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Meg Doerzbacher RN, MS, NNP-BC

INTERVENTIONS TO SUPPORT

BREASTFEEDING IN WOMEN ON

OPIOID MAINTENANCE THERAPY:

A SYSTEMATIC REVIEW

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Background

• Increased prevalence of opioid use disorder

• Increased incidence of Neonatal Abstinence Syndrome

- Acute opioid withdrawal

- Irritability

- Difficulty feeding

- Sleep disturbances

- Gastrointestinal dysfunction

- Central nervous system dysfunction

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Opioid Maintenance Therapy in Pregnancy

• Opportunity to “capture” women into treatment

• MAT improves maternal and neonatal outcomes

• Better physiologic outcomes

• Less NAS (MOTHER trial)

• Decreased risk of relapse

• Stigma and fear of losing custody of children a major barrier

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• Breastfeeding is more than safe – it is effective and beneficial

• Decreased severity of symptoms

• Decreased need for pharmacologic treatment

• Decreased newborn’s length of stay in hospital

• Decreased length of treatment, lower total dose of opioid

replacement

• Mothers more likely to retain custody of the infant

Significance of Breastfeeding and NAS

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• Impact on attachment and bonding

Attachment improves neurobehavioral development

• Impact on maternal health

Physical and mental

• Impact on infant health

Decreased risk of chronic disease with breastfeeding in comparison to formula feeding

Improved mental health

• WHO, CDC, AAP, ACOG, others all see breastfeeding as a public health concern

Additional Benefits of Breastfeeding

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Why are Attachment and Bonding Important?

• Impact on mental health

• Impact on self-efficacy and self-esteem

• Decreased postpartum anxiety and depressive symptoms in women who breastfeed

• Improved social functioning in the infant/young child

• Other neuropsychological and social benefits

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Basics of Lactation and the Importance of Education

• Colostrum begins developing during the 2nd trimester, triggered by pregnancy hormones

• Sudden drop in progesterone after delivery triggers production of larger volumes of milk

• It takes 30-40 hours for this “trigger” to take place, and 50-73 hours for milk to “come in”

• Once milk begins to be produced, the impetus for stimulating milk supply is emptying the breast – the more frequently the breast is emptied, the more milk the breasts will produce

• There is a psychologic component to the “let-down” reflex

• Positive and negative feedback loops from a physiologic and psychological standpoint

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• How many?

Mixed results

• When?

Mostly in immediate postpartum period

• Why/Why not?

Misinformation, barriers, lack of preparation

Breastfeeding and Women on OMT

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Question:

How do we promote and support breastfeeding for

women in treatment for opioid addiction?

How do we promote and support breastfeeding for

women in treatment for opioid addiction?

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Methods

PubMed, CINAHL, PsycINFO, Embase, Scopus, Web of Science, and Cochrane Database of Systematic Reviews

Search Terms: breastfeeding or lactation, opioid use disorder or opioid maintenance therapy

Published since 2008

291291

• Cochrane = 4

• PubMed = 33

• CINAHL = 15

• Web of Science = 11

• PsycInfo = 40

• Embase = 118

• Scopus = 70

230230

• 61 duplicates, or published before 2008

6363

• 167 screened out by title/abstract

22

• 61 excluded after reading for study design, inclusion criteria

44

• 2 studies added after reviewing references from articles read in previous step

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• Four Studies, 1312 participants

• 1 USA, 2 Canada, 1 Australia

• 1 prenatal model, 1 postpartum model, 2 newborn treatment models

• Urban, tertiary, specialized settings

• Quasi-experimental, non-randomized, retrospective cohort studies

• High risk of bias related to confounding variables (ROBINS-I tool)

Results of Systematic Review

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Author/YearLocation/

Time FrameIntervention Outcomes

Ordean & Kahan

(2011)

Toronto, ON, Canada

2000-2006

“One-stop” model of care for pregnancy

and substance use disorder, based on

harm-reduction and women-centered

philosophy

Longer duration in program associated

with higher rate of breastfeeding at

discharge

Abrahams, et al

(2010)

Vancouver, BC, Canada

2003-2006

Rooming-in on MBU (including

multidisciplinary care) v. standard care in

NICU/SCU

Rooming-in increased odds of receiving

breastmilk during hospitalization, but not

at discharge

Backes, et al

(2012)

Columbus, OH, USA

2007-2009

Intervention group transitioned from

inpatient NAS treatment to home-based

weaning program v. Usual model of care

Increased breastfeeding at discharge in

combined program, 24% v. 8%, p < 0.05.

