Just Us: Before, Birth, and Beyond

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

• MAHEC • Season 4 • Episode 8

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Breastfeeding can be an important part of a baby’s health and development. But what about families who are affected by substance use disorder?  this episode, a partnership with Project CARA, Dr. Amy Marietta, MD, Family Medicine and Olivia Caron, Pharmacist Practitioner, and Georganna Cogburn IBCLC, will talk about how to support lactation and infant feeding in patients who use substances or are being treated for SUDs.  Using the Academy of Breastfeeding Medicine guidelines as a key resource, they will discuss the latest findings and what they mean in the real world of infant feeding. They will also dispel some of the common myths about SUDs and breastfeeding. This conversation will help you understand the risks and benefits of breastfeeding when working with families impacted by SUDs. They will also talk about a wide variety of  resources available for further reference and education.
Resources:
Academy of Breastfeeding Medicine
Drugs and Lactation Database (LactMed®)
American Academy of Pediatrics Breastfeeding Policies
ACOG Breastfeeding Program
“Eat, Sleep, Console” reduces hospital stay and need for medication among opioid-exposed infants
MomtoBaby
WIC North Carolina
WIC Nutrition and Health Education
La Leche League of North Carolina
Baby Cafe USA
Infant Risk Center
Breastfeeding in the Setting of Substance Use and Substance Use Disorder Updates 2024 Online Course
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Music credit: "Carefree" Kevin MacLeod (incompetech.com)
 Licensed under Creative Commons: By Attribution 4.0 License
http://creativecommons.org/licenses/by/4.0/

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UNKNOWN:

Bye.

SPEAKER_00:

Hi everyone and welcome or welcome back to Just Us Before Birth and Beyond. We're so glad to have you here with us today. My name is Caitlin and I am one of the hosts of this podcast and I'm a nurse and I've been working in Western North Carolina in the world of women's and maternal health for over a decade now and I'm here today to introduce our episode. So today we have what we consider a special self-hosted episode. So we will be hearing from an amazing team of experts from Mayhek and Asheville and they're going to be talking about breast and chest feeding in the context of substance use disorder. So I will let them introduce themselves in the episode. They give a really great detailed introduction. And in the episode, they're going to cover everything from updated guidelines related to substance use disorder and breastfeeding. They're going to talk about the advantages to breastfeeding in this population, what is safe, what substances may need a little more guidance or education or monitoring. They're going to address myths about breastfeeding and substance use disorder and and so much more. This is a really detailed episode. They really deep dive into the nuance of breastfeeding and substance use disorder, and there is just really so much great practical information. So without further ado, let's jump into it.

SPEAKER_03:

So my name's Amy Marietta. I am the medical director of Project CARA, which is the Perinatal Substance Use Disorder Treatment Program at MHEC. It stands for Care that Advocates for Respect, Resilience, and Recovery for All.

SPEAKER_01:

Hi, everyone. My name is Olivia Caron. I am a clinical pharmacist here at MHEC. I split my time doing chronic disease management and family medicine and substance use disorder work, both in family medicine and OB-GYN. I also teach at UNC Eshelman School of Pharmacy and do a lot of research in the substance use disorder arena.

SPEAKER_02:

Hello, everyone. I'm Georgiana Cogburn. I'm a registered dietitian and international Board Certified Lactation Consultant. And I am the Region 1 Lactation Trainer with WIC LATCH, which stands for Lactation Area Training Centers for Health. And in addition to training healthcare professionals across the western and northwestern part of North Carolina, I also see patients in our clinic here at MAYAC.

SPEAKER_03:

So I'm really excited to be here with you both and to be having this conversation 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 this conversation now? And one of the exciting things is that last year in 2023, the Academy of Breastfeeding Medicine released an update to its guidelines for infant feeding in the context of substance use disorders, really focusing on the whens and hows of breast and chest feeding in the context of of substance use disorder and treatment for substance use disorders. So before we dive in, I did want to just speak to the use of inclusive language when referring to breast and chest feedings. We are going to make every effort in this recorded conversation to use inclusive language referring to breast and chest feeding. However, there may be times when we were referring to the literature that the language will use just breastfeeding. So, you know, in my day to day as a family medicine physician and obstetrician and addiction medicine specialist, I have the honor of taking care of my patients throughout pregnancy and postpartum and really working with them throughout the full scope of their recovery in this kind of intense and special time. And one of the things that comes up a lot is these discussions regarding how am I going to feed my baby? You know, do I want to breast or chest feed my baby. So just thinking through like a typical clinic, maybe like a Tuesday afternoon, patient comes in, maybe they're getting close to their third trimester, really starting to think about delivery and postpartum. And so how do I start to have this conversation about how are you planning on feeding your baby? And just having a really supportive and educational conversation about that, because we know that there are many advantages to breast and chest feeding. And I know or Jenna's going to talk about that a little bit more going forward. But we also know that patients with substance use disorder in treatment for substance use disorders have lower rates of breast or chest feeding at discharge from the hospital. So on average at a hospital, about 84% of patients have initiated breast or chest feeding. And with patients who have non-prescribed substance use or are in treatment for breast substance use disorders with medications for opioid use disorder, those percentages are going to be much lower, anywhere from like 14 to 30%. So can we talk about that a little bit?

