Plan B
(pump and dump, with lots of cheer-leading, to maintain supply while mom's
cocaine levels drop ...).
For the 1 or 2 days in the hospital, these messages associated with
breastfeeding may be the ONLY positive messages this Crack Mom will EVER
hear about her mothering skills.
There is no question: this picture is not a good one. In a well-funded and
well-staffed world, mom would be getting drug counseling, lactation support,
social work care, and home-based assistance -- in intensive amounts, both in
the hospital, and upon discharge. And to be clear: this mother needs these
supports even if she never breastfeeds, and her baby got formula from day
one. But the hospital's approach to all mothers and all babies HAS to be
that breastfeeding is to be supported and promoted as a biologic and public
health imperative, because that is what the evidence-base proves [yeah,
yeah, I know .. Mother Nature knew it all along, but those administrators
love their evidence base].
Liz Brooks JD IBCLC
Wyndmoor, PA, USA
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