Season 4, Episode 8: Breastfeeding in the Context of Substance Use Disorders

Episode Transcript
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UNKNOWN (00:00):
Bye.

SPEAKER_00 (00:04):
Hi everyone and welcome or welcome back to Just
Us Before Birth and Beyond.
We're so glad to have you herewith us today.
My name is Caitlin and I am oneof the hosts of this podcast and
I'm a nurse and I've beenworking in Western North
Carolina in the world of women'sand maternal health for over a
decade now and I'm here today tointroduce our episode.
So today we have what weconsider a special self-hosted

(00:26):
episode.
So we will be hearing from anamazing team of experts from
Mayhek and Asheville and they'regoing to be talking about breast
and chest feeding in the contextof substance use disorder.
So I will let them introducethemselves in the episode.
They give a really greatdetailed introduction.
And in the episode, they'regoing to cover everything from

(00:47):
updated guidelines related tosubstance use disorder and
breastfeeding.
They're going to talk about theadvantages to breastfeeding in
this population, what is safe,what substances may need a
little more guidance oreducation or monitoring.
They're going to address mythsabout breastfeeding and
substance use disorder and andso much more.
This is a really detailedepisode.

(01:09):
They really deep dive into thenuance of breastfeeding and
substance use disorder, andthere is just really so much
great practical information.
So without further ado, let'sjump into it.

SPEAKER_03 (01:21):
So my name's Amy Marietta.
I am the medical director ofProject CARA, which is the
Perinatal Substance Use DisorderTreatment Program at MHEC.
It stands for Care thatAdvocates for Respect,
Resilience, and Recovery forAll.

SPEAKER_01 (01:39):
Hi, everyone.
My name is Olivia Caron.
I am a clinical pharmacist hereat MHEC.
I split my time doing chronicdisease management and family
medicine and substance usedisorder work, both in family
medicine and OB-GYN.
I also teach at UNC EshelmanSchool of Pharmacy and do a lot
of research in the substance usedisorder arena.

SPEAKER_02 (02:04):
Hello, everyone.
I'm Georgiana Cogburn.
I'm a registered dietitian andinternational Board Certified
Lactation Consultant.
And I am the Region 1 LactationTrainer with WIC LATCH, which
stands for Lactation AreaTraining Centers for Health.
And in addition to traininghealthcare professionals across

(02:26):
the western and northwesternpart of North Carolina, I also
see patients in our clinic hereat MAYAC.

SPEAKER_03 (02:35):
So I'm really excited to be here with you both
and to be having thisconversation because I I think
it's so important.
We get so many questions.
So just briefly, I want to say,why now?
Why are we having thisconversation now?
And one of the exciting thingsis that last year in 2023, the
Academy of BreastfeedingMedicine released an update to

(02:56):
its guidelines for infantfeeding in the context of
substance use disorders, reallyfocusing on the whens and hows
of breast and chest feeding inthe context of of substance use
disorder and treatment forsubstance use disorders.
So before we dive in, I did wantto just speak to the use of

(03:19):
inclusive language whenreferring to breast and chest
feedings.
We are going to make everyeffort in this recorded
conversation to use inclusivelanguage referring to breast and
chest feeding.
However, there may be times whenwe were referring to the
literature that the languagewill use just breastfeeding.

(03:39):
So, you know, in my day to dayas a family medicine physician
and obstetrician and addictionmedicine specialist, I have the
honor of taking care of mypatients throughout pregnancy
and postpartum and reallyworking with them throughout the
full scope of their recovery inthis kind of intense and special

(04:01):
time.
And one of the things that comesup a lot is these discussions
regarding how am I going to feedmy baby?
You know, do I want to breast orchest feed my baby.
So just thinking through like atypical clinic, maybe like a
Tuesday afternoon, patient comesin, maybe they're getting close
to their third trimester, reallystarting to think about delivery
and postpartum.

(04:23):
And so how do I start to havethis conversation about how are
you planning on feeding yourbaby?
And just having a reallysupportive and educational
conversation about that, becausewe know that there are many
advantages to breast and chestfeeding.
And I know or Jenna's going totalk about that a little bit
more going forward.

(04:44):
But we also know that patientswith substance use disorder in
treatment for substance usedisorders have lower rates of
breast or chest feeding atdischarge from the hospital.
So on average at a hospital,about 84% of patients have
initiated breast or chestfeeding.
And with patients who havenon-prescribed substance use or

(05:08):
are in treatment for breastsubstance use disorders with
medications for opioid usedisorder, those percentages are
going to be much lower, anywherefrom like 14 to 30%.
So can we talk about that alittle bit?

SPEAKER_01 (05:21):
Yeah, I mean, I'm even thinking about a
conversation I had yesterdaywith a friend of mine who's due
to deliver soon.
And we're in the world of Googleand WebMD and all the
information's at our fingertips,which also leads to us having
lots of space for myths andmiscommunication and
misinformation.
information.
And so I think today our goal isreally to talk through maybe

(05:43):
some of these myths and have anidea of what do we know?
What do we not know?
What's still gray?
What feels a bit more black andwhite?
And I think that first myth thatwe want to dispel or talk about
is patients come into thatclinic, that Tuesday afternoon
clinic and say, well, I can'tbreastfeed, right?
I'm a history of substance use.

(06:03):
I'm actively using.
I'm someone with livedexperience.
Any of those scenarios come upto time and time again.
They just say, I'm not eligible.
I can't do that.
Or, you know, my mom told me notto do that.
I heard from a friend that'sreally bad for baby.
And so we really want to justsit with them and kind of talk
about really, let's talk aboutyour motivation and what we see

(06:26):
time and time again.
And I'd love to hear both ofyour input on this is parents,
birthing persons, moms, theywant to do what's best for their
baby.

SPEAKER_03 (06:34):
Absolutely.
Yeah, for sure.