Smirk, et al (2014)

Parkville, Victoria,

Australia

2004-2010

Home-based weaning (NAS) with frequent

contact v. inpatient infant weaning

45% of infants in home-based care

breastfeeding at discharge v. 22% in in-

patient care, p = 0.022

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• Breastfeeding was significantly increased in the intervention group in all

four studies

• Most effective programs had these common features:

Multidisciplinary, integrated

Continuity from pregnancy to after birth

Maintain the integrity of the mother/infant dyad

Consolidated, comprehensive prenatal care

Professional staff who are prepared

• Need to address misinformation and barriers

What does the research say?

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• More detailed understanding of barriers from patients’ and providers’ perspective

• More detailed understanding of women’s needs and wants related to breastfeeding

• Evaluation of specific components of care models or combinations of interventions

• Long-term outcomes (mother, child, family) in this population

Gaps in Knowledge – Future Directions for Research

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Key Take-Aways for Nurses Working in Addiction Treatment

• Pregnancy increases women’s vulnerability – physical, emotional, psychological

• Pregnancy is also a time to “capture” women – motivates access to and participation in treatment

• An opportunity to change the trajectory of their disease

• Potential benefits of breastfeeding for these women, relative to mental health:

• Decreased risk of postpartum morbidity, including relapse

• Self esteem

• Parenting skills

• But … women have to be given the necessary education, tools, and guidance

• Breast feeding is a skill that must be learned

• Lactation is a process that must be managed

• Anticipatory guidance is critical

If they are in treatment …

They need

To breastfeed!

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• Childbearing women with opioid addiction are a

vulnerable population who need exceptional care

• Breastfeeding is a public health issue with multiple

benefits to physical, mental, developmental, and

social health

• Improving breastfeeding in women with opioid use

disorder has the potential to make a significant

difference in their lives, the lives of their children, and

their communities

Conclusions

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QUESTIONS?

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Recommendations

Education

Update education and training of health care professionals and paraprofessional workers

Practice

Make breastfeeding the norm and overcome misinformation

Educate and prepare women for breastfeeding during pregnancy

Encourage family and social support system

Research

Descriptive and qualitative studies to explore barriers

Develop and test interventions

Longitudinal research of long-term outcomes

Policy

Improve access to substance abuse care and opioid maintenance therapy

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• Retrospective, cohort study

• Vancouver, 2003-2006

• 952 opioid-exposed newborns

• Interdisciplinary rooming in v. standard care

• Increased odds of receiving breastmilk during hospitalization, but not at discharge

Abrahams, R. R., MacKay-Dunn, M. H., Nevmerjitskaia, V., MacRae, G. S., Payne, S. P., & Hodgson, Z. G. (2010). An evaluation of rooming-in among substance-exposed newborns in British Columbia. J Obstet Gynaecol Can, 32(9), 866-871. doi:10.1016/s1701-2163(16)34659-x

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• Retrospective review with comparison of groups

• Columbus, Ohio, 2007-2009

• 121 Newborns treated for NAS

• Combined inpatient & outpatient treatment v. standard inpatient care for NAS

• Increased breastfeeding at discharge in combined program, 24% v. 8%, p < 0.05

Backes, C. H., Backes, C. R., Gardner, D., Nankervis, C. A., Giannone, P. J., & Cordero, L. (2012). Neonatal abstinence syndrome: transitioning methadone-treated infants from an inpatient to an outpatient setting. J Perinatol, 32(6), 425-430. doi:10.1038/jp.2011.114

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• Retrospective review

• Toronto, Ontario, 2000-2006

• 121 women in comprehensive treatment program

• Length of time in treatment program

• Longer duration of time in program associated with a higher rate of breastfeeding at discharge

(64.7% v. 39.3%, p < 0.05)

Ordean, A., & Kahan, M. (2011). Comprehensive treatment program for pregnant substance users in a family medicine clinic. Can Fam Physician, 57(11), e430-435.

