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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