Methadone Maintenance, HCV, and Breastfeeding

Meyer_de_Haan_detailSeveral times a year, Breastfeeding and Lactation of Jacksonville donates our expertise and our time to River Region Human Services in downtown Jacksonville through their Building Blocks program and we answer questions and teach breastfeeding classes to women who are choosing to breastfeed their babies while in a methadone maintenance treatment program.

In addition to the regular information about breastfeeding: latching techniques, infant feeding cues, etc., there are more specific considerations and information that women who are in a methadone maintenance program need to know. Because some of the women in maintenance programs are positive for Hepatitis C Virus, we also spend time discussing breastfeeding while being HCV-positive.

Why should we support women in their desires to breastfeed who are in methadone maintenance programs or are Hepatitis C positive?

It is important and meaningful for all mothers in general to be supported in breastfeeding and mothers who are beginning a new life may have additional needs to do things “right” with their baby. Breastfeeding promotes bonding as well as nutrition. The release of oxytocin during breastfeeding, the “love hormone”, is a natural aid for mothers to feel less stressed, more relaxed, and more protective of their baby. The baby who is breastfed gets all of the benefits of breastmilk without the risks associated with formula: greater risk of ear infections, greater risk of respiratory infections including pneumonia, greater risk of type 1 and type 2 diabetes, and greater risks of SIDS. Premature babies additionally have a greater risk of necrotizing enterocolitis (NEC), a life-threatening intestinal disease, if they are denied breastmilk. The American Academy of Pediatrics (AAP) encourages mothers who are in supervised methadone maintenance treatment programs and/or who are HCV-positive to breastfeed. In fact, babies born to mothers who are in methadone maintenance are especially needy of breastmilk, as discussed below.

Methadone Maintenance

How is breastfeeding compatible with methadone maintenance?

Pregnancy is often the wake-up call for women who have addictions to seek help while other mothers become pregnant while already in treatment–the time span needed on methadone maintenance can vary greatly. Mothers who are receiving methadone maintenance treatment during pregnancy will give birth to babies who are born with a dependency because of the exposure they received in-utero. When the baby is born, he will have the same concentration of methadone in his body that the mother does and will need to go through withdrawal treatment after birth. It is well observed that babies who are breastfed by their mothers during this treatment fare much better than babies who are formula fed. It is unknown whether it is the breastmilk by itself that is helping the baby or a combination of the fact that as a mother continues treatment, some of the methadone she receives as part of her maintenance will pass in low concentrations into her breastmilk, helping with withdrawal; estimates range from 1% to 5% of the weight-adjusted dose that the mother is taking enters breastmilk. Whether it is the breastmilk itself or the breastmilk working with the very small amounts of methadone that enters breastmilk, the low amounts of methadone present in milk is not enough to prevent neonatal abstinence syndrome. Babies born to mothers undergoing methadone treatment may have fewer withdrawal symptoms themselves, shorter hospital stays, shorter duration of abstinence therapy, and a shorter duration of treatment if they are breastfed.  Breastmilk, therefore, is key. In the past, the AAP only recommended breastfeeding when mothers were recieving doses of less than 20mg/d, but in September 2001 the AAP changed their policy and considers breastfeeding to be beneficial no matter what the treatment dose the mother is on. More than a decade later, they have had no reason to change this policy.

Hepatitis C Virus (HCV)

If a mother is HCV-positive, how does this affect breastfeeding?

There are currently no confirmed reports of any baby contracting HCV through breastfeeding, though a small number of infants (3-5% if mother is also HIV-negative) become infected through pregnancy and birth. Because hepatitis C is contracted through the blood and is not present in human milk in infectious amounts, the Center for Disease Control (CDC) and the American Academy of Pediatrics (AAP) state that mothers may breastfeed and/or express milk to feed their baby if they are HCV-positive or have the hepatitis C antibody. However, since it is unknown if bleeding, damaged nipples can spread hepatitis C to the baby, mothers who are experiencing this difficulty and are HCV-positive should express and discard their milk during this time from the breast that has an open wound and feed their baby from the unaffected breast. If both breasts are affected, she should feed the baby previously expressed milk or formula so that the baby does not come into direct contact with her blood. When a mother’s nipple damage has healed, she may once again feed her baby at that breast.

