Caffeine and breastfeeding: Do we need to wake up and smell the coffee?

I know it’s odd for the Fearless Formula Feeder to be discussing something that really only pertains to breastfeeding moms (except in one minute way, which we’ll get to), but I worry that a lot of studies which could be construed as “discouraging” to nursing moms are swept under the carpet like my son’s puzzles (don’t ask – I think he’s trying to protect them from his baby sister, who does have a criminal record for the capital offense of wrecking a 90-piece puzzle we worked on for a frustrating 2 hours; in any case, I find various and sundry puzzles hiding under the rug in our playroom on a daily basis). Plus, some of you are thinking of breastfeeding future children, or are combo feeding or pumping, and I think it’s really vital that we ALL get fully-informed about any form of infant feeding. We’re not children, nor Tom Cruise; we can handle the truth.

So, onward, fearless soldiers… Today’s post is about one of my favorite drugs: caffeine. I am currently maintaining a 4-cup-a-day habit with my coffee addiction; while I abstained during my first pregnancy, I held onto that 200-mg pregnancy “allowance” like it was a lifevest during my second. There was just no way to care for a 15-month-old who was still waking up several times a night, while suffering from pregnancy-induced exhaustion, without my faithful, beloved cup of joe. Or peppermint soy latte, depending on the day.

After I gave birth, one of the first thing I did was hit my local Coffee Bean. And I have to tell you, I think the ability to drink massive amounts of caffeine was as beneficial to my second postpartum experience as was my prescribed antidepressant. Alone with my new infant and a needy toddler, going on no sleep? No problem. I could even chug a Red Bull, if need be.

I know that I could have had a small cup of coffee every day that I was nursing (or pumping for) Fearless Child. But he was fussy; it would have been ridiculous for me to cut out dairy, soy, chocolate, green leafy veggies, and nuts if I was going to keep caffeine in my diet. So I abstained.

Perhaps I was being paranoid; my breastfeeding friends definitely drink caffeine, although probably in more moderate amounts than I typically consume. Most breastfeeding websites will tell you that caffeine is fine in moderation; that only a small amount passes through to the infant. However, breastfeeding mothers are counseled not to smoke due to low levels of nicotine passing through; how do those levels compare to that of caffeine in breastmilk? Is there a bias towards nicotine, because smokers are popularly vilified and coffee drinkers are not?

I came across an interesting interview with Ruth Lawrence, PhD,  an executive director of the Academy of Breastfeeding Medicine and the veritable grand dame of breastfeeding advocacy, which seems to suggest that this may indeed be the case. Published in the Journal of Caffeine Research, the discussion centers around how caffeine is passed to an infant during pregnancy and lactation, and how long-term – and especially early – exposure to the substance can affect development. “If caffeine is consumed by the mother, then a small amount of caffeine will get into the breast milk and, therefore, into the baby,” Dr. Lawrence explains. “This is probably not too important later on, but initially in the first week or so, babies do not metabolize and excrete caffeine very well. So, if a mother consumes a lot of caffeine, it accumulates and her baby can become quite symptomatic.” The interviewer then asks her if the 300 mg limit typically given to breastfeeding women is prudent. 

I think that (300 mg/day is a) reasonable starting place. I think it varies from mother to mother and baby to baby. Probably one of the biggest problems is that women do not realize all the sources of caffeine… (and) it depends on whether the mother drank coffee during her pregnancy and whether the baby is already attuned to it and has begun to be able to metabolize it. There is going to be some variation.”

Lawrence goes on to ponder if babies who are diagnosed as colickly may actually be suffering from higher levels of caffeine exposure. She even cites an extreme example, where a baby was thought to be having seizures:

“Unfortunately a lot of things about breastfeeding are based on opinion, and I do not know that the ‘‘safe’’ amount of caffeine for daily use has been carefully measured. I know of case reports. We had a case here in which a child was brought in, thought to be having seizures, and was headed for the mil- lion-dollar workup, the EEG, the MRI, the works. And in the emergency room we drew a caffeine level. It was off the charts! And we spared that child an admission. Taking a history from the mother, she said, ‘‘Oh yeah, I drink coffee all the time. I have a cup ready for me all day long. Is that a problem?’’

It’s an interesting read, and I think this journal piece speaks to the real lack of truly evidence-based advice given to nursing moms. As Lawrence suggests, further research into this issue is warranted, and for the love of all things Java, I hope that someone will fund an infant caffeine study instead of yet another showing the superiority of breastmilk over formula. 

