Previous and present evidence on drinking alcohol while nursing. PREVIOUSLY… “Alcohol has special virtues for the nursing mother” In the early and mid-1900s, alcohol was casually recommended to nursing women as a remedy. Beer was touted as a galactagogue, a substance that can increase milk supply; cocktails promoted napping. During midcentury decades, doctors and women were relatively relaxed about drinking during breastfeeding, especially given that so few women (less than 25%) were actually breastfeeding at the time. Plus, even drinking during pregnancy had yet to become a no-no. Alcohol and breastfeeding really wasn’t a very controversial issue. Nurses advised women to indulge in a drink or two as a relaxation aid, extolling alcohol as a stress-buster and a facilitator for the letdown reflex. In The Nursing Mother: A Guide to Successful Breast Feeding, in 1953, Frank Howard Richardson answered a woman’s question about whether having a cocktail while nursing could harm her baby by saying that there was “no unanimity of opinion among doctors” on the matter (a response he also supplied in regard to smoking), and “obviously, large amounts ought by all means to be avoided.” But, he quipped, “you don’t need a doctor’s opinion for that.”[1] In a 1965 review covering drug excretion through lactation, John A. Knowles summarized that “the amount of barbiturates excreted in breast milk has never been found to affect the nursing infant, nor does alcohol taken in moderation by the mother produce an untoward effect on her infant.”[2] In 1973, a book sanctioned by La Leche League read: “‘alcohol has special virtues for the nursing mother… this is the one time in life when the therapeutic qualities of alcohol are a blessing… Dr. Kimball’s succinct rule for nursing success is booze and snooze.”[3] “Booze and snooze” sounds pretty great, but underlying this easygoing perspective was almost no medical literature. Research on alcohol consumption during breastfeeding was practically nonexistent prior to the 1970s, when the “discovery” of Fetal Alcohol Syndrome (FAS) instigated mounting concerns about the effects of drugs in utero. (For a really wonderful exploration of how the FAS diagnosis came into existence, check out Janet Golden’s book Message in a Bottle.) In the wake of FAS research in the 70s, medicine started to think a little more critically about substance exposure through breastmilk. But prevailing medical opinion still held that drinking (within reason) while breastfeeding was just fine. Jay Arena, a prominent pediatrician, conveyed the general sentiment circa 1980: “in regard to alcohol, moderate amounts (say, one or two cocktails a day) are not harmful to the nursing mother or infant.”[4] Sound Advice?: Taking a Closer Look Yet doctors were working with virtually no real academic work on alcohol’s effects on nursing itself or nursing babies. Writing in 1981 in the Journal of Advanced Nursing, authors Sheena Davidson, Lynn Alden, and Park Davidson remarked that “not a single human study has looked at postnatal maternal drinking and its effects.”[5] (For obvious reasons, human studies on this are difficult to conduct.) In 1985, Margaret Lawton, a chemistry Ph.D. in New Zealand, expressed dismay that “in particular, the data on ethanol [and nursing], an almost universally accepted drug taken in some form by the majority of most social groups is conspicuous by its virtual absence.”[6] Writers like these were starting to worry that the standard line (“‘there are no dangers and [alcohol] is good for you!’”) was starting to sound eerily reminiscent of the previous message to pregnant women that alcohol posed no problems.[7] There was little doubt in anyone’s mind that babies might be ingesting miniscule amounts of alcohol, but the big questions were 1) does alcohol help or hinder breastfeeding? and 2) do even miniscule amounts of alcohol have the potential to harm nursing infants? What animal studies were available in the 80s (which were few) indicated that rather than helping with lactation, alcohol probably did just the opposite – it actually inhibited letdown by slowing the release of oxytocin. Furthermore, contrary to the widespread assumption that babies exposed to alcohol would not exhibit any effects unless their mothers consumed “enormous” quantities, animal studies thus far showed that baby rats exposed to alcohol consumed less, and therefore weighed less (15% less), than their counterparts.