Hi Jennifer,

The OB and pain management Dr.'s are not the best resources in terms of managing this infant's plan of care & feeding.  The best resource for the management of this infant/feeding/withdrawal would be the neonatologist in the NICU.  
The baby has already been exposed to these meds directly in utero.  Breastfeeding will continue to expose the baby, but at lower doses, and since the mom is going to wean off the meds anyway, it would make sense that she could continue to breastfeed during this weaning period.  
To the best of my knowledge, breastfeeding with meds, while baby is withdrawing has not been shown to interfere w/ the infant's withdrawal process.  **I would strongly suggest that the mom meet with the neonatologist before birth to discuss the anticipated plan of care, and to share with the MD the high value she places on breastfeeding.** 
In addition, the fact that the OB/Pain Mngmt docs are "allowing" mom to breastfeed only in the colostrum phase may reflect a lack of knowledge re: lactational pharmacology as Hale reports "It is generally agreed that medications penetrate into milk *more* during the colostral period than in mature milk. However the absolute does transferred during the colostral period is still low as the total volume of milk is <low>"  
Best wishes to you, mom, and baby as you sort through this situation!

Mary Foley RN BSN IBCLC
Melrose, MA
 

<<<<<<< From:    Jennifer Light IBCLC <[log in to unmask]>
Subject: Advice for mom on high dose pain medication

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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