It is important to note that damaged nipples can usually be avoided with proper attention to latch. It is especially crucial, therefore, for women who are HCV-positive to not accept painful nipples as a normal part of breastfeeding, as this pain could be evidence of a bad latch or other problems that may eventually cause cracks and bleeding in the nipple if not corrected. If breastfeeding hurts, she should have timely access to an IBCLC who can assess the situation and give her the assistance she needs to nurse her baby successfully.

Some mothers may be taking medicines to treat hepatitis C, as antiviral medications are typically taken for either 6 months or a year, depending on the genotype of the particular virus. Interferons plus ribavirin is a common choice. Interferons are large molecules which “are probably exceedingly low” in breastmilk. Ribavirin also does not transfer to milk well and is mostly destroyed in the stomach. It does tend to accumulate in the body and if there is long term exposure, it is theoretically possible that it could contribute to anemia. Newer medications are also in use and are becoming preferred due to fewer side effects, such as Harvoni (a combination of ledipasvir and sofosbuvir). Although it is too early for human data, animal research showed no ill effects on the unborn or nursing animal studies at 5-fold  the dose (and higher, with some components) that a person would take of Harvoni. Nursing mothers should be working with a breastfeeding-supportive physician to determine what the best course of treatment is for their particular situation.

It is imperative for a woman who wishes to breastfeed to be surrounded by support and knowledge. Despite the American Academy of Pediatrics clearing women who are in methadone maintenance treatment programs at any dose to be able to nurse their babies, some pediatricians remain uncomfortable with it. Some of the mothers who have attended our classes describe highly supportive physicians while others recount being told that breastfeeding during treatment would be tantamount to “child abuse.” If her pediatrician is unfamiliar with the AAP recommendations and does not wish to be educated or chooses not to believe the research that the AAP bases its recommendations on, it is usually in their interest to seek out another pediatric practice. In addition to support from her health care providers, breastfeeding mothers benefit greatly by immersing themselves in a supportive community. We encourage attendance at La Leche League Meetings and other community breastfeeding groups, such as hospital support groups and the peer-counselor support groups found through WIC.

Thomas W. Hale, PhD. and Hilary E. Rowe. Medications and Mother’s Milk 2014. Plano, TX: Hale Publishing, L.P. 2014. Print.

~Chrissy Bodin, IBCLC

Which Jacksonville Area Hospitals Support Breastfeeding?

Breastfeeding initiation in the hospital

You have read the breastfeeding books, taken a breastfeeding class, and maybe even attended breastfeeding support groups while you are pregnant. Education is important when it comes to breastfeeding your baby, but what is even more important is SUPPORT; support from your partner, support from your family, support from your community, and support from your health care providers.

It is in the earliest days when the breastfeeding relationship is the most vulnerable that this support is the most critical. Many breastfeeding experiences end before they really begin, before the baby has even been discharged from the hospital. The advice and suggestions of your hospital nurse or the availability of the hospital’s IBCLC will strongly influence whether or not a baby leaves the hospital exclusively breastfed.

The collected statistics displayed for the Greater Jacksonville Area do not include babies in the NICU or who had medical recommendations not to breastfeed (mother with AIDS, active herpes simplex virus with breast lesions, mother undergoing treatments such as cancer chemotherapy, etc.) The statistics only reflect babies who were given formula for elective, non-medical reasons. Babies did not need to drink breastmilk at the breast to be included in the exclusively breastmilk-fed percentages; mothers who were expressing their milk to feed to their babies by another method, such as bottle or syringe, were still exclusively breastmilk feeding.

The first percentage, “Exclusive breastmilk feeding,” reflects the number of babies in the hospital that year who were exclusively fed breastmilk during their stay with no elective feedings of any other kind (formula, sugar water, etc), regardless of a mother’s stated intention to exclusively breastfeed or not—she may have entered the hospital already knowing she wanted to either formula feed or combine feedings of formula and breastmilk. The second percentage reflects the number of babies with parents who filled out forms stating that their goal was to exclusively feed their babies breastmilk who were also then able to meet that goal during their entire hospital stay.