SPEAKER_01:

Yeah, I mean, I'm even thinking about a conversation I had yesterday with a friend of mine who's due to deliver soon. And we're in the world of Google and WebMD and all the information's at our fingertips, which also leads to us having lots of space for myths and miscommunication and misinformation. information. And so I think today our goal is really to talk through maybe some of these myths and have an idea of what do we know? What do we not know? What's still gray? What feels a bit more black and white? And I think that first myth that we want to dispel or talk about is patients come into that clinic, that Tuesday afternoon clinic and say, well, I can't breastfeed, right? I'm a history of substance use. I'm actively using. I'm someone with lived experience. Any of those scenarios come up to time and time again. They just say, I'm not eligible. I can't do that. Or, you know, my mom told me not to do that. I heard from a friend that's really bad for baby. And so we really want to just sit with them and kind of talk about really, let's talk about your motivation and what we see time and time again. And I'd love to hear both of your input on this is parents, birthing persons, moms, they want to do what's best for their baby.

SPEAKER_03:

Absolutely. Yeah, for sure.

SPEAKER_01:

And so we hear that we want to support them. And we think of patients and recovery, it's not a linear line, right? We talk about that a lot. You can return to use, you can be actively using, and that doesn't mean you're going backwards. And so empowering a patient during this time period to breastfeed may actually help support their recovery too. And we think about the new guidelines being pretty drastic in how they change their language around breast and chest feeding. I saw previous, you know, recommendations where if there was use in the last month, three months, the recommendation might have been, you know, you aren't eligible. So can we talk a little bit how that's changed recently?

SPEAKER_03:

Yeah, it's really exciting. I would say, you know, the new guidelines say that if at the time of presenting for delivery, there is no ongoing use, that initiation of breast or chest feeding should be supported. Correct. Yeah. So That's a really, yeah, that's a huge change for patients. And I think one of the other things that I hear a lot is, you know, once patients kind of hear from us that, yes, this is something that you can do, that we want you to do, like we encourage you, we're going to support you. They really embrace that, right? And the idea that this is something that only they can do, that only they can do for their baby, it's really empowering. It's really special and can be really motivating for a sustained recovery.

SPEAKER_02:

And I think a lot of that goes back to they look at the choices that they've made previously and they're feeling very guilty about the choices they've made. And they're going, okay, I have a chance now to make a different choice. And this choice I make is really going to be good for my infant. It's going to improve my infant's health, my infant's outcomes. And I've even had patients tell me, I want to breastfeed or chestfeed my infant because that's going to motivate Absolutely.

SPEAKER_03:

Yeah. Yeah.

SPEAKER_01:

Whoa, you just opened this world for me. Well, how can I do this safely? And as the pharmacist, I apologize to everyone listening, but I have to geek out on the science a little bit. It's the best part of it all. I get to bring in probably the most black and white into this conversation. We think a lot about substances with breastfeeding and how their half-life, so how long a substance can take to clear. In the medical world, we usually say four to five half-lives is how long a substance needs to clear. And your half-life is the time required for a substance to go down to 50% concentration in your body. So there's a time where a substance will have a peak effect, then it'll go down to 50% concentration, and the time to get to that is its half-life. And the way that we talk about in breastfeeding and the way that any pharmacist has been taught 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 dividing those two things. And I'm a big fan of having resources at your disposal. If you've heard this before, but pharmacists love to look into things and we're quick at looking 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 I was in school was called LactMed. It is now being updated to LactRx. And that is a great database from the NIH that just gives gives you really good hardcore data on here's a relative infant dose and here's the half-life of the substance and here's a recommendation. Very similar to these guidelines from the Academy of Breastfeeding Medicine. We look at those to make a decision to help that come into our shared decision-making with the patient. And generally, we like to see a relative infant dose of 10% or less and we consider that safe. And so kind of going back to those medications for opioid use disorder, we know that relative infant dose is very low for both methadone and buprenorphine and naltrexone, which are three primary medications we use to treat opioid use disorder. We also have lots of different substances that we treat like alcohol, tobacco, stimulants. And so you can look up the different medications that a patient is on and kind of make that decision with the patient, hey, is this safe for the baby? So that's kind of the big thing that I do in the room as the pharmacist with shared decision making. But we like to think about the team 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 talk to her about why she should do it?

