Medications and breastmilk – finding the truth behind the propaganda

I’m a little surprised that I haven’t see this story circulating around the blogosphere, but it has remained conspicuously absent from my Twitter feed and blog reader: Californian mother Maggie Jean Wortmon is being charged with second degree murder after her 6-week-old son died, supposedly from ingesting her methamphetamine-laced breastmilk.

Reading the comment threads on articles about this case has been enlightening. ” …If you don’t know that anything you consume while breastfeeding is passed on to your child via breast milk, you are too stupid to have a child. especially as it would be impossible for you to go through the process of childbirth and release from the hospital without being told at least five times that anything you consume is passed on to your child via breast milk,” one person said. “Its common knowledge that while nursing, what goes in, goes out in your milk, and to the baby,” said another.

But is it common knowledge?

According to the popular and respected site BreastfeedingBasics.com:

As a nursing mother, you should be aware that there are three things we know for sure about drugs and breastmilk:

1. Nearly all drugs pass into human milk.

2. Almost all medication appears in very small amounts, usually less than 1% of the maternal dose.

3.Very few drugs are contraindicated for nursing mothers.

    The site does explain that drugs are metabolized in different ways, and that the younger/smaller an infant is, the more he or she might be affected by the drugs. But the message that rings the loudest is this:

    “We…live in a society, which, in general, doesn’t place a high value on breastfeeding… Doctors tend to err on the side of caution and recommend that a mother wean rather that do research and reassure the mother that the medication is safe for her baby (as the majority of drugs are), or explore alternative, safer medications…..Most of the time, their primary source of drug information is the famous PDR…The PDR is not the best source of breastfeeding information, because it is an unfortunate fact that pharmaceutical manufacturers often discourage breastfeeding solely for fear of litigation, rather than for well-founded pharmacologic reasons…In deciding which drug to take, you should always look at the situation from a risk/benefit perspective: The benefits of breastfeeding are well known and undisputed, so doctors should recommend a mother wean only when there is scientific documentation that a drug will be harmful to her infant. In the rare cases where that is proven, a doctor who believes in the value of breastfeeding should take the time to explore alternative therapies, or if nursing must be interrupted, encourage the mother to continue pumping her milk to maintain her supply and return to breastfeeding as soon as possible. If your doctor prescribes a drug which he says in incompatible with breastfeeding, it is reasonable to ask for documentation and/or alternative medications. If your doctor isn’t flexible about this, and doesn’t understand how important continuing to breastfeed is to you, it makes sense to seek another opinion.”

    Now, obviously, BreastfeedingBasics is assuming their target audience is a woman debating whether she should take a prescription muscle relaxant after back surgery, not your run-of-the-mill, 6-week-postpartum meth addict. But there is a pervading belief in the breastfeeding community that the benefits of breastmilk far outweigh the “unproven” negatives of nursing while using medications, tobacco, or alcohol. If I were the meth-mom’s lawyer, I’d look to the breastfeeding literature as my best defense.

    Addicts are not counseled to bottle feed, but to breastfeed, even if their habit is far from kicked. “Breast milk contains small quantities of methadone, but the advantages of breastfeeding outweigh any possible negatives of passing very small amounts of methadone to the baby through breast milk,” states one site directed towards pregnant heroine addicts. An article written by an Australian IBCLC cites evidence of a plethora of substances – alcohol, nicotine, meth, marijuana, and more – coming through breastmilk in significant amounts, but then urges care providers to push breastfeeding at all costs:

    “Babies born to mothers who abuse drugs start life with a handicap. Their compromised intra-uterine life has affected their nutritional status, their growth and in some cases their intellectual ability. After birth they go through withdrawal symptoms that affect their health and adaptation to extra-uterine life…Artificial baby milk provides second grade nutrition, no protection against infections, has the potential to cause chronic disease and further inhibits the intellectual potential of the infant. Breastmilk is medicine for these babies and breastfeeding is about more than merely providing nutrition. Breastfeeding develops a bond between mother and baby, which may empower and motivate positive change on the part of drug-abusing parents, while decreasing the risk of future child maltreatment. This should be considered along with concerns about the likelihood or degree of drug exposure the baby has if breastfed….Giving birth and then breastfeeding can be an empowering and life changing experience for a woman and may be the catalyst that causes her to stop her substance abuse. Before counselling a woman to feed artificial baby milk, consider giving her the opportunity to meet this challenge.”