 Breastfeeding Statistics for Jacksonville Area Hospitals

Hospital Breastfeeding Rates in the Jacksonville, Florida Area , July 2013-June 2014

It obviously matters a great deal where you give birth as to how enabled you are to meet your breastfeeding goals. The amount of nurse breastfeeding education and support, the availability and amount of time the hospital’s lactation consultant can spend with the mothers and babies, and hospital policies greatly affect outcomes. St. Vincent’s Southside, recently recognized as one of the few “Baby Friendly” hospitals in Florida, is a clear standout for encouraging and supporting breastfeeding. Conversely, Shands looks like the most difficult hospital to successfully breastfeed or breastmilk feed in, with only one out of five healthy babies exclusively breastfed and only one out of every three healthy babies with mothers who came in with the stated goal to exclusively feed breastmilk leaving doing so.

This data was collected from July 2013 to June 2014. When you look at the Jacksonville Area statistics, keep in mind that the nationwide average during that time period is that 50% total exclusive breastmilk feeding and 64% exclusive breastmilk feeding considering mother’s choice. The Florida statewide average is 38% total exclusive breastmilk feeding and 51% exclusive breastmilk feeding considering mother’s choice. The source of the statistics is The Joint Commission’s  healthcare quality data, based on numbers submitted by the hospitals themselves.


St. Vincent’s Southside (Jacksonville, FL):

Exclusive breastmilk feeding: 81% (113 babies)

Exclusive breastmilk feeding considering mother’s choice: 87% (106 babies)


Flagler Hospital (St. Augustine, FL):

Exclusive breastmilk feeding: 67% (126 babies)

Exclusive breastmilk feeding considering mother’s choice: 87% (98 babies)


Naval Hospital Jacksonville (Jacksonville, FL):

Exclusive breastmilk feeding: 71% (202 babies)

Exclusive breastmilk feeding considering mother’s choice: 77% (188 babies)


St. Vincent’s Medical Center (Jacksonville, FL):

Exclusive breastmilk feeding: 57% (167 babies)

Exclusive breastmilk feeding considering mother’s choice: 77% (123 babies)


Orange Park Medical Center (Orange Park, FL):

Exclusive breastmilk feeding: 51% (162 babies)

Exclusive breastmilk feeding considering mother’s choice: 72% (114 babies)


Baptist Medical Center/Wolfson’s Children’s Hospital (Jacksonville, FL):

Exclusive breastmilk feeding: 56% (262 babies)

Exclusive breastmilk feeding considering mother’s choice: 60% (248 babies)


Baptist Medical Center of Nassau (Fernandina Beach, FL):

Exclusive breastmilk feeding: 50% (224 babies)

Exclusive breastmilk feeding considering mother’s choice: 58% (196 babies)


Baptist Medical Center Beaches (Jacksonville Beach, FL):

Exclusive breastmilk feeding: 51% (152 babies)

Exclusive breastmilk feeding considering mother’s choice: 57% (138 babies)


Memorial Healthcare (Jacksonville, FL):

Exclusive breastmilk feeding: 29% (126 babies)

Exclusive breastmilk feeding considering mother’s choice: 51% (72 babies)


Shands Jacksonville Medical Center (Jacksonville, FL):

Exclusive breastmilk feeding: 21% (185 babies)

Exclusive breastmilk feeding considering mother’s choice: 32% (125 babies)


When you are choosing a hospital to give birth in, along with the other things you are looking at, such as location, healthcare provider compatibility, and c-section rates, please remember to keep breastfeeding statistics in mind, as well! It can make a difference!

~Chrissy Bodin, IBCLC










Breastpump Recycling Program

By Jacoplane (well, his parents anyway) (Own work) [GFDL or CC-BY-SA-3.0], via Wikimedia Commons

I am sometimes asked to use my breastpump gauge to test the quality of a mother’s old pump that has been used with other children. It is not uncommon for these pumps to have reduced suction ability, as the motor loses strength with time. What can be done with these old pumps? I just learned about a recycling program for old breastpumps that ultimately will enable NICU mothers staying at the Ronald McDonald House to have access to high quality, hospital-grade breastpumps.