SPEAKER_02:

Right, right, right. So I like to always go back to, you know, we're talking about the Academy of Breastfeeding Medicine's position statement, their protocol that came out. And also like to look at and when i'm talking to patients well the american academy of pediatrics the american college of obstetricians and gynecologists all support breastfeeding for these patients on medications for the opioid use disorder and you know the benefits you were mentioning the concern with the nicotine the parents that smoke and the babies are in those smoke-filled environments and we know those infants are at higher risk of upper respiratory infection that higher risk of SIDS, that sudden infant death syndrome or sudden unexplained infant death. Well, when that parent is providing breast milk, is breastfeeding or chest feeding that infant, it lowers that risk of those upper respiratory infections, of those ear infections, which I think is a great benefit to talk to our parents about because they're doing the smoking and they're really concerned, am I going to hurt my infant? When they think, oh, I can do this and this can help protect my infant. And the other thing that the breast milk does is it really helps to build that infant's gut microbiome. It helps that baby to be able to fight other types of infections. Yeah. Asthma is another one it helps protect against. That's amazing. Yeah.

SPEAKER_03:

Yeah. It's incredible once you start listing it out. You know, patients, you know, we spend so much of our time in our clinic trying to overcome stigma and like reduce the risk for our patients. And so to have something really positive, like, you know, how can we support you in doing this thing that only you can do that you are uniquely, you know, in this situation to be able to be the only one that can offer your baby this, it really changes the dialogue.

SPEAKER_02:

It does. And then, you know, not just for the infant, but there's benefits for the parent as well. You know, we were talking about how a lot of our patients come in when they come into the clinic, they're anxious they're really concerned. Well, breastfeeding, chest feeding helps to reduce that risk of postpartum depression, which is great. And then especially when you start doing that history and you look at that family history, if you find there's been a history of premenopausal or postmenopausal breast cancer and ovarian cancer and endometrial cancer, it helps to lower the risk of those. We're seeing a lot of patients with gestational diabetes when they breastfeed chest feed, it helps to lower that risk of them developing type 2 diabetes later in life. And I think a really important thing for the patients that we're talking about today and working with is, you know, they're at that higher risk of that anxiety, of that kind of stress. Am I doing things right? The pressures of the world. When that infant is right here chest to chest with that parent, that cortisol level goes down for both the parent and the baby And guess what? It lowers that parent's stress level. So they're going to cope better with everything that's happening in the world.

SPEAKER_03:

Yeah. My turn to geek out a little bit, right? Yeah. Neurotransmitters. So those natural doses of oxytocin and dopamine that we get from breast or chest feeding and that skin to skin and that connection, boy, talk about a powerful tool in recovery, right? We spent a lot of time talking about substance use treatment finding other ways to cope with that cortisol, with that stress response, but how powerful to have something proactive that we can do that gives us a natural boost to our own endogenous capacity to, you know, have that natural feel good chemicals that happen, you know, in abundance when we're, when we're breast or chest feeding.

SPEAKER_02:

Right. Right. Yeah. And, you know, we're talking benefits, but also think we need to keep in the back of our mind that these parents have challenge

SPEAKER_01:

You

SPEAKER_02:

know, we hear parents say, well, I thought this was going to be so easy. Well, it takes a while to get it all going. And with our parents that we're talking about today, we do have concerns and we've already mentioned a couple of these. So to hone in on them is they receive inconsistent messages. You know, maybe one health care provider will say something and they go to another one and they're told something else or their family is telling them you already You mentioned that, Olivia, how they get these mixed messages. That's a big concern. And are they getting enough prenatal education? Are we spending that time talking to them about, well, this is what to expect. This is how you feed your baby. Are we giving them enough education? And then once the baby is here, there may be that chance that the parent and baby are separated. Maybe if they deliver early, baby may end up being in NICU, you know, and that's an added concern or an added stressor for an infant. And then this one, Olivia, is for you. You've also got to consider what else is that parent on? You know, what is their other polypharmacy or polydrug use? Are they taking medications for depression? Are they, you mentioned the nicotine or the alcohol already. So, you know, what else is that parent doing? And, you know, The other big thing for our parents to consider is what does their support system look like? How are they getting to clinic appointments? If they happen to deliver early and the baby's in NICU, but they've got other kids at home, do they have transportation back and forth to the hospital? So doing that total patient care, I think, and really doing the education and supporting that parent, Meeting them where they're at, making sure they have access to resources is going to help them to be successful in feeding their infant at breast or chest.

SPEAKER_01:

Gosh, you touched on a few things. And we all have the pleasure of working together here in Western North Carolina at MAHEC. But we talk all about what the hospital is going to look like and how many people you're going to see and what are they going to do when you get there. And Amy, you and I have talked about this and you've taught me about this. there's likely going to be a drug screen involved too, right? And how does that influence their care? We talked a little about the polysubstance use, right? Is something that comes up on the drug screen going to change the conversation I was having with my provider before I went to the hospital? And so we have some data to kind of walk us through that. I don't know if Amy, you want to talk about that a little?