SPEAKER_01 (06:36):
And so we hear that we want to support them.
And we think of patients andrecovery, it's not a linear
line, right?
We talk about that a lot.
You can return to use, you canbe actively using, and that
doesn't mean you're goingbackwards.
And so empowering a patientduring this time period to
breastfeed may actually helpsupport their recovery too.

(06:58):
And we think about the newguidelines being pretty drastic
in how they change theirlanguage around breast and chest
feeding.
I saw previous, you know,recommendations where if there
was use in the last month, threemonths, the recommendation might
have been, you know, you aren'teligible.
So can we talk a little bit howthat's changed recently?

SPEAKER_03 (07:20):
Yeah, it's really exciting.
I would say, you know, the newguidelines say that if at the
time of presenting for delivery,there is no ongoing use, that
initiation of breast or chestfeeding should be supported.
Correct.
Yeah.
So That's a really, yeah, that'sa huge change for patients.

(07:44):
And I think one of the otherthings that I hear a lot is, you
know, once patients kind of hearfrom us that, yes, this is
something that you can do, thatwe want you to do, like we
encourage you, we're going tosupport you.
They really embrace that, right?
And the idea that this issomething that only they can do,
that only they can do for theirbaby, it's really empowering.

(08:06):
It's really special and can bereally motivating for a
sustained recovery.

SPEAKER_02 (08:10):
And I think a lot of that goes back to they look at
the choices that they've madepreviously and they're feeling
very guilty about the choicesthey've made.
And they're going, okay, I havea chance now to make a different
choice.
And this choice I make is reallygoing to be good for my infant.
It's going to improve myinfant's health, my infant's

(08:32):
outcomes.
And I've even had patients tellme, I want to breastfeed or
chestfeed my infant becausethat's going to motivate
Absolutely.

SPEAKER_03 (08:42):
Yeah.
Yeah.

SPEAKER_01 (09:09):
Whoa, you just opened this world for me.
Well, how can I do this safely?
And as the pharmacist, Iapologize to everyone listening,
but I have to geek out on thescience a little bit.
It's the best part of it all.
I get to bring in probably themost black and white into this
conversation.
We think a lot about substanceswith breastfeeding and how their
half-life, so how long asubstance can take to clear.

(09:32):
In the medical world, we usuallysay four to five half-lives is
how long a substance needs toclear.
And your half-life is the timerequired for a substance to go
down to 50% concentration inyour body.
So there's a time where asubstance will have a peak
effect, then it'll go down to50% concentration, and the time

(09:53):
to get to that is its half-life.
And the way that we talk aboutin breastfeeding and the way
that any pharmacist has beentaught is the relative infant
dose, or RID.
And so we talk about that a lot,about the infant's dose in
relation to the parents dose,right?
And so that's just dividingthose two things.

(10:14):
And I'm a big fan of havingresources at your disposal.
If you've heard this before, butpharmacists love to look into
things and we're quick atlooking up things.
And I'll give you insight.
We like to cheat a lot, right?
We like to have quick things.
So the app that I used when Iwas in school was called
LactMed.
It is now being updated toLactRx.

(10:36):
And that is a great databasefrom the NIH that just gives
gives you really good hardcoredata on here's a relative infant
dose and here's the half-life ofthe substance and here's a
recommendation.
Very similar to these guidelinesfrom the Academy of
Breastfeeding Medicine.
We look at those to make adecision to help that come into

(10:58):
our shared decision-making withthe patient.
And generally, we like to see arelative infant dose of 10% or
less and we consider that safe.
And so kind of going back tothose medications for opioid use
disorder, we know that relativeinfant dose is very low for both
methadone and buprenorphine andnaltrexone, which are three

(11:19):
primary medications we use totreat opioid use disorder.
We also have lots of differentsubstances that we treat like
alcohol, tobacco, stimulants.
And so you can look up thedifferent medications that a
patient is on and kind of makethat decision with the patient,
hey, is this safe for the baby?

(11:40):
So that's kind of the big thingthat I do in the room as the
pharmacist with shared decisionmaking.
But we like to think about theteam orienting care.
And so I can talk about safety,but then I may look to my
lactation consultant to say,hey, what are the benefits?
How can we empower mom and talkto her about why she should do
it?

SPEAKER_02 (12:00):
Right, right, right.
So I like to always go back to,you know, we're talking about
the Academy of BreastfeedingMedicine's position statement,
their protocol that came out.
And also like to look at andwhen i'm talking to patients
well the american academy ofpediatrics the american college
of obstetricians andgynecologists all support

(12:20):
breastfeeding for these patientson medications for the opioid
use disorder and you know thebenefits you were mentioning the
concern with the nicotine theparents that smoke and the
babies are in those smoke-filledenvironments and we know those
infants are at higher risk ofupper respiratory infection that

(12:41):
higher risk of SIDS, that suddeninfant death syndrome or sudden
unexplained infant death.
Well, when that parent isproviding breast milk, is
breastfeeding or chest feedingthat infant, it lowers that risk
of those upper respiratoryinfections, of those ear
infections, which I think is agreat benefit to talk to our

(13:01):
parents about because they'redoing the smoking and they're
really concerned, am I going tohurt my infant?
When they think, oh, I can dothis and this can help protect
my infant.
And the other thing that thebreast milk does is it really
helps to build that infant's gutmicrobiome.
It helps that baby to be able tofight other types of infections.

(13:22):
Yeah.
Asthma is another one it helpsprotect against.
That's amazing.
Yeah.

SPEAKER_03 (13:28):
Yeah.
It's incredible once you startlisting it out.
You know, patients, you know, wespend so much of our time in our
clinic trying to overcome stigmaand like reduce the risk for our
patients.
And so to have something reallypositive, like, you know, how
can we support you in doing thisthing that only you can do that

(13:51):
you are uniquely, you know, inthis situation to be able to be
the only one that can offer yourbaby this, it really changes the
dialogue.