    Yeah, that worked out real well for Wortmon.

    To be fair, as many of these sites point out, depending on a meth addict to properly mix and serve formula is not the most reassuring state of affairs, either. But if we’re talking about a woman too high to feed her infant responsibly, we should probably be getting Child Protective Services involved. It’s almost an entirely separate discussion than the issue of breastfeeding and medications. Personally, I am more concerned with this potentially harmful meme that it is “common knowledge” that substances pass through breastmilk, with such conflicting messages out there.

    Obviously, if a woman believes that formula is poison, and that it will harm her child, the “possible” risks of drug-infused breastmilk pale in comparison. If care providers are explaining the risk-benefit analysis in this way, who could blame a mom for choosing breastfeeding, even if she is taking a contraindicated substance?

    It’s time we told women the truth. If nicotine passes through breastmilk, we have a right to know. If more than few glasses of wine is going to do more than make a baby a little sleepy, we have a right to know. If we’re addicted to cocaine and someone is telling us to try breastfeeding, because it will help us break the addiction, we have a right to know what might happen if we accidentally “slip up”.

    We have a right to know that formula is not poison, that children will grow well and thrive and be fine no matter if we feed them Enfamil or Similac or Earth’s Best or the Sam’s Club brand. We have a right to know exactly what the studies say about the differences between breastfed kids and formula fed kids, and what the real world meaning of these studies actually is, so that we can make an informed decision on which risks we’re willing to take. (I’d choose the possibility of a few more ear infections a year over potentially overdosing my newborn due to a medication which hasn’t been proven safe, but that’s just me.)

    As for Maggie Jean Wortmon…well, as one astute comment on the ABC version of this story suggested, “Breastfeeding is so pushed on Mothers and if she was off her face, she probably just thought she was doing the right thing.”

    Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

    Suzanne Barston – who has written posts on Fearless Formula Feeder.


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    28 thoughts on “Medications and breastmilk – finding the truth behind the propaganda

    1. It is generally advocated that if you smoke and intend to breastfeed, to quit. But if you can't quit, then cut back on the amount of cigarettes you smoke, don't smoke 20 minutes before breastfeeding, or definitely don't smoke during breastfeeding. I've read over and over in various sites that while smoking compromises the quality of breastmilk (lower in vitamin c, contains nicotine, etc.), that the health benefits allegedly outweigh any possible harm.

      Also, my understanding of drugs passing through breastmilk is that it is actually quite complex. There are so many things that can effect how substances the mother ingests transfers to breastmilk and then to baby. From what I understand, there are three types of “transferrance” that can take place. The first is that the substance is passed through porportionately. In other words, baby will get a smaller, but equivalent dosage. Alcohol is an example. So if you've had enough to get yourself drunk, baby will likely become intoxicated after nursing. The second type is one that is transfered at a porportionately much higher concentration to the breastmilk. I think this has something to do with fat cells in the breast or milk (I can't remember). I think cocaine is one such drug that can quickly reach toxic levels in breastmilk.

      And then there are drugs that actually don't transfer either at all, or in such negligible amounts that there is usually no cause for concern. Caffeine, much to my delight, is one such drug. I think you have to drink 12 cups to even produce a tiny amount to show up in breastmilk.

      Which leads me to my next point. Caffeine, while transferrence is low, is also very sensitive to a baby's system. While caffeine has something like a 2 hour half-life in an adult, it can take many, many times longer for an infant to reach that same half-life (I think it might be 3 times longer?). So, while caffeine may seem safe…if you drink alot, your baby actually might be getting the effects of it.

      It really is terribly complex and confusing. And I agree that if you smoke, if you are a moderate drinker, if you take a lot of prescription drugs or recreational drugs…probably best to be safe and consider formula feeding as a likely healthier option.

      *My apologies for lack of references and possible misstatement of facts, as I am depending solely on my poor memory. If anyone would like sources, please let me know & I'll do my best to find them again & cite them.

