Can you breastfeed your baby while taking Suboxone?
In most cases, yes. If you are stable on your medication, you are not using other opioids, and your doctors know what you take, you may breastfeed while taking Suboxone. In medicine, we now encourage it.
Suboxone is a film that dissolves under the tongue. It contains buprenorphine, a partial opioid that holds off withdrawal and cravings, and naloxone, an opioid blocker that is included to discourage injecting. Here, Suboxone also stands for the other buprenorphine films and tablets, such as ZubSolv, the generics, and the buprenorphine-only tablet that was once sold as Subutex.
Still, a flat yes rarely settles a new mother’s mind about Suboxone and breastfeeding. Will the medication get into your milk? Will it make your baby too sleepy, or cause withdrawal? Would formula be the safer choice?
These are fair questions. So, how much buprenorphine actually reaches a breastfed baby, and what should you watch for?
Is breastfeeding on Suboxone safe for the baby? How much gets into breast milk?
Very little gets into the milk, according to the Suboxone prescribing information, which is the official labeling approved by the Food and Drug Administration (FDA). It reports that buprenorphine and its breakdown product, norbuprenorphine, were found at low levels in human milk. The breastfed babies in those studies were exposed to less than 1% of the mother’s daily dose.
Why does your film go under your tongue? Buprenorphine is poorly absorbed when it is swallowed, and a baby swallows milk. So, even less of that small amount is likely to reach your baby’s bloodstream.
The same document states that the available data have not shown harm to breastfed infants. The combination of buprenorphine with naloxone has not been studied in breastfeeding, yet very little naloxone is absorbed by mouth.
While that is reassuring, it is not a guarantee. Those numbers come from 13 nursing mothers, and how breastfed babies do over the long term has not been well studied. That is why you are asked to watch your baby.
The leaflet in the box says that Suboxone can harm my baby. Which is it?
If you have read the Medication Guide, the leaflet that the pharmacy hands you with your prescription, you have seen the sentence. It says that Suboxone can pass into your breast milk and harm your baby.
Both statements come from the same FDA-approved labeling. The pages written for doctors report low levels in milk and no harm shown in the babies who were studied, while the page written for you leads with the worst case.
Think of the warning sticker on a stepladder. It tells you that you could fall and be seriously hurt, which is true, and it says so to every person who will ever buy that ladder. It does not tell you to stop changing light bulbs.
While a medication leaflet is not a ladder sticker, it does the same job. The next two lines of the leaflet are the ones to act on. Talk to your doctor about the best way to feed your baby, and watch your baby for increased drowsiness and breathing problems.
What should I watch for while I am breastfeeding?
There are two signs to watch for, increased drowsiness and difficulty breathing. Every newborn sleeps for most of the day, so the word that matters is increased. Call the pediatrician right away if your baby is sleepier than usual, is hard to wake for a feeding, or is too sleepy to finish one.
Call 911 if your baby cannot be woken, is limp, is working hard to breathe or has long pauses between breaths, or looks blue or gray around the lips. If you are not sure which kind of night you are having, make the call, because nobody in an emergency room will fault a new mother for asking.
What about a fussy evening? Sedation looks like the opposite of fussy, and crying, wanting to be held, and feeding every hour are ordinary newborn behavior. Still, keep the early weight checks, because a baby who is too sleepy to feed well does not gain as expected.
There is also a larger danger in the house than your milk. The Suboxone label warns that buprenorphine can cause severe, possibly fatal, breathing problems in a child who gets hold of it by accident. So, the trace in your milk is not what puts a child in the hospital. It is the film that was left on a nightstand.
Keep your medication out of sight and out of reach, and call 911 right away if a child may have put a film or tablet in the mouth. And, when the time comes to wean, do it gradually, because a breastfed baby may have withdrawal symptoms when the milk stops all at once.
Will my baby be born addicted to Suboxone?
No, a baby cannot be born addicted to anything. Many mothers ask this before they ask about milk, and they often ask it quietly.
Addiction is a pattern of behavior, which means craving a drug and using it compulsively in spite of the harm, and a newborn does none of that. What a newborn can have is physical dependence, and physical dependence is not addiction.
Dependence means that the body has adjusted to a medication that was there every day, and that it reacts when the supply stops. For your baby, the supply stops at birth. The reaction is called neonatal opioid withdrawal syndrome (NOWS), and you may also hear the older name, neonatal abstinence syndrome (NAS).
The Suboxone label calls NOWS an expected and treatable outcome of taking opioids through a pregnancy, whether they were prescribed or not. It also warns that NOWS can be life-threatening if it is not recognized and treated. So, the concern is not small, and nobody should tell you that it is.
The signs are irritability, a high-pitched cry, tremor, trouble sleeping, vomiting, diarrhea, and poor weight gain. They usually appear in the first days after birth, and how severe they are, and how long they last, will vary. The hospital may keep your baby a few days longer than usual to watch for them, and while some babies need only comfort and time, others need medicine as well.
How does Suboxone compare with methadone? In the trial described in the Suboxone prescribing information, there was no difference between the two medications in how many babies needed treatment for NOWS, or in how severe it was at its worst. Yet, the buprenorphine babies needed less medicine, were treated for fewer days, and left the hospital about a week earlier. More of the mothers taking buprenorphine left that trial before delivery, and the label itself says that this makes the findings difficult to interpret.
A mother who is stable on methadone is generally encouraged to breastfeed as well. While buprenorphine may be the easier medication to breastfeed on, that alone is no reason to change, because a switch between the two can bring on withdrawal. It is a decision for her and her own doctor.