SPEAKER_02 (13:59):
It does.
And then, you know, not just forthe infant, but there's benefits
for the parent as well.
You know, we were talking abouthow a lot of our patients come
in when they come into theclinic, they're anxious they're
really concerned.
Well, breastfeeding, chestfeeding helps to reduce that
risk of postpartum depression,which is great.

(14:20):
And then especially when youstart doing that history and you
look at that family history, ifyou find there's been a history
of premenopausal orpostmenopausal breast cancer and
ovarian cancer and endometrialcancer, it helps to lower the
risk of those.
We're seeing a lot of patientswith gestational diabetes when
they breastfeed chest feed, ithelps to lower that risk of them

(14:44):
developing type 2 diabetes laterin life.
And I think a really importantthing for the patients that
we're talking about today andworking with is, you know,
they're at that higher risk ofthat anxiety, of that kind of
stress.
Am I doing things right?
The pressures of the world.
When that infant is right herechest to chest with that parent,

(15:06):
that cortisol level goes downfor both the parent and the baby
And guess what?
It lowers that parent's stresslevel.
So they're going to cope betterwith everything that's happening
in the world.

SPEAKER_03 (15:19):
Yeah.
My turn to geek out a littlebit, right?
Yeah.
Neurotransmitters.
So those natural doses ofoxytocin and dopamine that we
get from breast or chest feedingand that skin to skin and that
connection, boy, talk about apowerful tool in recovery,
right?
We spent a lot of time talkingabout substance use treatment

(15:40):
finding other ways to cope withthat cortisol, with that stress
response, but how powerful tohave something proactive that we
can do that gives us a naturalboost to our own endogenous
capacity to, you know, have thatnatural feel good chemicals that
happen, you know, in abundancewhen we're, when we're breast or

(16:02):
chest feeding.

SPEAKER_02 (16:03):
Right.
Right.
Yeah.
And, you know, we're talkingbenefits, but also think we need
to keep in the back of our mindthat these parents have
challenge

SPEAKER_01 (16:10):
You

SPEAKER_02 (16:12):
know, we hear parents say, well, I thought
this was going to be so easy.
Well, it takes a while to get itall going.
And with our parents that we'retalking about today, we do have
concerns and we've alreadymentioned a couple of these.
So to hone in on them is theyreceive inconsistent messages.
You know, maybe one health careprovider will say something and

(16:35):
they go to another one andthey're told something else or
their family is telling them youalready You mentioned that,
Olivia, how they get these mixedmessages.
That's a big concern.
And are they getting enoughprenatal education?
Are we spending that timetalking to them about, well,
this is what to expect.

(16:55):
This is how you feed your baby.
Are we giving them enougheducation?
And then once the baby is here,there may be that chance that
the parent and baby areseparated.
Maybe if they deliver early,baby may end up being in NICU,
you know, and that's an addedconcern or an added stressor for

(17:17):
an infant.
And then this one, Olivia, isfor you.
You've also got to consider whatelse is that parent on?
You know, what is their otherpolypharmacy or polydrug use?
Are they taking medications fordepression?
Are they, you mentioned thenicotine or the alcohol already.
So, you know, what else is thatparent doing?

(17:39):
And, you know, The other bigthing for our parents to
consider is what does theirsupport system look like?
How are they getting to clinicappointments?
If they happen to deliver earlyand the baby's in NICU, but
they've got other kids at home,do they have transportation back

(18:00):
and forth to the hospital?
So doing that total patientcare, I think, and really doing
the education and supportingthat parent, Meeting them where
they're at, making sure theyhave access to resources is
going to help them to besuccessful in feeding their
infant at breast or chest.

SPEAKER_01 (18:22):
Gosh, you touched on a few things.
And we all have the pleasure ofworking together here in Western
North Carolina at MAHEC.
But we talk all about what thehospital is going to look like
and how many people you're goingto see and what are they going
to do when you get there.
And Amy, you and I have talkedabout this and you've taught me
about this.
there's likely going to be adrug screen involved too, right?

(18:44):
And how does that influencetheir care?
We talked a little about thepolysubstance use, right?
Is something that comes up onthe drug screen going to change
the conversation I was havingwith my provider before I went
to the hospital?
And so we have some data to kindof walk us through that.
I don't know if Amy, you want totalk about that a little?

SPEAKER_03 (19:02):
Yeah, I think one of the important points that was
brought up in the new guidelinesfrom the Academy of Breast Feed
medicine is that a urinetoxicology test is not the best
test to determine whether or nota patient should initiate breast

(19:22):
or chest feeding in thehospital.
And there are a couple ofreasons behind that.
I think like any test, it'simportant to know why you're
doing the test and what you'regoing to do with the
information.
And so when we think about thefactors that may contribute to
whether or not someone could sixinitiate breast or chest

(19:42):
feeding.
One of them is going to besubstance use.
You know, when is the last timeof use?
What substance was used?
You know, what has their usebeen like, right?
Going into labor is stressful.
It might be a trigger.
You know, have they been withoutany use throughout their
pregnancy and then, you know,delivery comes and it's

(20:04):
stressful and they have aone-time return to use or is
there ongoing active use that weneed to address as a team.
So a urine toxicology test isnot going to tell you all of
those things.
It's not going to say anythingabout their support network.
It's not going to say anythingabout if they're engaged in
treatment or have a desire toengage in treatment.

(20:25):
And so I think it's important toknow urine toxicology test tells
you at one snapshot in time whatis being metabolized by that
patient's body and what isshowing up in their urine.
And the other thing to know isthat there are substances that
are lipophilic or fat solublethat can hang out in urine for a

(20:47):
long time.
And so we've seen this for awhile with cannabis, you know,
and now we're starting to see itmore with fentanyl as well.
We can see that urine toxicologytests can be positive for these
substances for days, weeks, evenwith fentanyl metabolites, we
can see it be positive formonths.