SPEAKER_03:

Yeah, I think one of the important points that was brought up in the new guidelines from the Academy of Breast Feed medicine is that a urine toxicology test is not the best test to determine whether or not a patient should initiate breast or chest feeding in the hospital. And there are a couple of reasons behind that. I think like any test, it's important to know why you're doing the test and what you're going to do with the information. And so when we think about the factors that may contribute to whether or not someone could six initiate breast or chest feeding. One of them is going to be substance use. You know, when is the last time of use? What substance was used? You know, what has their use been like, right? Going into labor is stressful. It might be a trigger. You know, have they been without any use throughout their pregnancy and then, you know, delivery comes and it's stressful and they have a one-time return to use or is there ongoing active use that we need to address as a team. So a urine toxicology test is not going to tell you all of those things. It's not going to say anything about their support network. It's not going to say anything about if they're engaged in treatment or have a desire to engage in treatment. And so I think it's important to know urine toxicology test tells you at one snapshot in time what is being metabolized by that patient's body and what is showing up in their urine. And the other thing to know is that there are substances that are lipophilic or fat soluble that can hang out in urine for a long time. And so we've seen this for a while with cannabis, you know, and now we're starting to see it more with fentanyl as well. We can see that urine toxicology tests can be positive for these substances for days, weeks, even with fentanyl metabolites, we can see it be positive for months. So having a positive urine urine toxicology test may just indicate that someone had a return to use two months before they engaged in treatment, you know, and it's still showing up positive. And so taking all that into context when you're having these conversations with your patients and with the care team at the hospital.

SPEAKER_01:

I love the word, it's going to show what they're metabolizing, right? Like that is such a great way to put it. It's not going to show maybe what they're ingesting that morning. It's what your body's metabolizing. And so I think the Academy did a good job of saying that their history, right, talking to the patient is the most important thing you can do and that is going to kind of help you decide. So the rapport you can build with patients, letting them be open and honest with you and explaining why you're asking that question. Hey, we want to make our best informed decision of if this is both something we want you to do and we want you to do it, so we need to make a great decision for you. And so with things like fentanyl, right, I think they've come out and kind of informed us 72 hours if it's been 72 hours it may be safe to initiate breast and chest feeding but again will be a lot of shared decision making is it active use is it a history of use was it one time return to use all those things that amy mentioned that are so great to think about but that that urine drug screen is a snapshot in time i really really love that

SPEAKER_03:

yeah and the other thing to know is that you know like many tests urine toxicology tests are not perfect right so the tests thing that we do at the hospital is often a screening test and the way I like to explain this is it's like a key in a keyhole um if it unlocks the door or gets close enough it'll be positive but there are many things that could maybe mimic that key right so you can get some false positives so always sending those tests for confirmation because often we'll find them that that we'll find that the screening test is um there's a discrepancy in the the follow-up confirmatory testing um I was going to say, you know, thinking about, you know, the difference between the hospital setting and then the home environment as well, and thinking about, you know, it may be safe and there may be adequate support to start or initiate breast or chest feeding in the hospital where there's a lot of supervision and a lot of support, but how do we best support our patients when they're going back to their home environment or to treatment? Like, is there, you know, some intervention that we can do in that hospital, that really precise moment to set them up for success, not only with, you know, feeding their infant, but in their overall recovery. And I think that sort of teamwork together, really focusing on a patient centered approach and giving that patient, you know, voice and choice and how they want to move forward is kind of like the secret sauce to our team's approach. And I think like really really sets any sort of clinical team up for success.

SPEAKER_01:

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 the door and I feel like now we have to walk in the room and talk about it, right? Cannabis. As a pharmacist, I can't keep up with all the different variations in THC, CBD, the different legality across the US, right? Is it decriminalized? Is it legal? Is it for medical purposes. So I feel like this is a really unique substance and how we counsel patients. We know that it's passed through breast milk. I think that's one important thing to say is we know that it does. We know that it stores in our fatty tissue and is going to be on our drug screens for months and months. If we have a chronic use of cannabis, we know that folks use cannabis for all sorts of variety 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 of the why, but then what we don't know always, right, is who's the best candidate? I don't think it feels like the most black and white. So kind of how do we approach those discussions around cannabis with our patients?

SPEAKER_03:

Yeah, I think that's exactly right. So there's nothing about this that is black and white. And I think when we try to take something like cannabis use and make it either a black and white situation, that's when we get into trouble, right? Because every situation is going to be different. Um, the Academy of breastfeeding medicine guidelines, uh, reflected what the evidence shows is that we don't know. We don't actually know. And so their recommendation is to have a risk benefit conversation, to talk to the patient. Like you said, Olivia, that like the most important thing we can do as providers. And so, you know, there are some things we do know. We do know that THC is detected in, um, breast milk for weeks. We know that use doesn't appear to decrease milk supply, but it can change the composition and decrease duration of breast or chest feeding. It may be associated with an increased risk of postpartum depression. What we don't know are the short and long-term outcomes on infant health from cannabis use just through lactation. We do have some outcomes that we can kind of extrapolate from prenatal use. So exposure in utero has been associated with neurocognitive changes and poorer outcomes for infant brain development and growth. So, but what it's hard to tease out, you know, did the exposure just happen during pregnancy or then it also happened then during lactation? And so I think it's important to have a conversation because what comes up for me with patients a lot is the idea that cannabis use is natural or maybe more a better alternative to some of the other prescribed medications that we might think about using for things like mood or sleep or nausea. And I think it's important to have a conversation about the potency and strength of cannabis products has really increased over the last two decades. So the the amount of THC that someone may be getting from their current vape product or edible, or even things, you know, from their dispensary or dispensed for medical purposes, it much, it's much higher than it used to be. And so really having a conversation 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 is why, what, what is this doing for you? And are there other ways that we could help support you that are more compatible with lactation?