[8] Researchers needed to take a closer look. One of the first published human investigations into alcohol and breastfeeding was an absolutely shocking (and hilarious) study conducted in New Zealand in the 1980s: eight nursing mothers (volunteers) were “asked to drink as much alcohol as they could manage in the form they preferred in as short a time as possible.” Yes, that’s right – the lead investigator asked these women to binge drink, however they “preferred.” These women weren’t messing around. About half of them consumed between 3.5 and 4 drinks, and the remaining half drank approximately 5 to 7 drinks – within an hour. After measuring alcohol levels in blood and milk samples from the women, the author concluded that alcohol moved into breastmilk quickly, with breastmilk alcohol levels typically equaling or surpassing blood alcohol levels. The study corroborated earlier work demonstrating that alcohol is not “stored” in breastmilk in the traditional sense; it cannot be eliminated simply by removal (“pump and dump”). Instead, alcohol in breastmilk is metabolized just as it is in the body’s circulatory system, and only dissipates with time (just as achieving 100% sobriety is a matter of time).[9] A brief aside, since an understanding of the basic mechanisms here is helpful: the science of drug transfer and lactation is actually exceedingly complicated and confusing; not all substances are emitted into breastmilk in the same way, and every woman’s body is unique. Scientists know, however, that alcohol registers in breastmilk at the same levels as a mother’s blood alcohol concentration (BAC). When a woman takes a drink, alcohol moves into her bloodstream quickly, and her BAC peaks after about an hour. BAC itself rises commensurate with alcohol consumption, and in most states, driving with a BAC of 0.08 or higher is illegal, as it renders a person unable to drive. (Based on generic descriptions at WebMD, a person with a BAC of 0.2 – more than double the legal driving limit – may have trouble walking, experience blurry or double vision, or potentially vomit. At 0.3, someone could pass out, experience tremors, memory loss, and depressed body temperatures. At BAC levels of 0.4 and 0.5, a person would be in serious trouble – potentially facing death.) A woman’s BAC reflects the amount of alcohol in her blood; that percentage is transmitted to breastmilk, not directly to a baby. For example, if a nursing woman has a BAC of 0.06, her breastmilk would be 0.06% alcohol (a normal beer is about 5% alcohol). If she nursed her baby, the baby would consume milk that was legally non-alcoholic, and the baby’s own BAC would barely register as positive, not correspond to the mother’s BAC. This means that exposure to alcohol via breastmilk is fundamentally different than fetal exposure to alcohol in utero. Even though alcohol does move into breastmilk, the total exposure is very small, almost trivial, especially compared to a mother’s consumption. Thus, compared to the “drastic consequences of prenatal exposure seen in infants with fetal alcohol syndrome, the long-term effects of exposure to alcohol in the mother’s milk if any, are subtle.”[10] OK – back to the 1980s study in New Zealand: having demonstrated that alcohol presents in breastmilk, the author wondered whether it had any effects on a nursing baby. Musing, she calculated the “maximum” BAC for one of her subject’s 6-month-old babies. If the child consumed 6 ounces of breast milk – a hefty serving – when the mother’s own BAC was at its peak of 0.119 (well over the legal driving limit in the U.S.), the child would still only have a BAC of 0.006, she reported. (For perspective, this would be comparable to an adult drinking less than two ounces of 5% ABV beer.) “It is improbable,” Margaret Lawton measured, “that occasional exposure to alcohol of that quantity would affect the child. In conclusion it would therefore appear that the age-old advice given to nursing mothers regarding alcohol intake is sound.”