    2. hale's medications and mothers milk is ALL evidence based. please check here when you are looking for safety of meds.
      the mom who said you have to be healthy to breastfeed- not true! your body can make milk form almost anything…think of straving women in other countris. the vast majority make milk with no problem. It doesnt matterto me if you want to formula feed or breastfeed, but for your dr to make that comment suggesting moms who eat big macs all day should possibly not breastfeed….. ethically wrong with NO evidence to back it up

    3. Doctors told me that steroids were ok while breastfeeding. That just never seemed right to me, and it's how we figured out my kid was starving. I'm so cautious about the medicine I take as an adult; I can't imagine not being the same way with my infant.

    4. We don't even understand how much or how the drugs metabolize enough. I've had this argument in the past with people because right after birth I was put on a codeine based tyelnol basically for pain. Pain limits your ability to breastfeed, so it made sense, and no one has problems with this drug. Except now and then there's some woman who metabolizes it faster and it ends up being passed to the milk in a higher dosage so you're SUPPOSED to be told the side-effects and what to watch for if your baby is reacting. I wasn't making much milk, but my baby was sleeping SO much, more than a newborn should, and I didn't realize I was drugging my baby. It was one of a few things that made it so I didn't realize I didn't have enough milk, that she was dehydrated and starving. A few months later there was a story about women metabolizing things differently and that the rule of thumb should be NO drugs that are not baby-friendly while you're breastfeeding.

      But I still end up in arguments about it because so many moms get hydrocodiene and are told it's perfectly safe and there's no reason not to breastfeed and aren't told to watch for these warning signs. And the many people who say that the medicine manufacturers put “don't breastfeed while on this” not because there's a danger but because they haven't tested it enough (so you want YOUR baby to be the guinea pig? Yeah… you do that.)

    5. I find a lot of resources that say all or almost all meds are safe for breastfeeding are terribly unsympathetic about medical conditions that might require meds, especially meds that aren't safe for BFing (there's more than the articles typically imply). This does several bad things: first, it makes women who have medical conditions more stigmatized than they already are, during one of the most vulnerable periods of their lives. Second, it encourages them to have a skewed risk/benefit analysis and, as FFF pointed out, BF even when it is not healthy for mom and/or baby. Third, it perpetuates the “good mom vs bad mom” attitude that prevails among a lot of lactivists–where natural is not just something to strive for but is a moral imperative. So if you have a medical condition, whether you need medications for it or not, you're not just a bad mom, you're a bad person, morally, and those fortunate enough not to need meds are set up as goddesses. Lastly, lactivists who have such attitudes are doing what they accuse so many others of doing: booby trapping perfectly good moms who need meds, and not putting accurate, complete info out there about breastfeeding.

    6. I'm really sorry you've gotten so much flak from people and are having such a terrible time. I hope people learn to lay off and give you a break! Seriously!

      I do however, take slight issue with your opinion that milk sharing is morally and ethically wrong. I'm in a weird spot. I'm a donor, but would never give another woman's milk to my baby. I think formula is perfectly fine for babies. As it stands, I make a surplus, so I share informally. I am completely honest with the mother (or husband, when he's the one picking it up) when I have to take any additional medication, and keep her up to date on all health changes in me and every member of my family. The decision is always hers as to whether to take the milk. I told her upfront that I take no offense if she refuses. I have no reason or motivation to lie to her, as there's nothing in it for me whether she takes the milk or not. If she didn't take it, it would go down the drain. My freezer's pretty small. This precludes donating to my local milk bank, since your first donation has to be at least 150 ounces. I have nowhere to store 150 ounces!!

      One area where I have a problem is when women sell their breastmilk. Therein lies the moral & ethical issues, since suddenly there is motivation to be dishonest. I would never sell my breastmilk, because I don't want to encourage that type of industry.

