Comrades: 

Dealing with a complicated case -- bear with me. Mother breastfed first child, now 8, and really wants to breastfeed new baby, Her many health issues include diabetes insipidus (nothing to do with blood sugar --the kidneys are unable to conserve water, so she is intensely thirsty, and drinks and excretes excessive volumes), a blood clotting disorder, and multiple sclerosis. My concerns is, to cope with the pain of MS, for the last 10 years (though the previous pregnancy and breastfeeding, and through this latest pregnancy) she has taken Baclofen and Percocet 10-325 (which is 10 mg. oxycodone and 325 mg. acetaminophen) about 4 times a day. That's adding up to about 40 mg. of Oxycodone daily 

My first contact with her was a night-time phone call -- home from a 5-day NICU stay, and engorged, making her nipple disappear, so we talked short-term measures, until we could meet. (Hectic time, since I was going out of town.) Baby induced at 38 weeks+, fast labor, nuchal cord, BW 6 lbs 14 oz. and was 6 lbs. 5 oz. when we met on Day 7, with formula supplements begun. We worked through ordinary latching problems -- a tricky "fit" with large heavy breast and soft nipples, somewhat restricted tongue, but we helped baby latch, without shield and, with lots of encouragement, she transferred 0.9. So we discussed that this was a promising start, and supplements were necessary, and that pumping would help re-balance the situation. (She'd been pumping sporadically) 

Also got her health history, and found that the NICU stay was for some level of neonatal abstinence syndrome (baby withdrawing from drugs in system during pregnancy). At this point, I brought up concerns about the medications -- and she said I was the first to bring up concerns about this with breastfeeding. With her first child, she said an LC had looked it up in Hale and said it was ok. The mother is adamant that the medication at this level is necessary for her to be able to walk and function. 

Most of the references for Percocet and breastfeeding discuss(short-term post-csection use. Lactmed and Hale (which has it as L3) both suggest a maximum daily dosage of 30 mg. and monitoring the baby carefully for growth and respiratory vigor. I called Hale's Infantrisk help-line, which was rather inconclusive -- the person there said that the latest edition now said 40 mg. as the top dose (I'm now out of town, and can't access my copy -- only have the Lactmed app.), and perhaps this person should do partial breastfeeding. 

I met with the mother briefly for a rather jumbled follow-up visit (she had a doctor appt. regarding problems with the episiotomy stitches) and that morning the baby transferred 0.2 oz. 

In the meantime, the mother has discussed the medications with her doctor and the pediatrician, who have now suggested not breastfeeding. The home health nurse and the allergist she works with for her older child suggest at least partial breastfeeding. So the mother is absolutely stressed and very conflicted. She said the day after we met, she enjoyed nursing along with the baby about 6 times, but then was "hysterical" -- convinced that everything the baby did was a sign of something wrong due to her milk. (Though, unless there's been some upswing, I can't picture a huge amount of milk transferred). Right now the baby is gaining well on formula. The mother is pumping 1-2 times a day, because she can't bear the thought of losing the milk entirely, but can't bring herself to give the small amounts pumped to the baby, or to put the baby to the breast, unless I can reassure her that breastfeeding would be safe. 

I've discussed that this is a judgement call -- it's hard to peg where the risks of breastfeeding with a medication might possibly outweigh the risks of formula-feeding (and that some of her doctors do just see formula as the risk-free normal). 
I've pointed out that the medicine is not contra-indicated -- that the transfer seems to be highly variable, but the Relative Infant Does is generally under 10%, beyond which there is greater concern. I also have made the rather cruel point that her supply has been down-regulated -- at 18 days, it might take a lot of work to get back to providing even half the baby's intake. This reduced production is also lessening the baby's exposure. One plan could be to work on supply, keep the baby enjoying the breast, and just monitor everything. (But her hyper-vigilant approach might make that difficult.) 

I have to admit to feeling a little conflicted myself. This is a lot of medication (and through the pregnancy as well!) so it's hard for me to have my usual enthusiasm for getting this baby back to full breastfeeding. I have encouraged her to increase the pumping and save the milk, while I explore the issue further. I feel I'll also have to talk with her doctors to make sure that we're all on the same page. 

So I'd love to get some other thoughts and references from LCs who have worked with mothers in similar situations. Oxycodone is also a drug of abuse, and that fact that she's a nice middle-class woman who really values breastfeeding shouldn't tip my clinical judgment. 

Margaret Wills, IBCLC Maryland 



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