(21:08):
So having a positive urine urinetoxicology test may just
indicate that someone had areturn to use two months before
they engaged in treatment, youknow, and it's still showing up
positive.
And so taking all that intocontext when you're having these
conversations with your patientsand with the care team at the
hospital.

SPEAKER_01 (21:26):
I love the word, it's going to show what they're
metabolizing, right?
Like that is such a great way toput it.
It's not going to show maybewhat they're ingesting that
morning.
It's what your body'smetabolizing.
And so I think the Academy did agood job of saying that their
history, right, talking to thepatient is the most important
thing you can do and that isgoing to kind of help you

(21:49):
decide.
So the rapport you can buildwith patients, letting them be
open and honest with you andexplaining why you're asking
that question.
Hey, we want to make our bestinformed decision of if this is
both something we want you to doand we want you to do it, so we
need to make a great decisionfor you.
And so with things likefentanyl, right, I think they've
come out and kind of informed us72 hours if it's been 72 hours

(22:13):
it may be safe to initiatebreast and chest feeding but
again will be a lot of shareddecision making is it active use
is it a history of use was itone time return to use all those
things that amy mentioned thatare so great to think about but
that that urine drug screen is asnapshot in time i really really
love that

SPEAKER_03 (22:32):
yeah and the other thing to know is that you know
like many tests urine toxicologytests are not perfect right so
the tests thing that we do atthe hospital is often a
screening test and the way Ilike to explain this is it's
like a key in a keyhole um if itunlocks the door or gets close
enough it'll be positive butthere are many things that could

(22:54):
maybe mimic that key right soyou can get some false positives
so always sending those testsfor confirmation because often
we'll find them that that we'llfind that the screening test is
um there's a discrepancy in thethe follow-up confirmatory
testing um I was going to say,you know, thinking about, you

(23:15):
know, the difference between thehospital setting and then the
home environment as well, andthinking about, you know, it may
be safe and there may beadequate support to start or
initiate breast or chest feedingin the hospital where there's a
lot of supervision and a lot ofsupport, but how do we best
support our patients whenthey're going back to their home

(23:38):
environment or to treatment?
Like, is there, you know, someintervention that we can do in
that hospital, that reallyprecise moment to set them up
for success, not only with, youknow, feeding their infant, but
in their overall recovery.
And I think that sort ofteamwork together, really
focusing on a patient centeredapproach and giving that

(24:01):
patient, you know, voice andchoice and how they want to move
forward is kind of like thesecret sauce to our team's
approach.
And I think like really reallysets any sort of clinical team
up for success.

SPEAKER_01 (24:14):
We mentioned the word cannabis.
We did.
We put it out there.
It's one of those tough ones.
I am here for it.
I feel like we cracked open thedoor and I feel like now we have
to walk in the room and talkabout it, right?
Cannabis.
As a pharmacist, I can't keep upwith all the different
variations in THC, CBD, thedifferent legality across the

(24:39):
US, right?
Is it decriminalized?
Is it legal?
Is it for medical purposes.
So I feel like this is a reallyunique substance and how we
counsel patients.
We know that it's passed throughbreast milk.
I think that's one importantthing to say is we know that it
does.
We know that it stores in ourfatty tissue and is going to be

(25:02):
on our drug screens for monthsand months.
If we have a chronic use ofcannabis, we know that folks use
cannabis for all sorts ofvariety of reasons from even
just treating their anxiety,which may be a better benefit to
the birthing person.
So there's a lot that we know ofthe why, but then what we don't
know always, right, is who's thebest candidate?

(25:24):
I don't think it feels like themost black and white.
So kind of how do we approachthose discussions around
cannabis with our patients?

SPEAKER_03 (25:33):
Yeah, I think that's exactly right.
So there's nothing about thisthat is black and white.
And I think when we try to takesomething like cannabis use and
make it either a black and whitesituation, that's when we get
into trouble, right?
Because every situation is goingto be different.
Um, the Academy of breastfeedingmedicine guidelines, uh,

(25:56):
reflected what the evidenceshows is that we don't know.
We don't actually know.
And so their recommendation isto have a risk benefit
conversation, to talk to thepatient.
Like you said, Olivia, that likethe most important thing we can
do as providers.
And so, you know, there are somethings we do know.
We do know that THC is detectedin, um, breast milk for weeks.

(26:19):
We know that use doesn't appearto decrease milk supply, but it
can change the composition anddecrease duration of breast or
chest feeding.
It may be associated with anincreased risk of postpartum
depression.
What we don't know are the shortand long-term outcomes on infant
health from cannabis use justthrough lactation.

(26:42):
We do have some outcomes that wecan kind of extrapolate from
prenatal use.
So exposure in utero has beenassociated with neurocognitive
changes and poorer outcomes forinfant brain development and
growth.
So, but what it's hard to teaseout, you know, did the exposure

(27:05):
just happen during pregnancy orthen it also happened then
during lactation?
And so I think it's important tohave a conversation because what
comes up for me with patients alot is the idea that cannabis
use is natural or maybe more abetter alternative to some of
the other prescribed medicationsthat we might think about using

(27:27):
for things like mood or sleep ornausea.
And I think it's important tohave a conversation about the
potency and strength of cannabisproducts has really increased
over the last two decades.
So the the amount of THC thatsomeone may be getting from
their current vape product oredible, or even things, you

(27:53):
know, from their dispensary ordispensed for medical purposes,
it much, it's much higher thanit used to be.
And so really having aconversation about that and
getting into the details.
So how much is someone using,how often are they using, what
products are they using?
And then the big one for me iswhy, what, what is this doing

(28:13):
for you?
And are there other ways that wecould help support you that are
more compatible with lactation?

SPEAKER_02 (28:19):
And I think that leads to what I think is a
wonderful way they put it isencouraging the parents to not
use the cannabis, not sayingdon't chest or breastfeed your
infant, but refrain or not usethe cannabis while you're breast
or chest feeding your infant.
And that requires us having aconversation and figuring out

(28:41):
why are they using, what's thetrigger for them and helping
them to work through that sothat they're able to have that
experience with their baby.