    7. Supposedly evidence-based lactivists who trumpet their reliance on studies, science, whatever, are remarkably trusting of the same Big Pharma that makes formula when it comes to medications. Where's the evidence the drugs are safe? Ah yes, there really isn't any, because it's unethical to experiment on children. For such risk-averse people, going on and on about the risks of giving formula, they're shockingly cavalier about the risks of giving medications that are not approved for pediatric use to the most vulnerable of the pediatric population. Which, as someone else pointed out, indicates to me that it's less about doing what's best for babies' health and more about preserving an ideology…

    8. I was honestly stunned by the quote from the IBCLC who encouraged drug using mothers to BF. I knew that some encouraged women to ignore their doctor's advice about rx drugs, but meth? Heroin? seriously??!?!?! This is where I stop believing that militant lactivists are all about what's best for babies. This is about protecting their ideology at all costs. Addicts' babies are best off in a foster home with formula until their mother can get clean. Period.

      Oh and maybe she should update her article because this is obviously not true.

      “Effect of methamphetamine on infant:

      None reported via breastmilk. (Ilett 2002, Hale 2002)”

    9. This is a brilliant blog piece, as always!

      The thing that gets me is that these BF sites are trying the whole “Big pharma is ebil” tack (again), but what do they want the drug companies (and researchers) to do? It would be nigh on impossible to get ethical approval for a study into whether or not drugs passed into breastmilk! Are these sites going to offer up their own children to be guinea pigs to prove that all these myriad substances are perfectly safe? No? I didn't think so. It's such a double standard, it makes me sick.

      Hey, lets give a newborn baby methadone rather than a medical-grade substitute to breastmilk which has been extensively tested and heavily regulated to ensure that it is safe /facepalm

    10. The idea that someone would encourage a DRUG ADDICT to breastfeed is insane. When I had to go on antibiotics for an infection while nursing I made like 20 calls to my OB, LC, and pedi to make sure it was okay.

      On the other hand, I never “pumped and dumped” if I had a glass of wine, which I'm sure is anathema to other people.

    11. This is the part of bf that no one talks about. It is soooooo healthly, but only if the mother is healthy right? My family doctor talked about this openly with me to make me feel better when I had to switch to only formula (at the time feeling it was awful, later realizing it saved my baby and our relationship!). She basically said, if the mother is downing big macs all day, its not necessarily the healthiest things for the baby. I had never heard of milk sharing before, but once I did I thought it was kind of crazy because you don't know what that mother is consuming. At least formula is regulated and while you may not love everything that is in it, at least you know! I'm shocked drug users are not advised to use formula.

    12. It wasn't until I started reading this site that I stopped feeling guilty for refusing Domperidone. I instinctively felt really uncomfortable about taking a drug, but my concerns were dismissed by many people who felt that the benefits of breastmilk outweighed any possible adverse effect from the drug. But I do feel confident in that decision now.

    13. This is what bothers me about milk-sharing, and why I get so irritated when lactivists say milk-sharing is safe and that the few risks it entails can be easily mitigated, while the risks of formula just absolutely cannot be mitigated. That's BS. The true risks of formula feeding are things like contamination. That's pretty much all I can think of, since more ear infections isn't really a “risk” of formula. Opposite of benefit isn't risk and all that jazz. Anyway, I can help prevent formula contamination with clean bottles, water, etc. but I can't make Lactating Mama tell me the truth when asked if she drinks every night.

      I also wonder about this with stuff like Reglan. I took Reglan in an attempt to increase my supply, and I was told it was perfectly safe. I was told that it did pass into breastmilk, but that is no big deal because they give Reglan to babies directly for gastric issues. Now it has a black box warning about tardive dyskinesia, especially in high doses or for extended periods of treatment. Well, what is a high dose for a 3.5 pound baby? And how much ends up in breastmilk?

    14. I saw this article a couple of days ago – it is actually circling through some of the mental health feeds. Just as a legal FYI, as a mandated reporter I have to call child protective services if mother discloses she is using drugs.

    15. I took antidepressants while I was pregnant with my son. Just a low enough dose to keep me functional.. not enough to alleviate the depression. I got flack from WIC for not wanting to BF being an SA survivor, I was told if I could have sex than I could BF because I was over it quit making excuses, i mustnt love my son etc. When he was born they told me too quit my meds and BF as it would induce hormones oxytocin I believe that would help my depression. My OB my sons ped told me not to BF as my dosage was increased and switched to a more potent medication. This whole thing with informal milk sharing IMHO is morally and ethically wrong . You dont know what that donor has ingested or what diseases they may carry. I wouldnt blindly trust a medical report either. Milk banks are a good alternative for sick and premie babies. They should be regulated like blood banks and most that I know of require a script from a doctor.

