INTERVENTIONS TO SUPPORT BREASTFEEDING IN WOMEN ON OPIOID MAINTENANCE THERAPY: A SYSTEMATIC REVIEW. Meg Doerzbacher RN, MS, NNP-BC

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1 INTERVENTIONS TO SUPPORT BREASTFEEDING IN WOMEN ON OPIOID MAINTENANCE THERAPY: A SYSTEMATIC REVIEW Meg Doerzbacher RN, MS, NNP-BC 1

2 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 2

3 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 3

4 Significance of Breastfeeding and NAS 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 4

5 Additional Benefits of Breastfeeding 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 5

6 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 6

7 Basics of Lactation and the Importance of Education Colostrum begins developing during the 2 nd trimester, triggered by pregnancy hormones Sudden drop in progesterone after delivery triggers production of larger volumes of milk It takes hours for this trigger to take place, and 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 7

8 Breastfeeding and Women on OMT How many? Mixed results When? Mostly in immediate postpartum period Why/Why not? Misinformation, barriers, lack of preparation 8

9 Question: How do we promote and support breastfeeding for women in treatment for opioid addiction? 9

10 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 Cochrane = 4 61 duplicates, PubMed = 33 or published CINAHL = 15 before 2008 Web of Science = 11 PsycInfo = 40 Embase = 118 Scopus = screened out by title/abstract 2 61 excluded after reading for study design, inclusion criteria 4 2 studies added after reviewing references from articles read in previous step Published since

11 Results of Systematic Review 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) 11

12 Author/Year Location/ Time Frame Intervention Outcomes Ordean & Kahan (2011) Toronto, ON, Canada 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 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 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 < Smirk, et al (2014) Parkville, Victoria, Australia Home-based weaning (NAS) with frequent contact v. inpatient infant weaning 45% of infants in home-based care breastfeeding at discharge v. 22% in inpatient care, p =

13 What does the research say? 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 13

14 Gaps in Knowledge Future Directions for Research 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 14

15 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 If they are in treatment Parenting skills They need But women have to be given the necessary education, tools, and guidance To breastfeed! Breast feeding is a skill that must be learned Lactation is a process that must be managed Anticipatory guidance is critical 15

16 Conclusions 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 16

17 QUESTIONS? 17

18 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 18

19 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), doi: /s (16)34659-x Retrospective, cohort study Vancouver, opioid-exposed newborns Interdisciplinary rooming in v. standard care Increased odds of receiving breastmilk during hospitalization, but not at discharge 19

20 Backes, C. H., Backes, C. R., Gardner, D., Nankervis, C. A., Giannone, P. J., & Cordero, L. (2012). Neonatal abstinence syndrome: transitioning methadonetreated infants from an inpatient to an outpatient setting. J Perinatol, 32(6), doi: /jp Retrospective review with comparison of groups Columbus, Ohio, 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 <

21 Ordean, A., & Kahan, M. (2011). Comprehensive treatment program for pregnant substance users in a family medicine clinic. Can Fam Physician, 57(11), e Retrospective review Toronto, Ontario, 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) 21

22 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), doi: /apa Retrospective review Parkville, Victoria, Australia, Newborns treated for NAS Inpatient v. Home-based weaning from treatment 45% v. 22% breastfeeding at discharge, p =

23 Author/Year Design/Setting Sample Location/Time Frame Intervention Outcomes Limitations Ordean & Retrospective 121 women in Toronto, ON, Canada One-stop model of care for Longer duration in program No control for confounding Kahan review treatment pregnancy and substance use associated with higher rate of variables (2011) program disorder, based on harm-reduction breastfeeding at discharge and women-centered philosophy Abrahams, et Retrospective 952 opioid- Vancouver, BC, Rooming-in on MBU (including Rooming-in increased odds of Historical data extracted from al (2010) cohort study exposed newborns Canada multidisciplinary care) v. standard care in NICU/SCU receiving breastmilk during hospitalization, but not at database, no control for confounding variables discharge Backes, et al Retrospective 121 newborns Columbus, OH, USA Intervention group transitioned Increased breastfeeding at Significant risk of bias (mother- (2012) review treated for NAS from inpatient NAS treatment to discharge in combined program, infant dyads met specific home-based weaning program v. 24% v. 8%, p < criteria for referral to treatment Usual model of care group) Smirk, et al Retrospective 118 newborns Parkville, Victoria, Home-based weaning (NAS) with 45% of infants in home-based Significant risk of bias (infants (2014) review treated for NAS Australia frequent contact v. inpatient infant care breastfeeding at discharge v. met specific criteria for referral weaning 22% in in-patient care, p = to treatment group) 23

24 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), doi: /jbisrir Tsai, L. C., & Doan, T. J. (2016). Breastfeeding among mothers on opioid maintenance treatment: A literature review. Journal of Human Lactation, 32(3), doi: / 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: /j.jneb 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: /j.jneb

25 References 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), doi: /s (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: /01.aog c American College of Obstetricians and Gynecologists. (2017). Committee Opinion No. 711 Summary: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol, 130(2), doi: /aog 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), doi: /jp 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), doi: /s (16)

26 References Demirci, J. R., Bogen, D. L., & Klionsky, Y. (2015). Breastfeeding and methadone therapy: The maternal experience. Substance Abuse, 36(2), doi: / 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: /j.jneb Eidelman, A., & Schanler, R. (2012). Breastfeeding and the Use of Human Milk. Pediatrics, 129(3), e827-e841. doi: /peds Kocherlakota, P. (2014). Neonatal abstinence syndrome. Pediatrics, 134(2), e doi: /peds 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: /j.jneb 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). 26

27 References 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), doi: /jbisrir National Perinatal Association. (2017). Perinatal Substance Use. Retrieved from 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), doi: /jmwh Ordean, A., & Kahan, M. (2011). Comprehensive treatment program for pregnant substance users in a family medicine clinic. Can Fam Physician, 57(11), e 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), doi: /apa Tsai, L. C., & Doan, T. J. (2016). Breastfeeding among Mothers on Opioid Maintenance Treatment: A Literature Review. Journal of Human Lactation, 32(3), doi: /