Smoking and Breastfeeding
Dana Villamagna
Richmond VA USA
From: LEAVEN, Vol. 40 No. 4, August-September 2004, pp. 75-78.
Should mothers who smoke
cigarettes breastfeed? What overall effect does cigarette smoking have
on breastfeeding mothers and their babies?
It is common knowledge that
tobacco use is unhealthy. Many people still smoke, however, and many
smokers are battling nicotine addiction. It has been reported that less
than three percent of women who try to quit smoking each year succeed.
The addictive nature of cigarettes has been compared to heroin. It’s
not a simple matter to quit. Most people who quit do so only after repeated
attempts. While pregnancy provides a strong incentive for women to quit,
they may return to smoking once the baby is born.
According to the World Health
Organization, about 250 million women in the world are daily smokers:
22 percent of women in developed countries and about nine percent of
women in developing countries smoke tobacco. Many mothers who smoke
choose not to breastfeed due to psychological factors or social pressure;
some mothers who smoke may initiate breastfeeding and encounter physiological
problems related to smoking while breastfeeding that lead to weaning;
or some mothers who have given up smoking during pregnancy may choose
to wean early to resume smoking because they do not believe they should
smoke and breastfeed.
Studies have shown that breastfeeding
offers protection against respiratory infections to babies in smoking
households. Respiratory infections are much more common in babies exposed
to environmental tobacco smoke, or second-hand smoke. Mothers who smoke
cigarettes should be encouraged to breastfeed their babies and to try
to smoke as little as possible. Many factors work against a mother who
smokes and wants to breastfeed. As always, La Leche League Leaders are
there to offer information and support to breastfeeding mothers who
smoke.
Editor’s Note:
This article is specific to tobacco cigarette smoking. It does
not address marijuana or other smoking-related drugs, which are
all contraindicated during breastfeeding.
AAP Rethinks Its Opinion
In 2001, The American Academy
of Pediatrics (AAP) changed its official position on smoking and breastfeeding.
The change was attributed to new research findings, as well as to an
overall effort at the AAP to encourage an increase in US breastfeeding
rates. Additionally, the committee stated, the removal of nicotine from
the list of drugs of abuse not compatible with breastfeeding may afford
physicians and their patients a greater opportunity to discuss cigarette
smoking because: "Pregnancy and lactation are the ideal occasions
for physicians to urge cessation of smoking."
The AAP report explained
why doctors should discuss breastfeeding with mothers who do not wish
to stop, or cannot stop smoking:
It is recognized that
there are women who are unable to stop smoking cigarettes. One study
reported that, among women who continue to smoke throughout breastfeeding,
the incidence of acute respiratory illness is decreased among their
infants, compared with infants of smoking mothers who are bottle fed.
It may be that breastfeeding and smoking is less detrimental to the
child than bottle feeding and smoking. The Committee on Drugs awaits
more data on this issue.
Previously, nicotine was
on the list of contraindicated drugs of abuse during breastfeeding due
to documented decreases in milk production and infant weight gain, infant
respiratory illness, and transfer of nicotine and other compounds to
the babies from the milk of mothers who smoke. The 2001 report, however,
stated that the committee found no evidence to document whether the
amount of nicotine that passes to the infant through a mother’s
milk is harmful, and it awaits further study on that issue.
The Position of LLL
"We’ve always said
that, yes, mothers who smoke will have babies at greater risk for respiratory
illness, but babies of mothers who smoke and breastfeed will have less,"
says Katy Lebbing, BS, IBCLC, RLC, and manager of the LLLI Center for
Breastfeeding Information.
Lebbing comments that she
has received many calls from mothers who smoke cigarettes and want to
breastfeed during her tenure on the La Leche League International helpline
(800-LALECHE). Discussing the information stated in THE WOMANLY ART
OF BREASTFEEDING and THE BREASTFEEDING ANSWER BOOK about smoking, as
well as asking questions about the related topic of stress management,
is the best information and support LLL Leaders can offer.
"Smoking is something
that is done to relieve stress. But there are other things that relieve
stress," Lebbing says. "Going to LLL meetings or talking to
an LLL Leader can help relieve a mother’s anxiety about breastfeeding-related
problems."
If a mother is actively smoking,
THE WOMANLY ART OF BREASTFEEDING recommends:
- Smoke away from the baby, outdoors, or in a separate room;
- Smoke right after nursing sessions;
- Smoke as few cigarettes as possible. The risks to the baby increase
if a mother smokes heavily (more than 20 cigarettes a day). Reduction
in milk supply, inhibition of the let-down reflex, and physical symptoms
in the baby, such as nausea, abdominal cramps, vomiting, and diarrhea,
may occur.
THE BREASTFEEDING ANSWER
BOOK contains a comprehensive section about nicotine use. Again, the
same three guidelines are stressed: smoke away from baby, never smoke
during feedings, and smoke as few cigarettes as possible per day.