    16. Yes, you're damned if you do and damned if you don't. And since ADHD is often seen as problem for school boys, there isn't much compassion or understanding from others for how it can affect all aspects of life.

    17. I too have ADHD, I'm off the meds though and nursing.

      Its really a toss up. Sometimes I wonder if my son's life would be better if I were medicated, organized, and had formula fed him et. al. Which was the original plan – I would be medicated and formula feed after 3-6 months nursing. Didn't happen that way because our financial situation basically imploded right before he was born (my husband got laid off), we couldn't afford EITHER the meds (insurance stingily only covered like 40% of a $300 monthly prescription) or the formula. So, I'm just struggling here on my own. I have to take it sometimes 15 minutes at a time instead of 1 day at a time. And even if we could have afforded the meds, I don't know how comfortable i'd feel exposing my kiddo to them. And of COURSE unlike anti-depressants where there are a handful that are OK/safe for nursing, there's NO adhd med that is considered 100% “safe”

      Its just so FRUSTRATING that there's no good way to go about it. If you nurse and stay unmedicated, then your house always looks like the Visigoths came through on their way to sacking Rome and everyone is howling at you to be organized and stop whining about your life, but if you get your meds and formula feed, people cluck their tongues and tsk tsk and harp on you. :-/

    18. This is such a difficult issue, and is something I'm currently wrestling with. I have breastfed all four of my previous children, most into toddlerhood. I now have a one month old who is thriving on breastmilk. But between the last child's birth and this one's, I was diagnosed with ADHD and finally got to the root of my recurrent depressive episodes. I had to stop taking my medication while pregnant, and am trying to decide what to do now: continue nursing without meds, take the meds while nursing (perhaps combo feeding to avoid the peak level of medication in the milk), or switch to formula. There is just so little information out there. All the amphetamine based medications are definitely off the table, they pass into milk in greater quantities than most meds I've looked up. I'm on the fence about the methylphenidate meds. There is very, very little information, yet the few case reports that exist suggest that it passes into milk at very low doses — where the infant would get less than 1% of the maternal dose, adjusted for weight — and there are no reported negative effects. Yet a handful of case reports doesn't really tell you much about the actual safety of the medication. It is tough.

      My current plan is to nurse baby until he is three months, while trying nutritional and lifestyle means of handling life, and then re-evaluate. I'd like someone to just tell me what to do, however.

    19. Me too. They're worried about babies whose moms used illicit drugs when they were pregnant– and rightfully so. But I can't believe somebody would suggest drug (and whatever else those drugs might be laced with)-containing breastmilk as a solution. Are these IBCLC people on crack themselves?

    20. Agreed. Great post. And is BreastfeedingBasics nuts?

      As you wrote, you can't ethically conduct a study where you have BFing moms take a drug and see what happens to their babies. What if a BFing mom tries a drug that just went on the market? Should she just assume its safe, because she has no “scientific documentation that a drug will be harmful to her infant”?

    21. This is an issue that really concerns me, now that you've mentioned Joan Wolf's book and her participation at that stupid show. How can they so confidently say that although meds, illegal drugs, alcohol and nicotine pass into BM, the benefits outweigh the risks?

      This is not the first time I hear about a breastfed baby who dies because of intoxicated BM. I mean in 2009 (I think), a Russian mother killed her son who she breastfed, at the age of 4 months. That mother had a severe drinking problem, therefore, I think we can safely say that she was already drinking during her pregnancy, and for that reason her baby was probably born with liver problems. If she had FFed, his liver would probably have recovered, tho he might still have been affected by his mum's drinking during pregnancy. BUT she bfed him although she could down half a liter of pure ethanol before a feed. The almost inevitable happened, her poor baby died of alcohol poisoning. Some vocal lactivists were still skeptical about that. I read one post saying: “Surely drinking while bfing is perfectly safe, she must have given it to him directly (for him to die of liver failure)”. I have no idea how she could say that drinking during BFing was absolutely safe, regardless of quantity, and I saw noone say “Why on Earth would an alcoholic woman give out booze to her baby directly that she could keep for herself?” or even “Do you really think that baby would have accepted to swallow pure ethanol? After all, babies can show reluctance to drink BM (or formula) if they don't like the taste of it.”