[11] Research into the 1990s was muddled overall, but a couple of things began to shift into focus. First, alcohol was no breastfeeding elixir. By every measurement, alcohol handicapped breastfeeding. Numerous studies clarified that alcohol inhibited lactation by messing with the letdown reflex and milk production.[12] Second, it became evident that ascertaining any possible effects on infants was going to be very challenging. Most work produced ambiguous results or else was subsequently called into question. For example, in 1989, a piece came out in The New England Journal of Medicine: “Maternal Alcohol Use During Breast-Feeding and Infant Mental and Motor Development at One Year.” The study, which included some 400 babies, found that at one year, babies exposed to alcohol through breastmilk were just as well off in mental development but notably worse off in motor development. The differences were slight enough that the authors noted they were “not meaningful” for any given individual child, but they were there. These results seemed clear enough – but when the lead investigator set out to replicate them in 18-month-olds, her team turned out different results; motor development was not significantly different in babies exposed to alcohol via breastmilk than in controls.[13] So, alcohol might influence motor development? A 1991 piece in the New England Journal (a much smaller study, of just 12 infants and moms) reported that alcohol influenced breastmilk’s smell. “The consumption of ethanol,” researchers said, “significantly altered the intensity of the odor of [mothers’] milk as perceived by a panel of adults.” (Just imagine it: 17 adults on the “sensory panel” sitting in a lab, sniffing women’s breastmilk. A majority of them determined that the “alcoholic” breastmilk “smelled like alcohol” or “smelled sweet.”) Their observations have held stable over time. But their other finding – that in the three hours after their mothers drank alcohol, babies drank less milk – has a wrinkle.[14] Later research concluded that babies exposed to alcohol via breastmilk do drink less milk initially but make up for it and actually consume more milk over the course of the next half a day.[15] Alcohol also does seem to subtly impact babies’ sleeping patterns, correlating with reduced time in active sleep right after exposure.[16] PRESENTLY… Where Things Stand Additional research since then has continued to refine medicine’s understanding of the transfer and elimination of alcohol through breastmilk. Breastmilk alcohol levels rise and fall with blood alcohol levels; the popular “pump and dump!” slogan is misdirected at best. (Nursing women may still benefit from pumping and dumping as a strategy to mimic feedings and maintain breast supply, but it does not rid a woman’s body of alcoholic breastmilk.) Alcohol does tinker with milk production and letdown. But doctors are first to admit that scientific research documenting whether, and how, trace amounts of alcohol in breastmilk may or may not influence infants is lacking. Contemporary researchers are all in agreement as to three items: 1) alcohol, at least to a certain extent, inhibits breastfeeding; 2) the physiological transfer of alcohol into breastmilk works such that breastmilk alcohol levels roughly mimic blood alcohol levels; and 3) the amount of alcohol that actually reaches children is miniscule. Beyond this, things are more open to interpretation. The most recent review articles indicate that as yet, on the whole, alcohol exposure via breastmilk does not currently appear to have demonstrably negative effects for nursing babies, although it may have subtle, temporary effects (such as reduced time in active sleep). In 2014, reviewers Roslyn Giglia and Colin Binns assessed that it seemed “biologically implausible” that occasional exposure to alcohol, even if it was through binge drinking episodes, was clinically pertinent. “Minute behavioural changes in infants exposed to alcohol-containing milk have been reported,” they noted, “but the literature is contradictory.” “The effect of occasional alcohol consumption on milk production,” the Giglia and Binns said, “is small, temporary, and unlikely to be of clinical relevance. Generally, there is little clinical evidence to suggest that breastfed children are adversely affected in spite of the fact that almost half of all lactating women in Western countries ingest alcohol occasionally.”