This section focuses on the use of illicit substances and lactation.

While specific substances are discussed in more detail, a few general considerations:

• It is recommended to not breastfeed or feed pumped milk if the lactating person is actively using harmful or illicit substances.
• Use of unauthorized prescription medications or use of unauthorized doses are considered unsafe during lactation.
• Per recent recommendations from the Academy of Breastfeeding Medicine Protocol #21, if the lactating individual has stopped nonprescribed substance use by the delivery hospitalization, they can be supported in establishing lactation as most illicit substances are eliminated within hours to days.
• Families should be engaged in shared decision making about when it is safe to feed their breastmilk to their infant and when it is safe to initiate direct breastfeeding based on what substances were being used and the timing of last use.

A thorough review of these subjects can be found in ABM Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (SUD). For more detailed information and references on specific substances, please refer to LactMed, e-lactancia, Infant Risk, or Mother to Baby.

This section discusses moderate-to-heavy alcohol use and chronic alcohol abuse.

While there is no accumulation of alcohol in breastmilk, the short- and long-term risks of heavy alcohol use during lactation must be considered. Short term risks of heavy use include infant drowsiness and changes in usual eating and sleeping patterns. Long term risks include both possible neurodevelopmental risks for the infant and decreased milk production for the lactating parent.¹ Lactating individuals should be engaged in shared decision making if they are engaging in moderate-to-heavy alcohol use or chronic alcohol abuse as a disruption in lactation may be warranted. For more information on the use of alcohol during lactation, please see the section on Alcohol.

Tobacco use in a parent has risks to their infant including decreased appetite, poor sleep patterns, increased heart rate, increased risk of allergies and upper respiratory infections, and sudden unexpected infant death (SUID). However, breastfeeding in the setting of parental tobacco or nicotine use appears to decrease the risks of infant upper respiratory infections and SUID compared to not breastfeeding with a parent who uses tobacco or nicotine. Use of tobacco and nicotine also results in decreased milk production and decreased nutritional quality of breastmilk.¹

Although parental tobacco and nicotine use carries risks to the infant, there is no indication to disrupt lactation as it may protect against SUID compared to not breastfeeding with nicotine exposure.¹

While parents should be counseled on tobacco and nicotine cessation, there is no absolute indication to pump and dump. For more information on the use of tobacco and nicotine during lactation, please see the section on Tobacco.

Cannabis use by the lactating parent has possible risks of neurodevelopmental side effects in infants. Lactating parents should be counseled to discontinue cannabis use. If the lactating person continues to use cannabis, then they should be engaged in shared decision making regarding the potential risks to their infant.¹ For more information on the use of cannabis during lactation, please see the section on Cannabis.

This section reviews the use of nonprescription sedative-hypnotic use. Sedative-hypnotics include medications such as benzodiazepines, Z drugs (zolpidem/Ambien, zaleplon/Sonata, eszopiclone/Lunesta), gabapentin, and phenobarbital.

There is a lack of data on the impacts of non-prescribed doses of sedative-hypnotics on infant health. Infants are at increased risk of sedation, respiratory depression, withdrawal, and inadequate weight gain. The lactating parent may be more sedated and may have decreased responsiveness to the infant’s feeding cues.¹ Due to the lack of data on the impacts of non-prescribed sedative hypnotic use during lactation and the theoretical risk to infant health, infants should not breastfeed if a parent has ongoing non-prescribed sedative-hypnotic use.

For more information on the use of prescription sedative-hypnotics (including benzodiazepines), please see the sections on Sedatives & Sleep Aides, Antiseizure Medications, and PMAD Medications.

We currently do not have clear safety data of the short- or long-term impacts of illicit use of prescription opioids during lactation. Opioid use disorder (OUD) increases the risk of parental sedation, decreases their ability to respond to infant cues, and can increase the risk for injuries if bed-sharing. Non-prescribed doses of opioids have not been studied and they may pose an increase for both short-term side effects (sedation, withdrawal, and respiratory depression) and long-term side effects (infant neurodevelopment). Due to the lack of data on the impacts of non-prescribed opioid use during lactation and the theoretical risk to infant health, infants should not breastfeed if a parent has OUD with ongoing use of non-prescribed opioids.¹

For more information on the use of prescription opioids, please see the sections on Pain Medications and Anesthesia.

No data exists regarding the medical use of heroin in breastfeeding, however is known that infants can be exposed via breastmilk and develop withdrawal symptoms if the affected breastmilk is discontinued.^2,3 Use of heroin by lactating parents may be exposing the infant to a variety of other substances in addition to the heroin.  In lactating parents who are able to abstain from heroin and undergo medication assisted therapy for their substance abuse, breastfeeding should be recommended.¹  In the event that heroin abuse is ongoing, breastfeeding should not be recommended.

This section reviews the non-prescription use of stimulants.

Illicit use of prescription stimulants may put infants at higher risk of side effects, including gastrointestinal and cardiorespiratory symptoms, hypothermia, irritability, tremors, sleep disturbance, and seizures. Stimulants may decrease milk production and can accumulate in breastmilk. Due to the lack of data on the impacts of non-prescribed stimulant use during lactation and the theoretical risk to infant health, infants should not breastfeed if a parent has ongoing non-prescribed use of stimulant medications.¹

For more information regarding prescription stimulant medications, see the section on ADHD and Agents that Decrease Milk Production.

No data is available regarding medical use of cocaine in breastfeeding. Cocaine is noted to be transmitted through breastmilk due to binding of its metabolites to both albumin and lipids.⁴ Due to the transmissibility of cocaine through breastmilk, there is potential for cocaine intoxication in the infant with parental use.⁵ A few studies have noted transient neurological symptoms including seizures in children exposed passively to cocaine.^6,7 Due to the transmission of cocaine in breastmilk along with manifestation of symptoms with passive exposure, breastfeeding should not be recommended if there is known cocaine use and should be delayed until the drug has been eliminated from the system (approximately 24 hours).⁸

Amphetamines have been detected in breastmilk  24 hours after use.⁹ However, there is data showing that methamphetamines are undetectable in breastmilk on average 72 hours after last use.^9,10 Urine screening for methamphetamines may be a cost-effective strategy to assist with determination of whether there is likely to be substance transfer into breastmilk and it may be possible to resume breastfeeding 24 hours after a negative urine drug screen. ¹¹  Given case reports of infant deaths potentially linked to methamphetamine exposure via breastmilk and the lack of data on the use of methamphetamine during lactation, breastfeeding is not recommended with ongoing methamphetamine use. Parents should be engaged in shared decision making on breastfeeding with a history of methamphetamine use if last methamphetamine use was noted to be >72 hours ago and there has been a negative maternal urine drug screen.