THE BREASTFEEDING ANSWER
BOOK also has a segment related to nicotine replacement therapy products
for questions from mothers who are interested in using nicotine gum,
lozenges, or patches in order to stop smoking. Mothers should use the
chewing gum or lozenges right after feedings, not right before or during
feedings. If mothers are using the transdermal patch, THE BREASTFEEDING
ANSWER BOOK suggests mothers remove it at bedtime to allow for lower
nicotine levels during night feedings. Mothers who are using the replacement
products should never smoke cigarettes while using a replacement therapy
as "this would produce very high nicotine levels in her blood and
milk and could be a danger to her breastfeeding baby."
An additional source of information
that is mother-friendly is the recently published LLLI tear-off sheet,
"Smoking and Breastfeeding: The Effects of Smoking on Breastfeeding
Mother and Baby."
Tobacco smoke contains at
least 3,800 components. Nicotine is the most well-known and addictive
ingredient. As early as 1933, it was known that nicotine was present
in a smoking mother’s milk (Amir 2001). Second-hand cigarette smoke
is unhealthy for babies, increasing the risk of respiratory infections,
SIDS, and cancer (Ward 1999). As stated by the AAP, breastfeeding has
been shown to decrease the incidence of respiratory infections in babies
of smoking parents.
Mothers who smoke cigarettes
and want to stop or cut back can be encouraged to find support. But
if they do not stop smoking, breastfeeding is better for the baby than
formula feeding. However, mothers who smoke and breastfeed may experience
unique, smoking-related difficulties within the breastfeeding relationship—of
both psychological and physiological natures—which may create an
increased likelihood of early weaning.
Early Weaning Possible
Women who smoke are less
likely to breastfeed than non-smokers, and women who smoke and breastfeed
are more likely to wean early, although there does not seem to be a
physiological reason for this. These statements are included in an extensive
review of studies related to maternal smoking and lactation (Amir 2001).
Study author Lisa Helen Amir,
MBBS, MMed, IBCLC, from the Centre for the Study of Mothers’ and
Children’s Health at LaTrobe University in Australia, reviewed
previously published studies from US and international databases, libraries,
and medical journals to compare findings related to the topic of maternal
smoking and weaning.
Amir states early weaning
may be influenced more by psychological and social reasons than actual
physiological breastfeeding problems:
Although there is consistent
evidence that women who smoke breastfeed their infants for a shorter
duration than non-smokers, the evidence for a physiological mechanism
is not strong....Women who smoke seem to have significantly less motivation
to breastfeed: they are less likely to intend to breastfeed and less
likely to initiate breastfeeding.
Studies show a number of
psychosocial factors that may play into a mother’s decision to
not breastfeed or wean early if she smokes cigarettes including the
number of cigarettes she smokes, if the father smokes, and a mother’s
own anxiety about milk supply.
In one study, researchers
found that more than 60 percent of women who gave up smoking during
pregnancy resumed smoking in the months following birth; 50 percent
by approximately four months postpartum. Most of those who began smoking
again had a partner who smoked and most were less likely to breastfeed
for more than six weeks (Mullen 1997).
Smoking is a stress-relieving
mechanism for many people. New mothers who are under the inevitable
stress of early parenthood may find it difficult to avoid returning
to that stress-reducing habit if not given early support and alternative
relaxation methods (Ward 1999).
Early weaning may also be
related to physiological problems commonly attributed to smoking and
breastfeeding, such as inhibited let-down and decreased milk supply.
Lisa Helen Amir writes that it has been generally accepted that nicotine
in the mother’s bloodstream reduces prolactin and, therefore, milk
supply. However, she states, new evidence seems to second-guess the
importance of prolactin on overall milk supply (Amir 2000).
"The widespread
belief that smoking interferes with oxytocin release is currently
unsubstantiated and research is needed to prove or refute this assertion,"
Amir writes.
She also concludes that early
weaning is not in the best interest of babies whose mothers smoke:
In clinical practice, all pregnant and lactating women should be encouraged
and given help to stop smoking. However, women who continue to smoke
should be encouraged to breastfeed as the health risks of the combination
of parental smoking and artificial feeding outweigh the potential risks
of smoking and breastfeeding.
Iodine Deficiency
Smoking reduces the body’s
ability to absorb some vitamins and minerals. A recent study showed
that mothers who smoke cigarettes may have reduced ability to transport
iodine, which can also cause the same deficiency in the breastfed baby
(Laurberg 2004). The study was conducted in Denmark, a country where
iodized salt was not regularly used at the time of the study. Iodine
deficiency is of particular interest because it is the main cause of
preventable brain damage and mental retardation worldwide.
According to the study by
Dr. Peter Laurberg, smoking reduces the transport of iodine into breast
milk, increasing the risk of developmental brain issues. "During
the period of breastfeeding, thyroid function of the infant depends
on iodine in maternal milk," indicates Laurberg. The study did
not make specific suggestions for iodine supplementation in breastfeeding
mothers who smoke.
Iodized salt provides 400
mcg of iodine per teaspoon. The dose of iodine recommended for breastfeeding
mothers by the US is 290 mcg. The breastfeeding mother who smokes should
consult with her health care provider about supplementation of iodine
or other vitamins and minerals.