[17] So, where does all of this leave us? We know that alcohol is definitely no help to breastfeeding, and that it can reach nursing babies in tiny doses. But the outcomes and risks associated with those tiny doses are still indefinite, with some researchers believing them unsafe and others gauging them negligible. Giglia and Binns reflected that the “evidence available to give advice to lactating mothers is less than ideal….”[18] Less than ideal, indeed. Applications Given all of this, there are essentially three different reigning philosophies; each has backing and support from intelligent, thoughtful medical professionals and mothers: 1. Don’t Drink Any Alcohol. Obviously, this is the “safest-bet” option. It is also the simplest. The notion is that since scientists don’t entirely know the long-term possible effects, the safest thing for nursing women to do is to refrain from drinking alcohol: “a zero level of alcohol in milk is the safest for a nursing baby.”[19] This mentality is depicted on the Mayo Clinic’s website: “there’s no level of alcohol in breast milk that’s considered safe for a baby.”[20] I don’t find this logic particularly compelling, especially in the context of those scientific aspects we do know about alcohol and breastfeeding, but this is admittedly the most secure path. (Since alcohol in the breastmilk is a temporary condition, almost none of the experts and societies demand complete abstinence, as they do during pregnancy.) 2. When You Drink Alcohol, Follow These Rules. Heed the Chart. The most widespread recommendations fall into this category, and they basically suggest that women can drink small amounts of alcohol occasionally but should wait until they are completely sober, with a BAC of 0, before nursing.[21] In its 2012 policy statement on breastfeeding, the American Academy of Pediatrics advises that mothers really shouldn’t drink alcohol while nursing, but that if they do they should do so only occasionally, limit their consumption to no more than two drinks, and separate nursing episodes from drinking by at least two hours.[22] The UK’s National Health Service advises essentially the same.[23] Advocates in this camp mostly adopt the view that “until a safe level of alcohol in breast milk is established, no alcohol in breast milk is safe,” but they work to offer strategies that might help women who do wish to consume alcohol do so safely.[24] Chief among these strategies are charts – easily available on the web – aimed to simplify the matter by indicating how long a mother would, on average, need to wait after consuming “X” number of drinks before she would be 100% sober and able to nurse her baby. One of the most widely cited ones is the Motherisk algorithm, available here. I know women who have found these extremely helpful and a great relief. Yet others may find them stressful or inaccessible. They are devised for the average woman, standing 5’4” tall – what about women who are taller or shorter? What about women who metabolize alcohol at different rates? Furthermore, the recommended wait times come across as inordinately long. For my own weight range, I would need to wait almost five hours in between nursing sessions if I had just two drinks. If I had three drinks, I’d need to wait more than seven hours. (La Leche League notes that because of personal differences, it may take any given woman up to thirteen hours to eliminate the effects of a single drink.[25]) What breastfeeding mother can bank on these kinds of time spans? My son ate very often in the afternoons and evenings, even up until he was six months old. The prospect that I might reliably be able to wait two and a half hours to nurse (the time recommended I wait after consuming just one alcoholic drink) on a Friday evening seemed almost laughable. I turned to charts and tables like these for help, but I found them vexing and near-impossible to apply in my own life.