SPEAKER_02:

And I think that leads to what I think is a wonderful way they put it is encouraging the parents to not use the cannabis, not saying don't chest or breastfeed your infant, but refrain or not use the cannabis while you're breast or chest feeding your infant. And that requires us having a conversation and figuring out why are they using, what's the trigger for them and helping them to work through that so that they're able to have that experience with their baby.

SPEAKER_03:

Right. And I know plenty of patients who in preparation for delivery and because they want to breast or chest feed, you know, cease use and then it still shows up in their urine toxicology screen. And so then there may be barriers to breast or chest feeding initiation in the hospital. So one of the things that I talk about with my patients early on is why don't we do some control confirmatory testing to look at the levels to see them dropping and that is really satisfying for patients who are motivated and really wanting to they have that goal in mind of being able to breast or chest feed their infant just seeing the the numbers right there it's more than just pharmacists and physicians right it's really satisfying to see it on the paper

SPEAKER_02:

right and and you think about that too you maybe have this patient who has worked so hard to not use all during the pregnancy. And they get to that last few weeks and they're like, I'm miserable, I can't cope. And they remember using that to cope before, using the cannabis to cope before. And they go and they use it once. And you want to be able to support 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 is best. their baby. They want to be there for that baby and do that. And while we're mentioning babies, I think one of the things that come up with the patients who are using the substance, you know, the methadone, the buprenorphine, they're always concerned, how's it going to affect my baby? What's going to happen? And we hear a lot about the neonatal opioid withdrawal syndrome or NOWS. And we know that we typically are going to observe that within 24 to 48 hours after delivery. And, you know, there's factors. Just like Olivia, you were talking about the medications, how our body's metabolizing these medications, what's going to happen. You know, the factors that may impact that, the nows, are things like what were they using? What was the opioid that they were 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 SSRI for depression. All of that's going to affect that. And then you look at the list of things that we may see babies exhibiting. They may have that kind of high-pitched crying, being irritable, maybe have some tremors, difficulty sleeping. And I love this one, loose stools. Well, if a baby's getting breast milk, guess what? They're going to have loose stools So, I mean, is that a symptom of their nows or is this just normal metabolism, normal things with our babies? And so looking at that, the yawning and sneezing, those are also too. You see newborns always yawning, always sneezing, but it may not be the result of that. And what we have seen, there's great news for everybody that there's a 30% reduction in nows for infants whose parents our own treatment, who are getting treatment. And there's also a 50% reduction in hospital stays for these 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 parents going back to that prenatal education? What do we talk to them about as far as taking care of their baby? And we want to really encourage non-pharmacological treatment for the baby. And the terms now that we use are eat, sleep, and console.

SPEAKER_03:

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 opioid withdrawal syndrome, because it's so easy. It's treating a baby like a baby, right? Like what are the things we want our infants to do? We want them to eat. We want them to sleep probably more than they do. And we want them to be able to be easily consoled within 10 minutes. So if a baby is doing those things, great. No intervention necessary. Right. No Finnegan scoring. I

SPEAKER_02:

love that there's no Finnegan scoring because that is so subjective. You know, one person maybe sees one thing and another, another. And I think when we think sleep and consolates and going back to what you said, Olivia, about the hospital, you know, things that happen in the hospital is preparing our patients ahead of time. Talking to them about rooming in with that infant. Keeping that infant in the room with them throughout the hospital stay. Talking with them about baby. How do we know that this baby needs to eat? Those physiological infant feeding cues. I'm putting my hands to my mouth. I'm looking around. I'm starting to make noises. Talking to parents about this is normal. This is how they let you know that they're hungry. Talking to them about This is how babies communicate. Talking to them about doing skin-to-skin care. If they say, well, my baby's just really sleepy. They're not wanting to wake up. Having them do skin-to-skin care for 20 to 30 minutes, that baby is going to start to give us those cues and start to wake up to eat. We also want to talk to them about doing skin-to-skin care safely, meaning you don't want covers over the baby. You want the baby's head turned to its sides so they can breathe very easily. And this is a big one too, is keeping those distractions in the hospital low. We know patients, a lot of family wanting to come see the new baby, but keeping the lights down low, keeping the volume down low on the TV, keeping those distractions down low, really help those babies to cope and to come through.