Even those who go straight to the bottle could learn something from this interview: part of the discussion focuses on caffeine withdrawal, and if babies who are exposed to significant amounts of caffeine in utero may go through withdrawal after birth. In this case, a breastfeeding mom who consumed a specific level of caffeine might actually help her baby slowly withdraw. For those not breastfeeding, this knowledge could give a little hope to those with fussy babies in the first few days: maybe Junior just needs an espresso shot.

Dirty Milk

FFF Sarah, who is currently trying to induce lactation for her upcoming adoption, emailed me this afternoon with an interesting question:

So, I’m pumping all of this crap into my body in an attempt to see if I’m able to lactate.

Today, I was telling my husband why I buy x-type of dairy milk (b/c it doesn’t have rBGH)…I read him this tidbit from the dairy’s page:

rBGH is “recombinant bovine growth hormone” and also known as recombinant bovine somatotropin (rBST). Developed by Monsanto Corporation, rBGH is an artificial hormone that causes cows to artificially increase milk production.

We love our cows and believe that pure, natural milk tastes best and is healthiest for you. Here at Brown’s, our cows are not treated with artificial growth hormones like rBGH.

He said…”um…isn’t that what you’re doing? Taking stuff to artificially increase milk production? How is that good for a kid then?” I said I thought the ingredients were better, but honestly…I don’t know. Is it better? Do we know the danger of Reglan or Domperidone or Fenugreek or Blessed Thistle or any of the other crap we take in order to make milk or more milk for our babies?

Honestly, I had no idea how to answer this; however, I thought it was one of the most interesting questions I’d ever been asked. Even the mere concept of rBGH-free milk is worth talking about, and I can’t believe I’ve never thought about it before. Of course, we’ve discussed the fact that breastmilk can be a veritable smorgasboard of chemicals; in fact, scientists use this particular bodily substance for bio-monitoring (a way of measuring how many toxins are being stored in the human body). Typically, this concern is squashed by folks telling us not to worry, breastmilk is so amazing that it counteracts or cancels out all the bad stuff, or yelling at us not to peek at the man behind the curtain, like the titular dude in Wizard of Oz. (Read this article from to gain a frustrating, bang-your-head-against-the-wall understanding of why some breastfeeding advocates are fighting the trend of using breastmilk in bio-monitoring.)

So, isn’t it kind of funny that everyone is so concerned with the mercury in fish; the hormones in beef and milk… and not the food our own bodies produce?

There is ample proof that what we eat, breathe and absorb goes through our breastmilk. In fact, the NRDC has an entire website dedicated to the chemicals present in breastmilk, and they admit that “infant formula contains far lower quantities of dioxins, PCBs and organochlorine pesticides than breastmilk”. Of course, they go on to assure mothers that “formula has serious drawbacks that tip the scale against it”, and then list all the “risks” we have discussed on this blog, time and time again. The chemical contamination dangers they cite pertaining to formula are “contamination with substances such as broken glass, fragments of metal and salmonella and other bacteria. The fungal toxin aflatoxin has also been detected in some commercial formulas. Although detected levels were very low, this toxin is known to cause cancer and is not present in breast milk. Infant formulas also may contain excessive levels of metals, including aluminum, manganese, cadmium and lead.” However, many of these contaminants are avoidable if we could improve manufacturing processes; the first few listed, when discovered, led to recalls.

The important message here should not be choose formula over breastmilk, or vice versa. It should be, let’s all become more aware of the chemicals our babies are exposed to. Formula is a product; if we want to discuss the chemical contaminants in formula, we can address manufacturing processes, corporate responsibility, quality assurances, ingredient sources, etc. If we want to discuss the chemical contaminants in breastmilk… well, chances are we won’t be discussing that, because its tantamount to yelling fire in a crowded movie theater. Us girls are, like, panicky and hysterical, dontcha know?

Back to the original question which spawned this post, though. It’s one thing to worry about chemicals we have no real control over; quite another to discuss intentionally ingesting something potentially harmful to increase milk supply or induce lactation in the name of Liquid Gold. But could Reglan, Domperidone, Fenugreek, or Blessed Thistle really be harmful? Doctors prescribe them for nursing women all the time, and these folks would never prescribe something that they don’t know 100% for certain won’t harm a baby, right?