SPEAKER_03 (28:50):
Right.
And I know plenty of patientswho in preparation for delivery
and because they want to breastor chest feed, you know, cease
use and then it still shows upin their urine toxicology
screen.
And so then there may bebarriers to breast or chest
feeding initiation in thehospital.
So one of the things that I talkabout with my patients early on

(29:12):
is why don't we do some controlconfirmatory testing to look at
the levels to see them droppingand that is really satisfying
for patients who are motivatedand really wanting to they have
that goal in mind of being ableto breast or chest feed their
infant just seeing the thenumbers right there it's more
than just pharmacists andphysicians right it's really

(29:34):
satisfying to see it on thepaper

SPEAKER_02 (29:36):
right and and you think about that too you maybe
have this patient who has workedso hard to not use all during
the pregnancy.
And they get to that last fewweeks and they're like, I'm
miserable, I can't cope.
And they remember using that tocope before, using the cannabis
to cope before.

(29:57):
And they go and they use itonce.
And you want to be able tosupport them because obviously
when you look at their history,they're committed to not using.
They want to do what's best.
I think it always comes back.
These parents want to do what isbest.
their baby.
They want to be there for thatbaby and do that.

(30:18):
And while we're mentioningbabies, I think one of the
things that come up with thepatients who are using the
substance, you know, themethadone, the buprenorphine,
they're always concerned, how'sit going to affect my baby?
What's going to happen?
And we hear a lot about theneonatal opioid withdrawal
syndrome or NOWS.

(30:38):
And we know that we typicallyare going to observe that within
24 to 48 hours after delivery.
And, you know, there's factors.
Just like Olivia, you weretalking about the medications,
how our body's metabolizingthese medications, what's going
to happen.
You know, the factors that mayimpact that, the nows, are

(30:59):
things like what were theyusing?
What was the opioid that theywere using?
What's the parent's metabolism?
Are they using other substances?
Are they smoking?
Are they using nicotine?
Or is this patient on an SSRIfor depression.
All of that's going to affectthat.

(31:20):
And then you look at the list ofthings that we may see babies
exhibiting.
They may have that kind ofhigh-pitched crying, being
irritable, maybe have sometremors, difficulty sleeping.
And I love this one, loosestools.
Well, if a baby's getting breastmilk, guess what?

(31:42):
They're going to have loosestools So, I mean, is that a
symptom of their nows or is thisjust normal metabolism, normal
things with our babies?
And so looking at that, theyawning and sneezing, those are
also too.
You see newborns always yawning,always sneezing, but it may not

(32:02):
be the result of that.
And what we have seen, there'sgreat news for everybody that
there's a 30% reduction in nowsfor infants whose parents our
own treatment, who are gettingtreatment.
And there's also a 50% reductionin hospital stays for these

(32:23):
parents and these babies.
So that's encouraging news.
And so you're probably going,well, what do we do?
How do we educate our parentsgoing back to that prenatal
education?
What do we talk to them about asfar as taking care of their
baby?
And we want to really encouragenon-pharmacological treatment

(32:43):
for the baby.
And the terms now that we useare eat, sleep, and console.

SPEAKER_03 (32:50):
Yeah.
I'm so glad you brought up eat,sleep, console.
I love talking about eat, sleep,console as the evidence-based
treatment for neonatal opioidwithdrawal syndrome, because
it's so easy.
It's treating a baby like ababy, right?
Like what are the things we wantour infants to do?
We want them to eat.
We want them to sleep probablymore than they do.

(33:13):
And we want them to be able tobe easily consoled within 10
minutes.
So if a baby is doing thosethings, great.
No intervention necessary.
Right.
No Finnegan scoring.
I

SPEAKER_02 (33:25):
love that there's no Finnegan scoring because that is
so subjective.
You know, one person maybe seesone thing and another, another.
And I think when we think sleepand consolates and going back to
what you said, Olivia, about thehospital, you know, things that
happen in the hospital ispreparing our patients ahead of
time.
Talking to them about rooming inwith that infant.

(33:48):
Keeping that infant in the roomwith them throughout the
hospital stay.
Talking with them about baby.
How do we know that this babyneeds to eat?
Those physiological infantfeeding cues.
I'm putting my hands to mymouth.
I'm looking around.
I'm starting to make noises.
Talking to parents about this isnormal.

(34:09):
This is how they let you knowthat they're hungry.
Talking to them about This ishow babies communicate.
Talking to them about doingskin-to-skin care.
If they say, well, my baby'sjust really sleepy.
They're not wanting to wake up.
Having them do skin-to-skin carefor 20 to 30 minutes, that baby

(34:30):
is going to start to give usthose cues and start to wake up
to eat.
We also want to talk to themabout doing skin-to-skin care
safely, meaning you don't wantcovers over the baby.
You want the baby's head turnedto its sides so they can breathe
very easily.
And this is a big one too, iskeeping those distractions in

(34:51):
the hospital low.
We know patients, a lot offamily wanting to come see the
new baby, but keeping the lightsdown low, keeping the volume
down low on the TV, keepingthose distractions down low,
really help those babies to copeand to come through.

SPEAKER_03 (35:13):
Yeah.
I just love that, you know, oneof the main tenants of Eat Sleep
Console is breast or chestfeeding, right?
Because you get that skin toskin, you get the lactated milk.
And again, it's that concept oflike, this is the one thing that
only I can do for my baby.
And

SPEAKER_01 (35:33):
can we talk a little bit, you were talking about
preparing for the hospital andwe talk about nows or mass and,
you know, abstinence syndromebeing anticipated, right?
And I think so.
something for those of us thatwork in substance use.
It is just another chronicdisease, right?
It's another chronic diseasewhere we have treatment options.
We have behavioral healthoptions.

