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Caffeine, Alcohol, Marijuana, and Beyond: Substance Use & Breastfeeding

Updated: Feb 1

Baby gazing up at a couple laying in bed with a coffee mug in hand

Welcome to parenthood…where every day we make different decisions surrounding the well-being of our children and family. Some of these decisions have clear right and wrong answers, be they ethical, emotional, or safety-related, but some of these decisions live in a gray area. People may feel they are navigating a gray area when trying to make decisions about the use of substances or medications while breastfeeding. It is inherently a gray area due to the lack of studies and research available when it comes to substance use and breastfeeding. They may also be hearing different rules of thumb from family, friends, or the online boards on what is or isn’t okay. Families may come to different decisions, but it is important to be aware of the risks regarding substances used when breastfeeding.


This article walks through a few common questions when it comes to breastfeeding and “use”. While this list is not comprehensive, it does cover the safety basics, and references the literature (or lack thereof). The two most referenced resources in this post are Hale's Medications & Mothers' Milk, a sort of encyclopedia or textbook (I use it in app form) of medications and their impact with breastfeeding, and the Academy of Breastfeeding Medicine’s protocol #21, which helps guide substance use and compiles research on substance use safety when breastfeeding. The 6th edition of Breastfeeding and Human Lactation by Karen Wambach and Becky Spencer was also used.


Can I consume caffeine when breastfeeding?


Overall, the recommendation for caffeine use during breastfeeding is about the same as during pregnancy. Continue to limit intake, watch for effects in you and baby (mainly sleep disturbances), and keep your intake under 300mg. Hale’s Meds categorizes caffeine as L2 - Probably Compatible, which means caffeine has been studied in a limited number of breastfeeding women without an increase in adverse effects to their babies. 


Caffeine’s long half life in neonates and their poor ability to metabolize caffeine decreases with increased infant age. The older the baby gets the better their body processes caffeine. Caffeine levels peak at 60-120 minutes after ingestion. In mothers who consumed caffeine during pregnancy, there does not seem to be the same correlation between infant sleep disturbances and maternal caffeine intake under 300mg. Seemingly, the babies are adjusted due to the exposure. (Hale’s Medications and Mothers’ Milk)


Can I drink alcohol when breastfeeding? 


In January 2023, the World Health Organization released a statement that no level of alcohol consumption is safe for our health. That being said, many women report some form of alcohol consumption during their breastfeeding journey. 


Alcohol interferes with the milk ejection reflex (your let down), which can ultimately reduce milk production through inadequate breast emptying. Milk alcohol levels are consistent with maternal blood alcohol levels. Alcohol does not store in the breastmilk. Once it is out of the bloodstream, it is out of the breastmilk. The textbooks and resources consulted for this post recommend limiting alcohol intake while breastfeeding to 2 drinks (1 drink is measured as 5 ounces of wine, 12 ounces of beer, or 1.5 ounces of liquor), and then waiting for 2 hours after consuming to breastfeed again. Keep in mind that pours can contain more than 1 unit or drink and that many craft beers have higher than average alcohol content. If there is an occasion during which you are consuming alcohol at larger amounts or over a prolonged period of time, you may choose to “pump and dump”. This means using your breast pump to empty the breast and then throwing the milk away as it may not be safe or suitable for the infant. While this is a personal decision, it can be helpful to protect a supply. It will not, however, “sober” your milk. Your milk will continue to mimic or parallel maternal blood alcohol levels. 


Is it safe to use marijuana when breastfeeding?


There are no uniform guidelines on the varied use of marijuana in breastfeeding, and no set recommendations can cover all situations. This lack of data leads to the recommendation for abstaining or discontinuing use, since the scientific evidence on safety is lacking, and there are concerns about development, neurofunction, and SIDS in the infant. 


THC is present in milk at up to 8 times maternal plasma levels (blood levels) and can be stored in fat tissues for weeks to months. Your breast milk is highly lipid soluble, so lots of fat! Marijuana exposure during critical periods of brain development can result in long-lasting neurofunctional alterations. Second hand smoke exposure (yes, with marijuana too!) can increase an infant’s risk for SIDS. Overall, breastfeeding mothers should eliminate their use of marijuana to avoid exposing their infants and should know that use could cause long-term neurobehavioral effects. 


Can I smoke tobacco while breastfeeding?


Smoking while breastfeeding is not recommended; however, breastfeeding in a smoking mother should be supported along with vigorous support for smoking cessation. Patches or gum, etc are encouraged as smoking cessation modalities under the guidance of a healthcare provider.


The fat content of breastmilk in smoking mothers is lower than that of nonsmokers and contains nicotine. This is also observed in secondhand smoke exposed mothers (if someone else is smoking in the home). Maternal cigarette smoking is associated with respiratory illnesses, tremors, and muscular rigidity. It also puts mom at greater risk for breast abscess. E-cigarettes or vaping are not well studied, but the chemicals and nicotine in those products still pose the same concerns. 


Can I use my prescription medication while breastfeeding?


There are many prescription medications that can be safely used in the breastfeeding mother. If you know you will need medication to continue to manage a chronic condition after birth, discuss with your doctor and baby’s pediatrician about breastfeeding safety. Many situational medications, such as antibiotics, antivirals, and topicals, are also safe for use while breastfeeding. It is important no matter what medication you need to take to have an open conversation with your provider and baby’s provider. They can help you find the best medication option, at the lowest dose, for the shortest time, in order to keep you healthy and baby safe, while allowing you to meet your breastfeeding goals. 


Breastfeeding should be a protected act between mother and baby, but all the decisions that come with being a modern breastfeeding family can be overwhelming. Hopefully, this post provides some guardrails for that decision making. I want you to be empowered to make informed decisions with evidence-based information while protecting your breastfeeding relationship. This information provided should never replace recommendations from your OB, PCP, IBCLC, or baby’s PCP.  It is also important to keep in mind that you are in charge of caring for and providing for your little one, so make sure substances of any kind do not impair that. Let’s keep mom, baby, and breastfeeding safe! 

 

**A note about any substance use. If you have further questions or concerns you should always ask a healthcare professional – your IBCLC, your OB-GYN, your PCP, baby’s primary care provider, etc. If you harbor concerns, it is always better to be honest and seek out help than to try to navigate or struggle with substance abuse on your own. There are resources available, so if you feel that you may have a substance abuse problem, reach out!


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