When a breastfeeding child is hospitalized, breastmilk becomes more than food and comfort–it is medicine. It is even more important for the child to receive his mother’s milk and often more difficult for her to provide it. Unless the mother is allowed to stay in the hospital and the baby is able to breastfeed, pumping becomes a fact of life and a hospital grade pump becomes a necessity. If the mother is not allowed to stay in the hospital with her baby, she encounters even more difficulties: it is not always easy to obtain a hospital grade pump to take home, depending on circumstances, and it is difficult to find time to pump when the mother must spend a sizable amount of time commuting to and from the hospital. It is common for mothers who have babies in the NICU to have difficulty keeping up their milk supply.

The Ronald McDonald House is a place where families who have hospitalized babies and children can stay nearby either for free or a small donation while their child is treated, easing the financial burden for them at a time when their emotional burden is already high. 40% of families staying at the Ronald McDonald House are there because they have babies in the NICU. Being able to stay nearby the hospital also provides the additional benefits of spending less time commuting and more time in kangaroo care, providing breastmilk by pumping, and if possible, breastfeeding.

One breastpump company has committed to donating hospital grade pumps to Ronald McDonald House for the breastfeeding mothers staying there, funded by their pump recycling program. Having a multi-user, hospital grade pump available to breastfeeding mothers of babies in the NICU would be a huge boon to them!! If you have a Medela pump that you no longer want, consider donating it to this breastpump recycling program.

~Chrissy Bodin, IBCLC

Mexico’s Controversial, New Breastfeeding Ad Campaign

The image on the left says that breastfeeding your baby protects from diseases such as diabetes, obesity, and heart attacks, the image on the right says that breast milk is the natural vaccine that strengthens the defenses of your baby, and the banner across both says, “Do not turn your back, give him your breast.”

Images used in Mexico's new breastfeeding campaign.

Images used in Mexico’s new breastfeeding campaign.

The National Ad Council here in the US took a similar approach just a few years ago (with “regular” looking women rather than models) and was similarly controversial. One of its taglines was, “You wouldn’t take risks before your baby’s born. Why start now?” and it played video clips of pregnant women riding mechanical bulls and competing in log rolling contests (showing how absurd such risky activities would be when pregnant) , followed by information about the protective properties of breastmilk, leading to the transference of the idea that formula feeding is risky, too. Actually, the *original* ads that the Ad Council created to be played were never run–they used risk terminology, such as “Babies who are not breastfed are more likely to get ear infections…” rather than “Babies who are breastfed are less likely to get ear infections” but they were deemed too guilt-inducing, so the voice-overs in the ads that were played on TV (linked below) talk about reducing risks by breastfeeding, rather than creating risks by formula feeding.

Ironically, a bit of guilt is what the ad creators were going for. Research done prior to the creation of the ads showed that mothers who chose not to breastfeed without ever trying (not mothers who attempted to breastfeed but ran into problems and eventually quit) already knew about the “benefits” of breastfeeding but chose to formula feed from the start because they didn’t see formula as having risks, just breastfeeding as having that “extra” something that wasn’t worth the effort…just like we have heard that organic apples contain more nutrition than “conventionally” grown apples…but non-organic apples are seen as quite healthy. The ads attempt to show that comparing breastmilk to formula is like comparing apples to oranges, because formula carries risks. The studies done in preparation for the creation of the ads showed that when most mothers who were originally interested in formula feeding were informed that there were risks involved in doing so, they wanted to breastfeed. The “risk” approach seemed to be more effective than the “benefit” approach.

Whenever we talk about risks, we are looking at the big G word; Guilt. Mothers faced with accurate information about the facts of breastfeeding choose to offer their baby breastmilk because they would feel guilty to give them something that would cause problems. However, most of us flinch at the thought of telling a currently formula feeding mom that her baby has a higher risk of upper respiratory infections, ear infections, GI diseases, cancers, higher adult blood pressure, etc, because we don’t want her to feel bad about things she can’t change…and it is impossible to inform pregnant and future mothers about the importance of breastfeeding out of the earshot of mothers who have already formula fed their babies; it is easier to tell mothers that breastfeeding offers benefits because benefits don’t induce guilt.

