Drug Use by the Breastfeeding Mother: A Medical and Societal Challenge

The Academy Breastfeeding Medicine (ABM) protocols have been accepted worldwide as the standard guide both for clinicians in how to manage the maternal–infant breastfeeding dyad and for the public health system in how to create a breastfeeding support environment. The protocols are updated every 5 years, are evidenced based in their recommendations, and are appropriately balanced and cautious in situations where in real-world management decisions must be made in the absence of absolute scientific data. As such, the protocols have distributed by the National Guideline Clearing House of the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services (www.guideline.gov) under its mandate to provide a “public resource for evidence based clinical practice guidelines,” and the American Academy of Pediatrics refers to these ABM protocols for “detailed clinical guidance for management of specific issues” in lieu of duplicating their own protocols. ¹ These protocols are first published in Breastfeeding Medicine and are the flagship documents of Breastfeeding Medicine in its defined role as the platform for distributing the latest scientific information to the medical community worldwide. Following publication in Breastfeeding Medicine the protocols can be downloaded free of charge from either the Breastfeeding Medicine or ABM Web site.

Thus this month's protocol entitled “Guidelines for breastfeeding and substance use or substance use disorder, revised 2015,” authored by Reece-Stremtan and Marinelli, ² is most timely and welcome. The protocol addresses the issue of clinical management of mothers who have a history of past or current illegal/illicit drug abuse or legal substance use or misuse with two underlying guiding principles: (1) Drugs of any type should be avoided in pregnant and breastfeeding women, unless prescribed for specific medical conditions, and (2) in the situation of a mother who is already taking a drug for which there is no documented risk to the infant if one breastfeeds, then judicious counseling is appropriate, rather than “when in doubt don't breastfeed.” This balanced approach is particularly important given the widespread use of recreational marijuana, its increasing legalization, and thus its availability. Most important is that the authors address the difficulty of extrapolating from data that confirm that there is legitimate concern of risk to the fetus secondary to prenatal transplacental exposure to a presumed risk to the infant secondary to lower dose exposure from breastmilk.

The difficulty of developing uniform international recommendations for the use of medicine by breastfeeding mothers is addressed in this issue by Amir et al., ³ who surveyed a cohort of recognized experts in pharmacology, breastfeeding medicine, and pediatrics. The results of this Delphi survey confirmed the lack of uniformity of opinion of the experts and the inability to arrive at an agreed-on consensus. From the perspective of the Editor's chair, this survey confirms that the approach of the above-noted ABM protocol is what is needed for the clinician who has to balance theoretical concerns with the well-documented benefits of breastmilk.

Breastfeeding Medicine is truly a journal that reflects the contributions of physicians worldwide and as such provides a forum for the presentation and promulgation of scientific inquiry, basic biologic studies, and evidenced-based clinical studies to the worldwide medical community. Thus we welcome two contributions to the journal from our colleagues in China. Zhang et al. ⁴ studied a Chinese population and delineated the relationship of breastfeeding and the risk for hypertension and diabetes, information that clearly can be generalized to populations worldwide. Zhou et al. ⁵ presented an updated meta-analysis regarding the association of breastfeeding and breast cancer risk. Both these manuscripts confirm the truly international flavor of Breastfeeding Medicine.