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• Retrospective review

• Parkville, Victoria, Australia, 2004-2010

• 118 Newborns treated for NAS

• Inpatient v. Home-based weaning from treatment

• 45% v. 22% breastfeeding at discharge, p = 0.022

Smirk, C. L., Bowman, E., Doyle, L. W., & Kamlin, O. (2014). Home-based detoxification for neonatal abstinence syndrome reduces length of hospital admission without prolonging treatment. Acta Paediatr, 103(6), 601-604. doi:10.1111/apa.12603

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Author/Year Design/Setting Sample Location/Time Frame Intervention Outcomes Limitations

Ordean &

Kahan

(2011)

Retrospective

review

121 women in

treatment

program

Toronto, ON, Canada

2000-2006

“One-stop” model of care for

pregnancy and substance use

disorder, based on harm-reduction

and women-centered philosophy

Longer duration in program

associated with higher rate of

breastfeeding at discharge

No control for confounding

variables

Abrahams, et

al (2010)

Retrospective

cohort study

952 opioid-

exposed

newborns

Vancouver, BC,

Canada

2003-2006

Rooming-in on MBU (including

multidisciplinary care) v. standard

care in NICU/SCU

Rooming-in increased odds of

receiving breastmilk during

hospitalization, but not at

discharge

Historical data extracted from

database, no control for

confounding variables

Backes, et al

(2012)

Retrospective

review

121 newborns

treated for NAS

Columbus, OH, USA

2007-2009

Intervention group transitioned

from inpatient NAS treatment to

home-based weaning program v.

Usual model of care

Increased breastfeeding at

discharge in combined program,

24% v. 8%, p < 0.05.

Significant risk of bias (mother-

infant dyads met specific

criteria for referral to treatment

group)

Smirk, et al

(2014)

Retrospective

review

118 newborns

treated for NAS

Parkville, Victoria,

Australia

2004-2010

Home-based weaning (NAS) with

frequent contact v. inpatient infant

weaning

45% of infants in home-based

care breastfeeding at discharge v.

22% in in-patient care, p = 0.022

Significant risk of bias (infants

met specific criteria for referral

to treatment group)

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Discussion – Related Studies and Reviews

Lumbiganon, P., Martis, R., Laopaiboon, M., Festin, M. R., Ho, J. J., & Hakimi, M. (2016). Antenatal breastfeeding education for increasing

breastfeeding duration. Cochrane Database of Systematic Reviews(12).

Meedya, S., Fernandez, R., & Fahy, K. (2017). Effect of educational and support interventions on long-term breastfeeding rates in primiparous

women: a systematic review and meta-analysis. JBI Database System Rev Implement Rep, 15(9), 2307-2332. doi:10.11124/jbisrir-2016-002955

Tsai, L. C., & Doan, T. J. (2016). Breastfeeding among mothers on opioid maintenance treatment: A literature review. Journal of Human Lactation,

32(3), 521-529. doi:10.1177/0890334416641909

Edmunds, L. S., Lee, F. F., Eldridge, J. D., & Sekhobo, J. P. (2017). Outcome evaluation of the You Can Do It initiative to promote exclusive

breastfeeding among women enrolled in the New York State WIC program by race/ethnicity. J Nutr Educ Behav, 49(7s2), S162-S168.e161.

doi:10.1016/j.jneb.2017.05.350

Lee, C. H. M., O'Leary, J., Kirk, P., & Lower, T. A. (2017). Breastfeeding Outcomes in Washington State: Determining the Effect of Loving Support

Peer Counseling Program and Characteristics of Participants at WIC Agencies. J Nutr Educ Behav. doi:10.1016/j.jneb.2017.09.002

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Abrahams, R. R., MacKay-Dunn, M. H., Nevmerjitskaia, V., MacRae, G. S., Payne, S. P., & Hodgson, Z. G. (2010). An evaluation of rooming-in among substance-exposed

newborns in British Columbia. J Obstet Gynaecol Can, 32(9), 866-871. doi:10.1016/s1701-2163(16)34659-x