SPEAKER_03:

Yeah. I just love that, you know, one of the main tenants of Eat Sleep Console is breast or chest feeding, right? Because you get that skin to skin, you get the lactated milk. And again, it's that concept of like, this is the one thing that only I can do for my baby. And

SPEAKER_01:

can we talk a little bit, you were talking about preparing for the hospital and we talk about nows or mass and, you know, abstinence syndrome being anticipated, right? And I think so. something for those of us that work in substance use. It is just another chronic disease, right? It's another chronic disease where we have treatment options. We have behavioral health options. We have outcomes that we know may or may not happen. So I think of my parents with gestational diabetes, right? The risk of hypoglycemia for the infant. So thinking like, yes, with any substance, good, bad, whatever connotation it has around it, there's an anticipated outcome that we can prepare for. Every hospital is going to have different protocols in place for just in case. And so I think a lot of that education 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 room with my baby. You know, there's always going to be a backup option. And I like to see a lot this pendulum move with literature from using morphine to eat, sleep, console. And it's going to constantly keep shifting, but what stays is that you sleep console. And I see that time and time again in the literature that that stays a mainstay of therapy for nows, regardless of all your other options, regardless of the changing landscape of substances too, right? The substances keep changing. But what we know is that that stays true. And I think that that's really important. And you were talking about the benefits of medications for opioid use disorder. And we know that the said buprenorphine, methadone, naltrexone, all recommending and compatible with breastfeeding and chest feeding, right? That was just level A or B recommendation, which are really high levels of recommendation, really strong. And then it gets a little bit murky with our other substances. Like Amy was talking about, antidepressants can be difficult, right? Certain levels of antidepressants, we know that baby can experience some withdrawal, but it is really, really powerful. When I talk to patients about getting on medications for opioid use disorder, it's a lot of stigma to do that. You're trading one drug for another, one addiction for another. And to be able to say, hey, we have data that this is going to help you during your recovery, during your birth and postpartum, right? The benefits don't stop. And I think that that is one of the things that we talk about when someone presents to our clinic and we're giving them all their options, that this isn't just for the pregnancy, that this goes beyond pregnancy and is a really powerful tool in your recovery.

SPEAKER_03:

Yeah. You know, the way I talk about it is the most important thing for your baby is that you be okay, that you be solid in your recovery, that you have the tools in place so that you are well, because what we know is that babies that are born to parents who are well do well. And so it's the number one question, right? Is this going to hurt my baby? Are these medications going to hurt my baby? So we know, like Olivia said, that now's is an antithesis. anticipated and expected outcome from exposure to medications for opioid use disorder in utero, about 30 to 50% of the time. And then talking specifically about things that we can do to help prevent nows, which, by the way, includes breast or

SPEAKER_02:

chest feeding, right? Yeah. And another thing, you know, and I want to go back to this is one of the standard treatments that we see that we see a lot with baby friendly hospital initiatives. So this again is tried and true, skin to skin care with that baby. Putting that baby immediately skin to skin with the parent after delivery does so much for the baby. We call that the golden hour after delivery. You mentioned your gestational diabetics. You know, having that baby skin to skin lowers that baby's blood glucose level. It helps to stabilize their respirations. It helps to regulate their heart rate. And we're doing this across the board with all babies, regardless of that parent's history. We're even seeing it happen in a lot of hospitals with parents who deliver bisetharian. It's automatic standard practice because we know the benefits for both that parent and that infant. It helps the parent to have uterine contractions, which helps to deliver that placenta. It helps to lower that parent's cortisol level. So it's just a great way to talk to all of our our patients about expect that this is going to happen immediately after delivery and then encouraging them to room in together throughout the hospital stay and continue to do that skin to skin care.

SPEAKER_03:

Yeah. Yeah. I love that. Love that. I love the term the golden hour. I do want to bring up something that's like one of the tougher questions that we get, which is, you know, we obviously are big breast and chest feeding advocates and we also work with people who are in different stages of recovery and so you know and we talk about when it may not make sense to initiate breast or chest feeding or when it may not be safe because everyone wants both the birthing parent and the infant to do well and sometimes there may be contraindications or reasons to not initiate breast or chest feeding

SPEAKER_01:

yeah one of the first things I can think of is you know chronic heavy act of use, right? It is ongoing and just from a pharmacokinetic component, right? There's just maybe too much passing through the birthing person's body that may have the potential to pass through the baby and maybe having an effect on the birthing person's mind, their mentality, right? That is a unique connection and time with your baby. It's difficult, as we mentioned So thinking about, it's not black and white to me though, right? Again, because cannabis, right? Chronic use, that may be a different definition for someone than chronic fentanyl use and what that looks like. So I don't actually like to put anyone in active use as an absolute no. I will say that, but that is definitely one of my red flags that go off is what is this use looking 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:

And I think sometimes, and I agree about that active use, and sometimes they're going, well, how am I going to bond with my baby? Because maybe they have heard about the Chester breastfeeding. It helps you bond with your baby. If there are those concerns about the baby getting the breast milk because we don't know how much of that substance the baby's getting, we don't know how that's going to impact the baby, we could still talk to those parents about doing that skin-to-skin care with their baby. They're still going to be able to get that bonding, but maybe just not the breast milk. So keeping that in mind as we talk to our patients.

SPEAKER_03:

Right. So, you know, I think it's like many of the things that we've talked about today. It's worth a conversation. It's worth really making that focused on the patient and their goals and, you know, coming up with a plan that's going to be safe and patient-centered.