(35:54):
We have outcomes that we knowmay or may not happen.
So I think of my parents withgestational diabetes, right?
The risk of hypoglycemia for theinfant.
So thinking like, yes, with anysubstance, good, bad, whatever
connotation it has around it,there's an anticipated outcome

(36:14):
that we can prepare for.
Every hospital is going to havedifferent protocols in place for
just in case.
And so I think a lot of thateducation is really important to
prepare mom.
Hey, you can use your voice,prepare that birthing person to
say, empower them.
I want to do this in the roomwith my baby.
You know, there's always goingto be a backup option.

(36:36):
And I like to see a lot thispendulum move with literature
from using morphine to eat,sleep, console.
And it's going to constantlykeep shifting, but what stays is
that you sleep console.
And I see that time and timeagain in the literature that
that stays a mainstay of therapyfor nows, regardless of all your
other options, regardless of thechanging landscape of substances

(36:59):
too, right?
The substances keep changing.
But what we know is that thatstays true.
And I think that that's reallyimportant.
And you were talking about thebenefits of medications for
opioid use disorder.
And we know that the saidbuprenorphine, methadone,
naltrexone, all recommending andcompatible with breastfeeding

(37:19):
and chest feeding, right?
That was just level A or Brecommendation, which are really
high levels of recommendation,really strong.
And then it gets a little bitmurky with our other substances.
Like Amy was talking about,antidepressants can be
difficult, right?
Certain levels ofantidepressants, we know that
baby can experience somewithdrawal, but it is really,

(37:40):
really powerful.
When I talk to patients aboutgetting on medications for
opioid use disorder, it's a lotof stigma to do that.
You're trading one drug foranother, one addiction for
another.
And to be able to say, hey, wehave data that this is going to
help you during your recovery,during your birth and
postpartum, right?
The benefits don't stop.

(38:00):
And I think that that is one ofthe things that we talk about
when someone presents to ourclinic and we're giving them all
their options, that this isn'tjust for the pregnancy, that
this goes beyond pregnancy andis a really powerful tool in
your recovery.

SPEAKER_03 (38:15):
Yeah.
You know, the way I talk aboutit is the most important thing
for your baby is that you beokay, that you be solid in your
recovery, that you have thetools in place so that you are
well, because what we know isthat babies that are born to
parents who are well do well.
And so it's the number onequestion, right?

(38:36):
Is this going to hurt my baby?
Are these medications going tohurt my baby?
So we know, like Olivia said,that now's is an antithesis.
anticipated and expected outcomefrom exposure to medications for
opioid use disorder in utero,about 30 to 50% of the time.
And then talking specificallyabout things that we can do to

(38:57):
help prevent nows, which, by theway, includes breast or

SPEAKER_02 (39:00):
chest feeding, right?
Yeah.
And another thing, you know, andI want to go back to this is one
of the standard treatments thatwe see that we see a lot with
baby friendly hospitalinitiatives.
So this again is tried and true,skin to skin care with that
baby.
Putting that baby immediatelyskin to skin with the parent

(39:22):
after delivery does so much forthe baby.
We call that the golden hourafter delivery.
You mentioned your gestationaldiabetics.
You know, having that baby skinto skin lowers that baby's blood
glucose level.
It helps to stabilize theirrespirations.
It helps to regulate their heartrate.

(39:43):
And we're doing this across theboard with all babies,
regardless of that parent'shistory.
We're even seeing it happen in alot of hospitals with parents
who deliver bisetharian.
It's automatic standard practicebecause we know the benefits for
both that parent and thatinfant.
It helps the parent to haveuterine contractions, which

(40:05):
helps to deliver that placenta.
It helps to lower that parent'scortisol level.
So it's just a great way to talkto all of our our patients about
expect that this is going tohappen immediately after
delivery and then encouragingthem to room in together
throughout the hospital stay andcontinue to do that skin to skin

(40:26):
care.

SPEAKER_03 (40:27):
Yeah.
Yeah.
I love that.
Love that.
I love the term the golden hour.
I do want to bring up somethingthat's like one of the tougher
questions that we get, which is,you know, we obviously are big
breast and chest feedingadvocates and we also work with
people who are in differentstages of recovery and so you

(40:49):
know and we talk about when itmay not make sense to initiate
breast or chest feeding or whenit may not be safe because
everyone wants both the birthingparent and the infant to do well
and sometimes there may becontraindications or reasons to
not initiate breast or chestfeeding

SPEAKER_01 (41:09):
yeah one of the first things I can think of is
you know chronic heavy act ofuse, right?
It is ongoing and just from apharmacokinetic component,
right?
There's just maybe too muchpassing through the birthing
person's body that may have thepotential to pass through the

(41:30):
baby and maybe having an effecton the birthing person's mind,
their mentality, right?
That is a unique connection andtime with your baby.
It's difficult, as we mentionedSo thinking about, it's not
black and white to me though,right?
Again, because cannabis, right?
Chronic use, that may be adifferent definition for someone

(41:53):
than chronic fentanyl use andwhat that looks like.
So I don't actually like to putanyone in active use as an
absolute no.
I will say that, but that isdefinitely one of my red flags
that go off is what is this uselooking like?
Talk to me through it.
We need to talk more.
We need to talk more.
That's the first dig endpoint.
Right.

SPEAKER_02 (42:15):
And I think sometimes, and I agree about
that active use, and sometimesthey're going, well, how am I
going to bond with my baby?
Because maybe they have heardabout the Chester breastfeeding.
It helps you bond with yourbaby.
If there are those concernsabout the baby getting the
breast milk because we don'tknow how much of that substance
the baby's getting, we don'tknow how that's going to impact

(42:37):
the baby, we could still talk tothose parents about doing that
skin-to-skin care with theirbaby.
They're still going to be ableto get that bonding, but maybe
just not the breast milk.
So keeping that in mind as wetalk to our patients.