[26] 3. Go Ahead and Drink. (And use some common sense.) (And maybe plan ahead.) Many breastfeeding experts lament the blanket message that nursing women abstain from alcohol, and many of them have further criticized the two-hour-per-drink waiting period between drinking and nursing. The basic premise behind this third philosophy is that without clear evidence to back it up, breastfeeding mothers hardly need another restriction like this on their lives. Dr. Jack Newman, a renowned breastfeeding expert, advises women to go ahead and have a drink. “Nursing mothers have enough unnecessary artificial constraints on their lives,” explains Dr. Jack Newman. “Ethanol is not so bad,” he writes, “that mothers should avoid nursing their babies for two hours after a single drink.”[27] Spanish breastfeeding expert Dr. Carlos Gonzalez goes even further: “The legal driving limit in the UK is 0.08 per cent. If your alcohol level is higher than 0.15 per cent you are unmistakably drunk. If it goes above 0.55 per cent you simply drop dead. Therefore, it’s absolutely impossible for breastmilk to contain more than 0.55 per cent alcohol.” Gonzalez stresses that heavy drinking does not mix well with breastfeeding, but mostly for the mother, not the baby – “even if the mother drinks three glasses of wine a day,” he says, “breastfeeding is still better for her baby than bottle feeding.”[28] (As a side note, this dictum, that the benefits of breastmilk outweigh its possible contamination with alcohol – which the World Health Organization also declares – has its own problems.[29] Even though it’s intended to assuage breastfeeding women, what does this message convey to formula-feeding mothers? You would be better off serving your child a little alcohol than formula? This seems implicitly judgmental.) I’ve come across a driving analogy that encapsulates the more casual approach to alcohol and breastfeeding: if you are sober enough that you would get behind the wheel of a car, go ahead and nurse. (Of course, as Gonzalez more provocatively explains, plenty of research also indicates that even if you couldn’t drive, nursing would still be fine. According to Dr. Thomas Hale, maternal BAC levels have to hit about 0.3 – more than three times the legal driving limit – before “significant side effects are reported” in a baby.[30]) A little less dramatically, the popular website kellymom.com, a resource that lactation consultants at my hospital as well as the Cleveland Clinic recommended, nonchalantly explains that a drink or two with food is fine, and that less than 2% of the alcohol a mother drinks actually reaches her nursing baby.[31] This perspective seems to be gaining traction, as far as I can tell. One of my favorite lay pieces broadcasting a balanced approach is this one, by Melinda Wenner Moyer. Moyer argues that breastfeeding moms can afford to relax a little about alcohol consumption. Others who ascribe to this perspective suggest that if women want to consume more than a couple of drinks, they plan ahead. One option is to pump milk in advance.[32] (No one suggests intermixing a formula feeding.) At the end of the day, I find myself wishing there was more research. As is, undoubtedly, each of these outlooks is standing on firm ground. Personally, I fell in line with the third take, and chose to imbibe, but I would be lying if I said I never hesitated. Even though some quality research has explored this issue, I still think the casual moderation championed by 1970s physicians rings true. I took up the driving rule, and although it’s somewhat contrived, I liked the planning mantra. I tried to anticipate when I might want to have drinks, and pumped to store extra breast milk for those occasions. In hindsight, I might have forgone pumping and simply used formula instead. Maybe next time around. But hopefully we’ll all have some better answers by then. _____________________________________________________________________________________________ [1] Frank Howard Richardson, The Nursing Mother: A Guide to Successful Breast Feeding (New York: Prentice-Hall, 1953), 110. [2] John A. Knowles, “Excretion of Drugs in Milk: A Review,” Pediatric Pharmacology and Therapeutics 66, no. 6 (June 1965): 1077. [3] Sheena Davidson, Lynn Alden, and Park Davidson, “Changes in Alcohol Consumption after Childbirth,” Journal of Advanced Nursing 6 (1981): 196. [4] Jay M. Arena, “Drugs