      The benefits of BF, tho they do exist, are not proven to be that strong even when it comes to healthy mothers. I doubt that they outweigh the risks of drugs and adult-only medication passing into BM, that is known to be heavy in side effects. Therefore why put pressure on women on that kind of medication to BF if they do not want to? Unless some studies prove that the benefits really do outweigh the risks, which the case of Maggie J. Wortmon does not, I do not think it is necessary.

    22. So what about people who need to take prescription medications like wellbutrin and topamax for anxiety disorders and depression, but still desperately want to breastfeed their babies? I am in this terrible situation and had to go back on my meds one month postpartum and my poor newborn's got terrible stinky gas and can't poop now because of the formula, and he seemed so much happier with the breastmilk. I wouldn't mind doing both, or even just the formula if it made him happy, but the poor kid just seems so unhappy. I'm ready to quit the meds at the risk of being a walking panic attack all day just so he can be my happy baby again.

    23. Honestly, talk to your doctor and your son's pediatrician about the actual risks and benefits of different meds and continuing to breastfeed. Most of the newer SSRI antidepressants don't pass through in significant amounts to baby. Some pass through more than others. Some have higher rates of adverse effects than others. Some probably will work better for you than others. The dose you need might be lower or higher than the doses women were on in the few studies that have been done. You might find that you are comfortable continuing to breastfeed while on your meds (or on a lower dose or different meds). You might decide that you want to go off your meds and breastfeed, and your doctors should know about that so they can keep track of how you're both doing. You might decide to try different types of formula or different bottles to see if those help with the gas.

      I've been there, and I was ashamed to get advice from professionals, so I made a lot of decisions very suddenly without considering all the possible middle roads.

      Also, don't forget that taking care of yourself and your mental health is good for your baby too.

    24. I think these are all fabulous points. And as I recently said on the Facebook page, I strongly believe the possible risks involved with nursing while on these drug are well worth the benefit of getting emotionally healthy. If you want to or need to breastfeed, and you also need medication, then take your meds and breastfeed. Whatever is going to make you a happy and healthy mom is crucial, end of story.
      My concern is that women are being led to believe that formula is a riskier choice than breastfeeding while on practically all meds, and I haven't seen evidence to support that. I also haven't seen evidence that most common antidepressants pose a significant risk.

    25. Have you investigated the possibility of food allergies in your baby? We had to switch formulas a few times before we found one that worked. We also added a probiotic, and that helped a lot.

      I'd strongly suggest getting as many docs as you have at your disposal on this, because you have many factors to balance. Also just because in general, going off medications suddenly can be hard on the body, not to mention what happens when you don't have the positive benefits of those medications. As Jennifer said below, taking care of yourself is healthy for your baby. In many areas of life, there is no perfect solution–just the risks we are willing to accept. I can't tell you what risks you should or shouldn't accept, but I hope you can figure out a solution that works best for you and your child.

    26. The thing with methadone is that it IS safe for babies…to an extent. Some babies NEED methadone after they are born because the mother was taking some sort of narcotic (legally or illegally). If the mother is already IN a methadone clinic and on a weaning program the best choice IS breastfeeding because then the baby continues to receive the same amount(ish) they were getting in utero and wean as mom does and many times you can skip over the neonatal withdrawal. Keep in mind, there are many women that take legal narcotics for chronic pain. When the mom chooses not to breastfeed, then the baby must be monitored for withdrawal, placed on methadone, monitored for correct dosage, and then sent home (or to foster care if appropriate) to continue weaning. Although, the baby that is breastfeeding is also monitored for a short time for withdrawal but it tends to be easier to keep withdrawal at bay and no need to give additional methadone.

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