On Wed, 22 Mar 2000, Vishakha S Patel wrote:

> On my OB clinical, my assigned client was a
> cigarette smoker. She planned to breastfeed her baby. In my
> client-teaching plan, I wanted to include the risks of smoking on a
> breastfed infant.

Vishakha:  You have done some excellent research and identified some areas
of very real concern.  The question of whether or not a mother who smokes
should breastfeed, despite the AAP Committee's having put nicotine on
their contraindicated list, is actually quite controversial, and it has to
be viewed in somewhat of a larger context.  I am a family physician and
breastfeeding specialist and I will try to address some of your concerns.

> Since I was able to find all this information, I am wondering if
> anyone out there would have had this checked and what percentage of
> mothers in population do you see smoking while they breast-fed their
> infants.

I don't believe any good studies have been done on this.  However, there
are some factors which make the combination of smoking and breastfeeding
somewhat unlikely.  First of all, smoking rates are higher among lower
socio-economic people with lower education levels.  Young women have
the highest increase in smoking rates.  These are the same populations in
which breastfeeding rates are very low.  Secondly, smoking has been shown
to reduce the milk supply -- breastfeeding mothers who smoke are less
likely to continue because of this.  Thirdly, mothers who smoke during
their pregnancy are often discouraged from breastfeeding.  In the studies
which I have seen which addressed health-related issues associated with
second-hand smoke, the numbers of breastfeeding mothers who smoked were
extremely small. My favorite example is Klonoff-Cohen HS, Edelstein SL,
Lefkowitz ES, et al.  The effect of passive smoking and tobacco exposure
through breast milk on sudden infant death syndrome.  JAMA, March 8,
1995;273(10):795-8.  In this study, the breastfed babies had the lowest
rates of SIDS, except for the subset whose mothers breastfed and smoked.
The researchers concluded that mothers who smoked should be told not to
breastfeed.  However, the conclusion was based on laughable numbers.  The
extremely small number of women who breastfed and smoked was really too
small to draw *any* conclusions from.  For the purposes of my current
discussion with you, I only use this to point out that it appears that
very few women smoke and breastfeed.

It's possible, however, that we will be seeing an increase in this group
of mothers.  Breastfeeding rates are increasing overall, and mothers in
the low socio-economic groups have been targeted for breastfeeding
promotion (WIC, for example, has a strong emphasis on breastfeeding
promotion, and they have achieved almost a doubling of breastfeeding
rates).  So the issue of breastfeeding and smoking may well become much
more prevalent in the near future. That is why your question needs to
be addressed seriously, taking various aspects into consideration.  We
also need some more good research, looking not only at cotinine levels but
long-term outcomes.

I also would like
> to know the method used to teach mothers about this type of risks. I would
> appreciate your information on this kind of a situation.

When I teach mothers about risks, I deal with weighing risks and benefits.
There are some situations in which the risks and/or the benefits of a
particular course of action are very clear.  Certainly the risks of not
breastfeeding far outweigh the risks of breastfeeding in the majority of
cases.  However, in situations where the risk of breastfeeding may be
considerable, we really have to look at the situation more carefully, and
we will find that in the absence of good studies it can be very difficult
to properly weigh the risk/benefit ratio.  Most of the time I end up
individualizing according to each mother/baby's case.

The most important principle, IMHO, is to be very clear on the fact that
formula-feeding has been demonstrated beyond any reasonable doubt to be
associated with many significant health risks, and further has been
suggested by other studies which have not yet established it beyond
reasonable doubt but still have strong data, to be responsible for a
whole host of other illnesses. This includes not only the immediate and
long-term health of the child, but also that of the mother.  Because of
this fact, we cannot simply make a case for not breastfeeding just on the
basis of nicotine having been demonstrated to pass in breast milk.  This
would, of course, be reason enough if there was a truly safe and healthy
alternative.  But formula isn't that safe and healthy alternative.  In
fact, until we have easily available and affordable pasteurized donor
human milk throughout this country, we really do not have a safe
alternative to breastfeeding by the mother herself.

So this is what I do when I counsel a mother who may have a factor which
could increase the risk of breastfeeding to her baby (e.g. a
contraindicated medication, infectious agent, etc).  I explain the
information available about the potential risks of breastfeeding with this
behavior or condition.  Then I explain the known risks of formula-feeding
both to her baby's and her health (if the baby is at particular risk of an
illness such as diabetes or asthma which could be prevented by
breastfeeding, then I make that particularly clear and that increases the
weight on the side of the risks of formula-feeding).  I think it's also
important, especially in a situation such as a baby inherently at higher
risk of certain diseases from formula-feeding, to make the mother aware
that there is a limited amount of banked, pasteurized donor milk which can
be obtained by prescription and will be covered by insurance if her
physician can justify its use.

In the case of smoking, of course we want the mother not to smoke,
regardless of how she feeds her infant.  That should be a clear message
from all healthcare providers. If she actually quit smoking for the
duration of the pregnancy, there's a chance that she will choose not to
resume smoking while she breastfeeds (and hopefully never resume it again
once she realizes that the habit now has an important potential impact on
her baby's health, regardless of how she feeds the baby).  If she is
unlikely to quit, we go over the risk/benefit stuff I mentioned above and
she then makes an informed choice (as informed as possible under the
circumstances).  If she chooses to breastfeed and continue to smoke, I
urge her to smoke only *after* nursing in the hope of minimizing the dose
of nicotine the baby ingests.  I also urge her to smoke *outside* the
baby's room and preferably outside the house, and to ensure that other
smokers in the household do the same.  If she chooses not to breastfeed
and continues to smoke, I urge her equally about the importance of not
smoking in the house and not exposing baby to any second-hand smoke.  I
make it clear that if the baby is formula-fed, he's missing the protection
her milk could provide against common respiratory tract infections,
therefore second-hand would be an even more serious risk to her
formula-fed baby.

I don't have a lot of references handy for everything I've told you, but I
can obtain them if you need them.  I just wanted to respond to you as
quickly as possible.  Best of luck with this young woman.  Hopefully you
can persuade her not to smoke, which is best for not just her baby but
also for her.  Regards, Alicia Dermer, MD, IBCLC, Clinical Associate
Professor, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ.
(732)254-1515; fax (732)651-0774.

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