and Chemicals Excreted in Breast Milk,” Pediatric Annals 9, no. 12 (December 1980): 22; “Symposium on Human Lactation” (George Washington University, March of Dimes, Office for Maternal and Child Health, Bureau of Community Services, 1979), 84–85. [5] Davidson, Alden, and Davidson, “Changes in Alcohol Consumption after Childbirth,” 196. [6] Margaret E Lawton, “Alcohol in Breast Milk,” Australian and New Zealand Journal of Obstetrics and Gynaecology 25, no. 1 (1985): 71. [7] “What about Drinking Alcohol and Breastfeeding?,” La Leche League International, December 19, 2015, http://www.llli.org/faq/alcohol.html. [8] Davidson, Alden, and Davidson, “Changes in Alcohol Consumption after Childbirth,” 196. [9] Lawton, “Alcohol in Breast Milk”; Y.A. Kesaniemi, “Ethanol and Acetaldehyde in the Milks and Peripheral Blood of Lactating Women After Ethanol Administration,” Journal of Obstetrics and Gynaecology of the British Commonwealth 81, no. 1 (1974): 85. [10] Julie A. Mennella and Gary K. Beauchamp, “The Transfer of Alcohol to Human Milk: Effects on Flavor and the Infant’s Behavior,” The New England Journal of Medicine 325, no. 14 (October 1991): 982, 984. [11] Lawton, “Alcohol in Breast Milk,” 73. [12] Roslyn Giglia and Colin Binns, “Alcohol and Lactation: A Systematic Review,” Nutrition & Dietetics 63 (2006): 106, 110, 114; Maija Bruun Haastrup, Anton Pottegard, and Per Damkier, “Alcohol and Breastfeeding,” Basic and Clinical Pharmacology and Toxicology 114 (2014): 169, 171. [13] Ruth E. Little, Kate Northstone, and Jean Golding, “Alcohol, Breastfeeding, and Development at 18 Months,” Pediatrics 109, no. 5 (May 2002): 425, 429; Ruth E. Little et al., “Maternal Alcohol Use During Brest-Feeding and Infant Motor Development at One Year,” The New England Journal of Medicine 321, no. 7 (1989): 425–30. [14] Mennella and Beauchamp, “The Transfer of Alcohol to Human Milk: Effects on Flavor and the Infant’s Behavior,” 982, 984. [15] Haastrup, Pottegard, and Damkier, “Alcohol and Breastfeeding,” 171. [16] Giglia and Binns, “Alcohol and Lactation: A Systematic Review,” 114. [17] Haastrup, Pottegard, and Damkier, “Alcohol and Breastfeeding,” 172, 168. [18] Giglia and Binns, “Alcohol and Lactation: A Systematic Review,” 114. [19] Elaine Ho et al., “Alcohol and Breast Feeding: Calculation of Time to Zero Level in Milk,” Biology of the Neonate 80, no. 3 (2001): 219. [20] Elizabeth LaFleur, “I’m Breastfeding. Is It OK to Drink Alcohol?” (mayoclinic.org, n.d.), http://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/expert-answers/breast-feeding-and-alcohol/faq-20057985. [21] National Health Service, “Breastfeeding and Alcohol,” January 29, 2016, http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/breastfeeding-alcohol.aspx. [22] American Academy of Pediatrics, “Policy Statement: Breastfeeding and the Use of Human Milk,” Pediatrics 129, no. 3 (March 2012): 496. [23] National Health Service, “Breastfeeding and Alcohol.” [24] Gideon Koren, “Drinking Alcohol While Breastfeeding: Will It Harm My Baby?,” Motherisk, January 2002, http://www.motherisk.org/women/updatesDetail.jsp?content_id=347. [25] “What about Drinking Alcohol and Breastfeeding?,” La Leche League International, December 19, 2015, http://www.llli.org/faq/alcohol.html. [26] Koren, “Drinking Alcohol While Breastfeeding: Will It Harm My Baby?” [27] Jack Newman, “Is Alcohol So Bad for Breastfeeding Mothers?,” Journal of Human Lactation 12, no. 2 (June 1996): 93. [28] Milli Hill, “Breastfeeding Mums Rejoice! You Can Drink Alcohol (Christmas or No Christmas),” The Telegraph, December 17, 2015, http://www.telegraph.co.uk/women/health/breastfeeding-mums-rejoice-you-can-drink-alcohol-christmas-or-no/. [29] Angela Bowen and Lindsay Tumback, “Alcohol and Breastfeeding: Dispelling the Myths and Promoting the Evidence,” Nursing for Women’s Health 14, no. 6 (December 2010): 459. [30] “What about Drinking Alcohol and Breastfeeding?” [31] Kelly Bonyata, “Breastfeeding and Alcohol,” Kellymom, June 1, 2016, http://kellymom.com/bf/can-i-breastfeed/lifestyle/alcohol/. [32] Giglia and Binns, “Alcohol and Lactation: A Systematic Review,” 114; “What about Drinking Alcohol and Breastfeeding?”
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