When in Doubt,Breastfeeding Is the Default

I have recently written about the process of how the Academy of Breastfeeding Medicine develops and formulates its Clinical Protocols ¹ and the role that the journal Breastfeeding Medicine plays in providing a platform for the publication and the worldwide distribution of these protocols as a standard of care. Thus, it may surprise some that in this issue of Breastfeeding Medicine we are publishing a letter from Jansson et al. ² that vehemently takes issue with some of the clinical recommendations of the revised protocol entitled “Guidelines for Breastfeeding and Substance Use or Substance Use Disorder.” ³

It should be clear that that it is not the role of Breastfeeding Medicine as a peer-review journal, or of the Editor-in-Chief in his responsibility to maintain scientific standards, to respond to Dr. Jansson and colleagues; that is best left to the authors of the Protocol itself. ⁴ Likewise, it is not the task of the Editor to serve as an arbiter between the authors and their critics or to judge as to whose arguments carry the most weight; that is best left to the community of practicing physicians who are responsible for the care of the mother–infant dyad.

What I am struck by, though, is conceptual differences reflected in the two correspondences. On the one hand, Jansson et al. ² correctly raise the issue of possible long-term consequences to the infant if he or she is exposed to marijuana by ingesting breastmilk from a mother who is indulging in marijuana. Simply put, they state that when in doubt about the degree of risk, then don't breastfeed. Marinelli and Reece-Stremtan ⁴ are equally forceful in recommending to mothers who are breastfeeding not to smoke marijuana. However, given the real-world situation, wherein marijuana is ubiquitously available, socially acceptable for recreational purposes, and in an increased number of states no longer classified as an illicit illegal drug, they come down on the side advising to continue with breastfeeding, even if the mother continues with a degree of “pot smoking.” Simply put, they do not want an increasing population to lose the well-documented benefits to mother and child of prolonged breastfeeding.

One needs to remember that a similar difference of opinion existed for years when mothers were being prescribed psychotropic drugs, both the tricyclic antidepressants and selective serotonin reuptake inhibitors, for treatment of postpartum depression. For many clinicians, the long-term theoretical possibility that there would be a negative effect on neurodevelopment secondary to the infant's exposure to substances that impact on neurotransmitters at a critical stage of brain development was enough to conclude that breastfeeding was incompatible with maternal treatment with such drugs. As a result, in practice all too many mothers were advised to not initiate or continue breastfeeding. Those clinicians, initially a minority, who concluded that the risk–benefit equation was weighted in favor of breastfeeding recommended judicious use of these psychotropic drugs and not discontinuing feeding the infant with mother's own breastmilk.

Perusal in this month's issue of Breastfeeding Medicine of the Clinical Protocol entitled “Use of Antidepressants in Breastfeeding Mothers” ⁵ clearly reflects this conceptual approach. The authors recommend use of selective psychotropic drugs combined with nonpharmacologic therapy while advising the mother to continue to breastfeed, even though the long-term follow-up data of exposed infants are not as yet available. Of interest is that this approach is now universally acceptable and raises the question why a similar approach should be not be appropriate for mothers who are using marijuana as a recreational drug.

The complexity and importance of identifying mothers who are suffering from antenatal depression so as to continue postpartum without interfering with the initiation of breastfeeding are addressed by Yusuff et al. ⁶ and thus this article complements the new Protocol. ⁵