SPEAKER_03 (42:54):
Right.
So, you know, I think it's likemany of the things that we've
talked about today.
It's worth a conversation.
It's worth really making thatfocused on the patient and their
goals and, you know, coming upwith a plan that's going to be
safe and patient-centered.

SPEAKER_01 (43:13):
And I will put out there some substances again.
I always like to think of myyellow or red flags as a
practicing clinician.
Stimulant use is one that wehaven't touched on much today.
But methamphetamine is a reallytricky one and one that the
academy, you know, tried toquantify as best as you can.
But that one can stay in yoursystem longer.

(43:35):
And the way that stimulants workthat we all know can cause
really big spikes in heart rate,can cause a lot of physiologic
changes to the body.
And so there are longer waitingperiods.
I know that we mentioned kind ofthat 72 hours for fentanyl.
There's some data that supportswaiting up to 100 hours since

(43:57):
the last use withmethamphetamine.
So methamphetamine is definitelyone that if there's active use,
I'm kind of starting to havethat trigger, that discussion
with my patient.
Hey, this is when it may besafe.
So we may need to plan ahead.
Another one that comes up oftenin folks that Our tobacco users
is thinking about verniciclineor Chantix and that there is not

(44:20):
a lot of good safety data aroundwhether that is recommended or
not.
So that is one that if that iswhat someone's using, often we
don't use it in pregnancyeither.
So less of a concern, but maybetransitioning to nicotine
replacement therapy and findingalternatives for that patient.
Just kind of the conversationswe have around cannabis and all
our substances.

(44:40):
Why are you using it?
Can we find you a saferalternative?
And then the other one that Ithink is tricky is alcohol,
right?
Is it chronic?
Is it a glass of wine?
And so that is anotherdiscussion.
I feel like we're going to soundlike a broken record by the end
of this, but talking to yourpatient, often if it is
occasional use, you can kind ofwait those two to three hours

(45:03):
per drink to feed.
But with really chronic use,moderate to high use, a severe
alcohol use disorder, that'sanother one I have a red flag of
maybe not recommending breast orchest feeding.

SPEAKER_02 (45:16):
And one of the things to remember with alcohol,
you know, AAP, Academy ofBreastfeeding Medicine, I'll say
that two hours after a drink.
We need to be doing a lot ofeducation with our patients, a
lot of conversations about whatis that drink?
You're going out to celebrate abirthday.
You want to celebrate with yourfriends.

(45:37):
Well, what is that drink?
It's like that one five ounceglass of wine.
It's that one 12 ounce beer.
it's that two ounces of liquorand if you have two of those you
need to extend your time ittakes that little bit longer to
clear your system I think it'shaving like you said getting
into is it chronic is it thatoccasional well if it's

(45:59):
occasional how much are theydrinking at that time yeah and I
think about these parents youknow we've talked a lot about
the pregnancy making thatdecision also think preparing
the patients during pregnancyhaving the conversations about
having a newborn regardless ofhow you feed that newborn that's

(46:24):
a stressful time for new parentsyou've got this new person in
your household you're adjustingto this new person they're not
on the schedule that you're on Ican remember asking patients
they're like oh yeah the baby'sgoing to sleep I thought they
would sleep through the nightwell what is your definition of
through the night.
You know, they're thinking thisbaby is gonna sleep, what, six

(46:46):
to eight hours?
And we know that a newborn isnot gonna do that.
They're gonna be waking up everyone to three hours.
So I think having thatconversations with patients
prenatally about this is theexpectation and how are you
going to cope?
What are things that you canplan to put into place now to

(47:11):
help you get that rest, Who isthere to support you?
Maybe can this person feed thebaby a bottle so you can get a
little bit more sleep at night?
Because just think, thosenewborns, they were used to
eating continuously throughoutthe pregnancy.
Wasn't a good life.

(47:32):
Continuous.
They had a constant source offood, a constant source of
nutrition.
And their stomachs are so small.
You know, at birth, it's aboutthe size of a grape or a
shooting marble and it's goingto hold like a teaspoon.
By the time they go home, baby'sprobably holding about an ounce
at a feeding.

(47:52):
Their stomach's about the sizeof that golf ball or ping pong
ball.
And then by the time 10 days totwo weeks roll around, the
stomachs are about the size of alarge egg or a lemon.
So they're probably going to beholding two to three ounces.
So they've got to eat often.
And our parents need, that'swhat I see a lot with parents

(48:13):
when I see them in clinic isthey're struggling with not
getting that sleep.
So how can we help them byhaving those discussions during
the pregnancy to be able to copewith those early days at home?

SPEAKER_01 (48:26):
And how is that layered by substance use, right?
We're talking a lot about maybethe parent making changes in
their pregnancy.
That's a short period of time.
And we talk about recovery andwe talk a little bit about the
brain with substance use.
We think a about thoseneuroadaptations, right?
When you use a substance, youget a dopamine burst and how

(48:49):
when you have those unnaturalbursts time and time again, your
body's going to change.
So something like breastfeedingshould give you a normal, maybe
burst of dopamine that you'renot getting.
And so that's even harder.
And you just spent maybe twomonths putting in new support
systems for yourself and whatyour world looks like without
use.
That's going to be tested.

(49:10):
Having a new baby at home Yeah.
And maybe your support systeminvolves some of the people that
you previously used with.
And so how does that involvefinding a new support system
while you're in pregnancy, butalso being around those that you
feel comfortable and lovedaround?
Like, gosh, I can only thinkabout all the complexities that
come up with being a new parentand being in early recovery or

(49:34):
coming in and out of active useand how difficult that can be.

SPEAKER_03 (49:38):
Yeah.
I think like it just points tothe need for kind of this
multi-pronged approach, right?
Like really capitalizing on allthe resources that we can
identify in our clinic, but alsolike outside the clinic or in
the hospital, but also outsidetrying to offer that kind of
like wraparound care.