SPEAKER_01:

And I will put out there some substances again. I always like to think of my yellow or red flags as a practicing clinician. Stimulant use is one that we haven't touched on much today. But methamphetamine is a really tricky one and one that the academy, you know, tried to quantify as best as you can. But that one can stay in your system longer. And the way that stimulants work that 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 waiting periods. I know that we mentioned kind of that 72 hours for fentanyl. There's some data that supports waiting up to 100 hours since the last use with methamphetamine. So methamphetamine is definitely one that if there's active use, I'm kind of starting to have that trigger, that discussion with my patient. Hey, this is when it may be safe. So we may need to plan ahead. Another one that comes up often in folks that Our tobacco users is thinking about vernicicline or Chantix and that there is not a lot of good safety data around whether that is recommended or not. So that is one that if that is what someone's using, often we don't use it in pregnancy either. So less of a concern, but maybe transitioning to nicotine replacement therapy and finding alternatives for that patient. Just kind of the conversations we have around cannabis and all our substances. Why are you using it? Can we find you a safer alternative? And then the other one that I think is tricky is alcohol, right? Is it chronic? Is it a glass of wine? And so that is another discussion. I feel like we're going to sound like a broken record by the end of this, but talking to your patient, often if it is occasional use, you can kind of wait those two to three hours per drink to feed. But with really chronic use, moderate to high use, a severe alcohol use disorder, that's another one I have a red flag of maybe not recommending breast or chest feeding.

SPEAKER_02:

And one of the things to remember with alcohol, you know, AAP, Academy of Breastfeeding Medicine, I'll say that two hours after a drink. We need to be doing a lot of education with our patients, a lot of conversations about what is that drink? You're going out to celebrate a birthday. You want to celebrate with your friends. Well, what is that drink? It's like that one five ounce glass of wine. It's that one 12 ounce beer. it's that two ounces of liquor and if you have two of those you need to extend your time it takes that little bit longer to clear your system I think it's having like you said getting into is it chronic is it that occasional well if it's occasional how much are they drinking at that time yeah and I think about these parents you know we've talked a lot about the pregnancy making that decision also think preparing the patients during pregnancy having the conversations about having a newborn regardless of how you feed that newborn that's a stressful time for new parents you've got this new person in your household you're adjusting to this new person they're not on the schedule that you're on I can remember asking patients they're like oh yeah the baby's going to sleep I thought they would sleep through the night well what is your definition of through the night. You know, they're thinking this baby is gonna sleep, what, six to eight hours? And we know that a newborn is not gonna do that. They're gonna be waking up every one to three hours. So I think having that conversations with patients prenatally about this is the expectation and how are you going to cope? What are things that you can plan to put into place now to help you get that rest, Who is there to support you? Maybe can this person feed the baby a bottle so you can get a little bit more sleep at night? Because just think, those newborns, they were used to eating continuously throughout the pregnancy. Wasn't a good life. Continuous. They had a constant source of food, a constant source of nutrition. And their stomachs are so small. You know, at birth, it's about the size of a grape or a shooting marble and it's going to hold like a teaspoon. By the time they go home, baby's probably holding about an ounce at a feeding. Their stomach's about the size of that golf ball or ping pong ball. And then by the time 10 days to two weeks roll around, the stomachs are about the size of a large egg or a lemon. So they're probably going to be holding two to three ounces. So they've got to eat often. And our parents need, that's what I see a lot with parents when I see them in clinic is they're struggling with not getting that sleep. So how can we help them by having those discussions during the pregnancy to be able to cope with those early days at home?

SPEAKER_01:

And how is that layered by substance use, right? We're talking a lot about maybe the parent making changes in their pregnancy. That's a short period of time. And we talk about recovery and we talk a little bit about the brain with substance use. We think a about those neuroadaptations, right? When you use a substance, you get a dopamine burst and how when you have those unnatural bursts time and time again, your body's going to change. So something like breastfeeding should give you a normal, maybe burst of dopamine that you're not getting. And so that's even harder. And you just spent maybe two months putting in new support systems for yourself and what your world looks like without use. That's going to be tested. Having a new baby at home Yeah. And maybe your support system involves some of the people that you previously used with. And so how does that involve finding a new support system while you're in pregnancy, but also being around those that you feel comfortable and loved around? Like, gosh, I can only think about all the complexities that come up with being a new parent and being in early recovery or coming in and out of active use and how difficult that can be.

SPEAKER_03:

Yeah. I think like it just points to the need for kind of this multi-pronged approach, right? Like really capitalizing on all the resources that we can identify in our clinic, but also like outside the clinic or in the hospital, but also outside trying to offer that kind of like wraparound care. Yeah, I... I am so grateful that at Project CARE, I work with an amazing team and, you know, we're a multidisciplinary team. I'm grateful that we have lactation support. I'm wondering, you know, with our patients that you've worked with that have, you know, substance use disorders and maybe they're in early recovery, what are kind of the most common issues that come up when you're counseling, you know, and supporting them postpartum?

SPEAKER_02:

It's actually not much different than the parenthood Does it have substance use disorder? I imagine that may

SPEAKER_03:

be true.