(Pause for diabolical laughter…)

Fenugreek and Blessed Thistle are probably the least concerning of these substances, as they are herbal remedies. However, while NIH’s Medline Plus cites “increasing breastmilk quantities” as one of Blessed Thistle’s uses, they also warn, “Don’t take blessed thistle by mouth if you are pregnant. There is some evidence that it might not be safe during pregnancy. It’s also best to avoid blessed thistle if you are breast-feeding. Not enough is known about the safety of this product” and list “irritat(ion of) the stomach and intestines” as a possible side effect. As for Fenugreek, Kellymom warns that while “(m)ost of the time, baby is unaffected by mom’s use of fenugreek (except that more milk is usually available)”, sometimes “baby will smell like maple syrup…some moms have noticed that baby is fussy and/or has green, watery stools when mom is taking fenugreek and the symptoms go away when mom discontinues the fenugreek. Fenugreek can cause GI symptoms in mom (upset stomach, diarrhea), so it’s possible for it to cause GI symptoms in baby too.” A search on WebMD’s database found that “(s)ome reports have linked fenugreek tea to loss of consciousness in children”.

(I feel I should interject here to remind everybody that just like everything else we discuss on here, we should look at these warnings in terms of relative risk. If you read the possible side effects on a bottle of Children’s Advil, it’s a hell of a lot scarier. I’m merely trying to illustrate a point, so bear with me, please, and don’t panic if you’ve been binge-drinking Fenugreek tea.)

Reglan and Domperidone carry more severe warnings. Reglan is one of those drugs that repeatedly come up on litigator’s websites (never a comforting sign), and it has been suggested that it can cause a condition called Tardive Dyskinesia. As one of the litigators explains, “Before Reglan was released, the FDA only approved its use for 12 weeks at a time, which means that women who are breastfeeding are at an even higher risk for developing TD because of the timeframe spent breastfeeding.” (Ironically, I found a really great opinion piece about the relative risks of Reglan on another of these lawyer sites. Go figure.) Perhaps a more real-world concern – and definitely one that worries me a great deal, what with PPD being such a real threat to new moms – Reglan is also linked with depression.

Domperidone, a drug typically used for cancer patients or those with gastrointestinal issues, does seem to be a safer bet, although on a UK site detailing the prescription use of Domperidone, it clearly states that “this medicine passes into breast milk in very small amounts that are not expected to be harmful to a nursing infant. However, the medicine is not recommended for use in women who are breastfeeding unless the potential benefit to the mother outweighs any risks to the nursing infant. Seek medical advice from your doctor.” If that doctor happens to be breastfeeding guru Jack Newman, you’ll be reassured that it is indeed safe (“Worldwide experience with domperidone over at least two decades suggests that long-term side effects also are rare. Some of the mothers in our clinic, breastfeeding adopted babies, have been on the medication for 18 months without any apparent side effects…patients using domperidone for stomach disorders may be on it for many years. I hope you won’t need domperidone for very long, but if it’s necessary and helpful, stay on it,” he breezily suggests, adding links to back him up (nearly all of which are dead links, btw, save for one study which simply proves that Domperidone increases milk supply. Sort of a moot point, don’t you think?)

If a mom needed to take either of these drugs for a medical condition, I would think the benefits absolutely outweigh the risks. Aside from the depression risk, neither seems to be that scary, especially when you consider Reglan was discussed as a potential therapy when my infant daughter was suspected to have delayed gastric emptying (so one would hope it isn’t all that toxic to babies).

But we’re talking about selectively consuming these drugs in order to do something which is often marketed to women as the “natural” choice, the “biological norm”. If a woman wants to breastfeed, I would totally understand her desire to try these drugs, and more power to her. If a woman feels like she has to breastfeed, and has to take these medications in order to fulfill her biological and maternal responsibilities, that’s another story. And regardless, let’s stop the hypocrisy and ignorance so prevalent in the way we view and discuss breastmilk. If it is full of chemicals, the answer is obviously not to discourage breastfeeding, but shouldn’t it also be obvious that we can’t ignore the problem? Likewise, if someone has to take medication in order to breastfeed, we need to support her in her goals in whatever way we can, but we also need to ensure that she has adequate research on her side that proves she is not putting herself or her baby at risk.

Breastmilk, left to its own devices, is one of the most amazing and purest foods in the universe. Unfortunately, we live in a time when pretty much nothing has been left to its own devices. Nobody is saying that breastfeeding isn’t worth it, but in the world we currently inhabit, I don’t think we should view breastmilk as unadulterated, absolute perfection. It can be corrupted, like any biological substance.

So, FFF Sarah’s husband… I’m not sure what the answer to your question is, exactly. But I can tell you that while writing this, this image kept running through my head of one of those “Not treated with rBST!” messages stamped on a nursing bra. Thanks for that, buddy.

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

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.”

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