Does breastfeeding make NOWS worse? There is no sign that it does, and it may ease the symptoms somewhat, although the small amount in your milk will not prevent them. The article on Suboxone and pregnancy covers NOWS, the delivery, and the fear of a report to child protective services.
Do I have to switch to Subutex in order to breastfeed?
No. Subutex was the brand name of a tablet that contains buprenorphine without naloxone, and while the brand is no longer sold, the generic tablet still is.
Dr. Leeds recommends the buprenorphine-only tablet during pregnancy, in order to keep naloxone away from the baby. Many women are still taking it when the baby arrives. If that is you, nothing needs to change, because the breastfeeding studies in the label were done with buprenorphine itself.
And, if you take the combination film or tablet, breastfeeding alone is not a reason to switch, because very little naloxone is absorbed by mouth. Any change from one to the other is a decision to make with your doctor, and it should never leave you without medication for a day.
Why did doctors once tell mothers in treatment to use formula?
Past generations saw breastfeeding as old-fashioned. In the 1960s, manufactured formula looked like progress, and it was not unusual for a mother to choose the bottle without a second thought. Formula came in a can with a scientific-looking label. Breast milk had no marketing department.
During that same decade, methadone maintenance arrived as a medical treatment for heroin addiction, and a mother could finally get help. Yet, when she asked about nursing her baby, her doctor likely played it safe and told her to use formula.
In medicine, we called that caution, although much of it was stigma. Little had been measured about what was in the milk, and we assumed the worst about the medication and about the mother who took it.
So, what does a can of formula from the 1960s have to do with you? The measurements have since been made, and the old assumption did not hold up. If a relative, a nurse, or a doctor tells you that a mother on Suboxone should not breastfeed, they are repeating advice from before anyone checked.
The greatest risk to your baby is not the buprenorphine.
The greatest risk is a mother who has been pushed off of her medication. The months after a birth are short on sleep and long on advice, and some of that advice will be to get off of that stuff, now that the baby is here.
Unfortunately, stopping your medication does not make your milk safer. It brings back withdrawal and cravings at the moment when you can least afford them. And, street opioids are nothing like a prescribed film, because the dose is unknown, and fentanyl in breast milk can be dangerous, or even deadly, for a baby.
It is common for a new mother to quietly cut her dose in half, so that less will reach the baby. She means well, she tells no one, and before long she is sick, short-tempered, and counting the hours until the next dose.
Does the lower dose protect her baby? The mothers in the breastfeeding studies took anywhere from 2.4 mg to 24 mg a day, and across that range their babies were exposed to less than 1% of the dose. Half of a very small amount is not much protection, and a dose that leaves you in withdrawal does your baby no favors.
While wanting to come off of Suboxone someday is reasonable, and the decision is yours, the first months with a newborn are rarely the time. When that time comes, taper gradually with your doctor. Never quit cold turkey.
What if I use again, or drink alcohol, while I am breastfeeding?
If you return to street opioids, even once, do not hide it and do not nurse through it. Give your baby formula or milk that you stored earlier, call your prescriber that same day, and ask the pediatrician when it is safe to breastfeed again.
A return to use is a reason to adjust your treatment. It is not a reason to give up on treatment, or on breastfeeding for good.
The same honesty applies to alcohol and to sedatives. Combining buprenorphine with alcohol, benzodiazepines such as Xanax (alprazolam), or other sedating drugs raises the risk of overdose, heavy sedation, and slowed breathing. A mother who is that sedated cannot safely care for a newborn. If anyone in your home cannot be woken, or is breathing slowly or not at all, call 911.
If you are prescribed a benzodiazepine, never stop it suddenly because of what you read here. Sudden discontinuation can trigger seizures and can be life-threatening. Tell both prescribers, and the pediatrician, everything that you take.
Should I tell my obstetrician and the pediatrician that I take Suboxone?
Yes, both of them, and before the delivery if you can. A pediatrician cannot watch for sleepiness, or for NOWS, in a baby whose history has been kept from the office.
The wish to hide it is understandable, because people make assumptions about a pregnant woman who is dependent on opioids. In fact, many of these women are educated, have good careers, and are raising families.
Opioid dependence is not a weakness, and it is not a moral failing. Those of us who have not gone through opioid withdrawal have no right to judge those who have. A mother who stayed on her medication through a pregnancy, when the alternative was street opioids, chose the far safer path for her baby, and she is owed respect at the hospital.
So, ask your obstetrician how the hospital cares for babies who were exposed to buprenorphine, choose the pediatrician before your due date, and bring a letter from your prescriber that confirms your treatment. Planning ahead, and being honest with your doctors, is the best way to give your newborn a good start.
What if I decide not to breastfeed?
Then you feed your baby formula, and that is a good choice too. While breastfeeding has real benefits, for a baby’s immune system and nutrition and for the bond between the two of you, it is your choice. There is no shame in a bottle.
What should not make the decision for you is fear of your own medication. Suboxone is not free of risk, and nobody can promise a nursing mother that it is. However, the amount in your milk is small, and your baby can be watched.
Fortunately, you can stay on the medication that keeps you well, and you can feed your baby the way you choose.
Dr. Leeds provides buprenorphine treatment by telemedicine throughout Florida.
Dr. Leeds provides buprenorphine treatment with Suboxone and its film and tablet generics to new patients throughout Florida by telemedicine, with in-office visits available in Fort Lauderdale. The first doses are taken at home with phone support, and visits are monthly, or weekly when needed. Care is one-on-one and patient directed. Treatment with buprenorphine does not replace the care of an obstetrician or of a baby’s pediatrician.
If you are pregnant or breastfeeding and you have questions about treatment with buprenorphine, contact Dr. Leeds through the contact form.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