(50:01):
Yeah, I...
I am so grateful that at ProjectCARE, I work with an amazing
team and, you know, we're amultidisciplinary team.
I'm grateful that we havelactation support.
I'm wondering, you know, withour patients that you've worked
with that have, you know,substance use disorders and

(50:22):
maybe they're in early recovery,what are kind of the most common
issues that come up when you'recounseling, you know, and
supporting them postpartum?

SPEAKER_02 (50:31):
It's actually not much different than the
parenthood Does it havesubstance use disorder?
I imagine that may

SPEAKER_03 (50:37):
be true.

SPEAKER_02 (50:37):
Yeah, because the big question, and I'm glad you
segued into that, the bigquestion that comes up across
the board is, do I have enoughmilk for my baby?
And I mean, whether it's apatient who is not using versus
a new parent who is using, it'salways, do I have enough milk
for my baby?
And I think that's one of thereasons, as I just mentioned,

(50:59):
you know, the baby's stomachsize, how much is this baby
going to take?
Getting back to that And thenmaking sure that, you know, they
get a consult with a lactationconsultant if they're thinking
about that.
Or if they happen to be on WIC,they have support there through
the WIC breastfeeding peercounselors, through the WIC

(51:20):
breastfeeding experts.
Having someone observe the babynursing.
Is baby nursing effectivelystaying engaged throughout the
feeding?
Or because they're experiencingsome nausea, are they trying to
fall asleep or nausea?
Are they trying to fall asleepat breast?
So they're not nursingeffectively.
So reaching out, connecting themwith those resources.

(51:43):
But milk supply is a bigconcern.
And if this parent happens tohave an infant who's not nursing
effectively, supporting thatparent to be pumping as well as
putting baby to breast tostimulate that milk production.
But yeah, that's the big onethat I always get from parents
is do I have enough milk for mybaby?
How do I know I have enoughmilk?

SPEAKER_01 (52:04):
Mm-hmm.
And if clinicians don't havethis interprofessional team at
their disposal, you know, when Ithink about when I trained
someone as a pharmacist, Imentioned that LactRx, that's a
great, you know, app you canpull up a med, kind of read
through something.
I think of Mother2Baby hasreally great handouts that I can
hand the patient.

(52:24):
If they don't have one of you intheir office, what handouts are
you sending them or who do yougo to first?
You know, you mentioned a fewgoverning bodies that you turn
to for advice.
But if I'm in clinic, fiveminutes to pull something up,
kind of what do you go to first?
Oh my goodness.

SPEAKER_02 (52:43):
That is a great question, Olivia.
You know, you think about, andagain, it depends upon where
this patient is at.
Where do they live?
You know, because what we dealwith in a lot of our rural
communities is that lack ofaccess, that lack of resources
for them.
But you think about theresources to connect them with
our Lactation Consult who may bein the WIC offices, may be in

(53:09):
the hospitals, may be in somehealthcare provider offices.
And there's more like lactationconsultants in private practice.
You think about the WIC offices,I've mentioned those already.
And then in some areas, supportgroups are abounding.
And I know in our little area ofWestern North Carolina, there

(53:33):
have been a couple of new mommyand me groups start.
One is in, you know, like MaconCounty has just started one.
They're starting one down inPolk County.
You know, they've worked withthe hospitals, especially the
one out in Macon County.
And then, you know, there's alittle HA League.
A lot of them are now going backto meeting in person after doing

(53:55):
virtual.
That's good.
Yeah.
And baby cafes in some areas.
And that's a big going thing Sofinding out where those support
groups are in your area andconnecting them with those.
It takes a village, right?
What's

SPEAKER_03 (54:12):
the saying?

SPEAKER_01 (54:12):
And I feel like we're going back to it.
Yeah.
It's hard to do it alone.

SPEAKER_03 (54:16):
Oh man, definitely takes a village.
I would add kind of additionallike learning opportunities for
providers.
You know, there's the infantrisk center that has a great,
great information and somesessions for like continued
learning.
They, There's, uh, we, so Oliviaand I gave a talk through Mayhek

(54:39):
in January.
Maybe we can put the link tothat talk that goes kind of
specifically substance bysubstance.
It's very nerdy.
There's a lot more of thepharmacokinetics on it.
Just giving you enough heads up.
But, um, if you like to geek outabout, uh, half lives and

(55:00):
pharmacokinetics of lactation,it's for you.
Um, And I would say likeaccessible, but it goes
specifically by the differentsubstances and breaks down the
recommendations from the Academyof Breastfeeding Medicine
Guidelines.
So that's accessible online.

SPEAKER_02 (55:17):
And in addition to that, we have through the WIC
lactation area training centersthat I work with.
So there's one in Western,Northwestern North Carolina, one
in Central North Carolina, andone in Eastern.
And we're always doing trainingsin our communities We've got
several that are posted onlinethrough Mayhek.

(55:39):
We do breastfeeding basics.
So those resources are outthere.
You just have to go search themout, but we're doing a lot to
educate the healthcareprofessionals on breastfeeding
so that you're able to answerthose questions from parents.

SPEAKER_03 (55:57):
Thank you so much, you guys.
This has been really fun to sitdown and talk breast and chest
feeding and geek out a littlebit.
Mm-hmm.
And just really think about howto center the needs of our
patients and to really kind ofembrace them in that wraparound
care and that tender, tendertime.
So thanks for joining us.
It was really great to spendthis time with you.

(56:19):
The hour

SPEAKER_00 (56:20):
flew.
The hour flew by.
Like I said, such a practicalepisode.
Dr.
Marietta, Dr.
Caron, Georgiana, we are sograteful for your expertise.
Thank you so much for your timeand for coming on the podcast.
We really, really appreciate it.
Listeners, if you like whatyou're hearing, we would also

(56:42):
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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Season 4, Episode 8: Breastfeeding in the Context of Substance Use Disorders