Adams, J. H., Liew, Z. Q., Sangtani, A., Frantz, K., McCarroll, M. L., & Silber, A. (2016). Comparison of outcomes in maternal opiate medical support using centering

pregnancy versus maternity care home. Obstet Gynecol, 127, 95S. doi:10.1097/01.AOG.0000483822.09194.9c

American College of Obstetricians and Gynecologists. (2017). Committee Opinion No. 711 Summary: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol,

130(2), 488-489. doi:10.1097/AOG.0000000000002229

Backes, C. H., Backes, C. R., Gardner, D., Nankervis, C. A., Giannone, P. J., & Cordero, L. (2012). Neonatal abstinence syndrome: transitioning methadone-treated infants

from an inpatient to an outpatient setting. J Perinatol, 32(6), 425-430. doi:10.1038/jp.2011.114

Cleveland, L. M. (2016). Breastfeeding Recommendations for Women Who Receive Medication-Assisted Treatment for Opioid Use Disorders: AWHONN Practice Brief

Number 4. Nursing for Women's Health, 20(4), 432-434. doi:10.1016/S1751-4851(16)30207-0

References

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Demirci, J. R., Bogen, D. L., & Klionsky, Y. (2015). Breastfeeding and methadone therapy: The maternal experience. Substance Abuse, 36(2), 203-208.

doi:10.1080/08897077.2014.902417

Edmunds, L. S., Lee, F. F., Eldridge, J. D., & Sekhobo, J. P. (2017). Outcome Evaluation of the You Can Do It Initiative to Promote Exclusive Breastfeeding Among Women

Enrolled in the New York State WIC Program by Race/Ethnicity. J Nutr Educ Behav, 49(7s2), S162-S168.e161. doi:10.1016/j.jneb.2017.05.350

Eidelman, A., & Schanler, R. (2012). Breastfeeding and the Use of Human Milk. Pediatrics, 129(3), e827-e841. doi:10.1542/peds.2011-3552

Kocherlakota, P. (2014). Neonatal abstinence syndrome. Pediatrics, 134(2), e547-561. doi:10.1542/peds.2013-3524

Lee, C. H. M., O'Leary, J., Kirk, P., & Lower, T. A. (2017). Breastfeeding Outcomes in Washington State: Determining the Effect of Loving Support Peer Counseling Program

and Characteristics of Participants at WIC Agencies. J Nutr Educ Behav. doi:10.1016/j.jneb.2017.09.002

Lumbiganon, P., Martis, R., Laopaiboon, M., Festin, M. R., Ho, J. J., & Hakimi, M. (2016). Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane

Database of Systematic Reviews(12).

References

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Meedya, S., Fernandez, R., & Fahy, K. (2017). Effect of educational and support interventions on long-term breastfeeding rates in primiparous women: a systematic review

and meta-analysis. JBI Database System Rev Implement Rep, 15(9), 2307-2332. doi:10.11124/jbisrir-2016-002955

National Perinatal Association. (2017). Perinatal Substance Use. Retrieved from http://www.nationalperinatal.org/position

O'Connor, A. B., Collett, A., Alto, W. A., & O'Brien, L. M. (2013). Breastfeeding rates and the relationship between breastfeeding and neonatal abstinence syndrome in

women maintained on buprenorphine during pregnancy. J Midwifery Womens Health, 58(4), 383-388. doi:10.1111/jmwh.12009

Ordean, A., & Kahan, M. (2011). Comprehensive treatment program for pregnant substance users in a family medicine clinic. Can Fam Physician, 57(11), e430-435.

Smirk, C. L., Bowman, E., Doyle, L. W., & Kamlin, O. (2014). Home-based detoxification for neonatal abstinence syndrome reduces length of hospital admission without

prolonging treatment. Acta Paediatr, 103(6), 601-604. doi:10.1111/apa.12603

Tsai, L. C., & Doan, T. J. (2016). Breastfeeding among Mothers on Opioid Maintenance Treatment: A Literature Review. Journal of Human Lactation, 32(3), 521-529.

doi:10.1177/0890334416641909

References