SPEAKER_02:

Yeah, because the big question, and I'm glad you segued into that, the big question that comes up across the board is, do I have enough milk for my baby? And I mean, whether it's a patient who is not using versus a new parent who is using, it's always, do I have enough milk for my baby? And I think that's one of the reasons, as I just mentioned, you know, the baby's stomach size, how much is this baby going to take? Getting back to that And then making sure that, you know, they get a consult with a lactation consultant if they're thinking about that. Or if they happen to be on WIC, they have support there through the WIC breastfeeding peer counselors, through the WIC breastfeeding experts. Having someone observe the baby nursing. Is baby nursing effectively staying engaged throughout the feeding? Or because they're experiencing some nausea, are they trying to fall asleep or nausea? Are they trying to fall asleep at breast? So they're not nursing effectively. So reaching out, connecting them with those resources. But milk supply is a big concern. And if this parent happens to have an infant who's not nursing effectively, supporting that parent to be pumping as well as putting baby to breast to stimulate that milk production. But yeah, that's the big one that I always get from parents is do I have enough milk for my baby? How do I know I have enough milk?

SPEAKER_01:

Mm-hmm. And if clinicians don't have this interprofessional team at their disposal, you know, when I think about when I trained someone as a pharmacist, I mentioned that LactRx, that's a great, you know, app you can pull up a med, kind of read through something. I think of Mother2Baby has really great handouts that I can hand the patient. If they don't have one of you in their office, what handouts are you sending them or who do you go to first? You know, you mentioned a few governing bodies that you turn to for advice. But if I'm in clinic, five minutes to pull something up, kind of what do you go to first? Oh my goodness.

SPEAKER_02:

That is a great question, Olivia. You know, you think about, and again, it depends upon where this patient is at. Where do they live? You know, because what we deal with in a lot of our rural communities is that lack of access, that lack of resources for them. But you think about the resources to connect them with our Lactation Consult who may be in the WIC offices, may be in the hospitals, may be in some healthcare provider offices. And there's more like lactation consultants in private practice. You think about the WIC offices, I've mentioned those already. And then in some areas, support groups are abounding. And I know in our little area of Western North Carolina, there have been a couple of new mommy and me groups start. One is in, you know, like Macon County has just started one. They're starting one down in Polk County. You know, they've worked with the hospitals, especially the one out in Macon County. And then, you know, there's a little HA League. A lot of them are now going back to meeting in person after doing virtual. That's good. Yeah. And baby cafes in some areas. And that's a big going thing So finding out where those support groups are in your area and connecting them with those. It takes a village, right? What's

SPEAKER_03:

the saying?

SPEAKER_01:

And I feel like we're going back to it. Yeah. It's hard to do it alone.

SPEAKER_03:

Oh man, definitely takes a village. I would add kind of additional like learning opportunities for providers. You know, there's the infant risk center that has a great, great information and some sessions for like continued learning. They, There's, uh, we, so Olivia and I gave a talk through Mayhek in January. Maybe we can put the link to that talk that goes kind of specifically substance by substance. It's very nerdy. There's a lot more of the pharmacokinetics on it. Just giving you enough heads up. But, um, if you like to geek out about, uh, half lives and pharmacokinetics of lactation, it's for you. Um, And I would say like accessible, but it goes specifically by the different substances and breaks down the recommendations from the Academy of Breastfeeding Medicine Guidelines. So that's accessible online.

SPEAKER_02:

And in addition to that, we have through the WIC lactation area training centers that I work with. So there's one in Western, Northwestern North Carolina, one in Central North Carolina, and one in Eastern. And we're always doing trainings in our communities We've got several that are posted online through Mayhek. We do breastfeeding basics. So those resources are out there. You just have to go search them out, but we're doing a lot to educate the healthcare professionals on breastfeeding so that you're able to answer those questions from parents.

SPEAKER_03:

Thank you so much, you guys. This has been really fun to sit down and talk breast and chest feeding and geek out a little bit. Mm-hmm. And just really think about how to center the needs of our patients and to really kind of embrace them in that wraparound care and that tender, tender time. So thanks for joining us. It was really great to spend this time with you. The hour

SPEAKER_00:

flew. The hour flew by. Like I said, such a practical episode. Dr. Marietta, Dr. Caron, Georgiana, we are so grateful for your expertise. Thank you so much for your time and for coming on the podcast. We really, really appreciate it. Listeners, if you like what you're hearing, we would also really appreciate if you would fill out our podcast survey. There is a link down in the description box below in our show notes where you can tell us what we're doing well. Let us know the things that we could improve on and even suggest topics for future episodes. We'd love to hear from you. We also have a Facebook and an Instagram. So our handles are down in the show notes as well. We would love for you to hop on over, leave us a like, leave us a comment. We would love to engage with our listeners on our social media platforms. And finally, if you're listening to this on a podcast platform, five stars and review is always helpful. And if you can share what you're listening to with your colleagues and your patients and anyone who you think the material would be interesting to we would really really appreciate it and until next time thank you