I don’t want moms feeling guilt. No mom should feel guilty for feeding her baby formula or donor milk when her baby cannot get milk properly from her breasts and no mom should feel guilty about decisions made without full understanding about the differences between breastmilk and formula. As the late Maya Anjelou said, “I did then what I knew how to do. Now that I know better, I do better.” When a mother understands the difference between formula and breastmilk and still chooses to formula feed from birth, I trust that she knows more than I do about her family situation. When a mother chooses what she believes is best based on the information she has, she should also feel no guilt. We should all have the freedom to weigh our options and choose what is best…but we do need all of the facts before we can make an educated decision.

Another point of contention with the new campaign other than the “guilt” slogan “Don’t turn your back,” is the absence of a nursing baby and the use of sexy models rather than “regular” mothers. I am not sure why they chose to have a sexy campaign. In the United States, we are constantly working against the concept that breasts, being sexual objects, are therefore awkward to use to nurture and feed a baby, especially in public, so I would have rather seen a nursing baby in those photos. I wonder if the ad creators thought models would call more attention to the message than a nursing mother…but I don’t know what their research or what their thought process was as they made the decisions that they did.

Breastfeeding promotion is tricky! We don’t want to create “Mommy wars” but we also don’t want to undermine breastfeeding or stick our head in the sand. What do you think of Mexico’s new, controversial breastfeeding campaign? Are they on the right track or did they go over the edge with the words, “Don’t turn your back”?

Creating a breastfeeding culture, one restaurant at a time

photo of a breastfeeding mother in a Florida restroom

photo of a breastfeeding mother in a Florida restroom

A new campaign in NYC is rating restaurants according to how hospitable they are to breastfeeding mothers. This effort, called “Latch,” also offers decals to restaurants to show they support nursing mothers. It was the brainchild of four NYU graduate students and recently won first place (and $10,000) in the National Invitational Public Policy Challenge. Like Florida, New York law upholds a child’s right to nurse anywhere they are allowed to be, but some mothers still encounter opposition and ignorance when they are feeding their child. “Latch” is an effort to help create a cultural change, one restaurant at a time, by raising awareness, rewarding businesses who are friendly to nursing mothers, and empowering the hesitant public breastfeeding mom by giving her a place to go where she knows she will be supported by the establishment.

I was in a restaurant in the Orlando area when I took the photo above of a flyer promoting a 2013 exhibit, “Nursing is Natural…Naturally Beautiful,” by Christine Santos, who hoped to use her photography to destigmatize breastfeeding. The flyer’s location struck me as a bit ironic due to its placement in the woman’s restroom. Of course, in this instance, the restaurant’s restroom happened to be where they always kept their flyers, but it was poignant to me to enter and see a woman nursing by the toilet, even if it was just an image; it happens in real life too often.

When breastfeeding is hidden, either because society makes the mothers uncomfortable or because mothers are actively asked to nurse elsewhere or cover with a blanket, babies are often nursed for a shorter duration. It is difficult for the mother to constantly be separated from the company she is with or to have to drag her other children into the toilet or other location with her as she feeds her youngest. As babies grow older and the days grow warmer, many babies object to eating with their head under a blanket or nursing cover. Although some  mothers have an inner circle of support that enables them to feel comfortable nursing in public and other mothers without that comfort bravely push through some social separation (or the difficulty of pumping, storing their milk, and dealing with the possible consequences of supply irregularity and plugged ducts so that they can offer public bottles) for the sake of their babies, others are less willing. Breastfeeding will become more common and babies will be nursed for a longer duration overall when women are surrounded by the type of breastfeeding culture that sees a nursing baby in a restaurant as one more person having lunch.

I am thankful for all of the campaigns that normalize breastfeeding. I am thankful for the mothers who nurse in public according to their children’s needs, because it not only nurtures and feeds their own children, it fosters an environment where other women feel that it would be normal for them to do the same with their babies. I am thankful for the community who make each breastfeeding mother that they encounter feel integrated with everyday life. One day, perhaps, programs like “Latch” will no longer be necessary due to the normalcy of breastfeeding being so widespread that a baby’s need to nurse goes unquestioned. The next time you are in a restaurant and notice a baby nursing, remember that your reaction is part of creating a breastfeeding culture. Bon appetit!

~Chrissy Bodin, IBCLC