Key Information for LLL
Leaders
When giving information and
support to a mother who is smoking and breastfeeding, an LLL Leader
may need to set aside personal biases about smoking. It is important
to offer breastfeeding information and support, and to not mix the separate
cause of smoking cessation.
Leaders may encounter breastfeeding
mothers who want to stop smoking and who ask for information. In those
cases, they can offer information from THE BREASTFEEDING ANSWER BOOK
about nicotine replacement therapies and their effects on breastfeeding.
They can offer alternative methods of stress relief, including attending
LLL meetings. They can refer mothers desiring to stop smoking to related
treatment organizations (see resources at end of article).
Leaders may also encounter
mothers who don’t want to stop smoking. In those instances, they
can offer the recommended guidelines from THE BREASTFEEDING ANSWER BOOK
and THE WOMANLY ART OF BREASTFEEDING. Leaders can provide mothers with
the information that babies who are exposed to cigarette smoke have
a higher incidence of respiratory infections, and that breastfeeding
offers some protection against those illnesses. Leaders may also want
to ask open-ended questions about how the mother is handling the stress
associated with new motherhood.
In Conclusion
- Breastfed babies of mothers
who smoke cigarettes have fewer respiratory infections than formula-fed
babies of mothers who smoke.
- Breastfeeding mothers
who smoke should smoke as few cigarettes as possible each day.
- Mothers who smoke should
smoke away from the baby, outdoors, or in a separate, well-ventilated
area to reduce amount of second-hand smoke and particulate matter
the baby is exposed to.
- Mothers who smoke should
do so after feedings to allow time for the level of nicotine in the
milk to decrease before the next feeding.
- Mothers who smoke and
breastfeed may discuss iodine and other vitamin and mineral supplementation
with their health care provider.
- Smoking may reduce the
protection against SIDS that breastfeeding offers.
- If a mother who is breastfeeding
uses nicotine replacement products, she should not smoke any cigarettes
while using the products.
- Mothers who want to quit
smoking should seek support to do so.
- Smoking is often an anxiety-related
activity. Encourage the mother to find other ways to reduce stress.
Dealing
with Biases About Smoking
Do you have mixed
feelings about encouraging a breastfeeding mother who smokes
to continue breastfeeding? If so, you’re not alone. For
a variety of reasons, many in the LLL community have strong
feelings about the risks of smoking. A Leader can best help
a mother who smokes by offering clear and objective information
about the relationship between breastfeeding and smoking.
A breastfeeding
mother who smokes may conjure up unconscious concerns about
mother’s milk being "good enough" for babies.
This is a fear that baby milk manufacturers have played upon
subtly over the years.
As a demographic
group, LLL Leaders are probably less likely to smoke than
the general population. However, we may have family members
who smoke. Or we may have a spouse, parent, or friend suffering
from a smoking-related illness. Our concerns for loved ones
may magnify any concern we have for the breastfeeding mothers
we are helping.
Many of us have
heard or read about unfavorable comparisons between how the
health care community treats smoking by a pregnant mother
verses how the health care community treats a pregnant mother’s
"feeding choice." Health care professionals may
strongly condemn smoking during pregnancy and lactation, while
downplaying the health risks of not breastfeeding. Our unconscious
or conscious awareness of such contrasts may affect our language
on a subtle level.
The history of
smoking being targeted as a public health issue also affects
our attitudes. Some of us are old enough to remember times
before smoking was banned on airplanes and in many public
buildings in the US. The drastic change in attitudes may make
us feel more militant about offering advice about quitting
smoking, thus straying from our primary responsibility to
help mothers with breastfeeding.
LLL Leaders tend
to be more health-conscious than the general public. They
are more aware of nutrition, and tend to do lots of reading
about pregnancy, birth, nutrition, and childcare. Smoking
is not the only health issue that may be of concern, but it’s
a highly sensitive one. When a mother asks for input on her
decision about smoking, both the mother and the Leader are
put in a very delicate situation. Health care providers, family
members, or friends have likely criticized the mother for
her smoking. The Leader needs to be especially compassionate.
It is not our job
to get mothers to quit smoking, or even to cut down on smoking.
We can offer a mother information about the effects of smoking,
including that the half-life of nicotine in the mother’s
blood and milk is 95 minutes (Steldinger and Luck 1988), to
help the mother make her own decisions. Leaders can feel confident
encouraging the mother who smokes to continue breastfeeding
for the positive health benefits to her baby and herself.
Steldinger,
R. and Luck, W. Half lives of nicotine in milk of smoking
mothers: Implications for nursing. J Perinat Med
1988; 16:261-62.
|
References
American Academy
of Pediatrics Committee on Drugs. The transfer of drugs and other
chemicals into human milk. Pediatrics 2001; 108(3): 776-89.
Amir, L. Maternal smoking and reduced duration of breastfeeding: A
review of possible mechanisms. Early Hum Dev 2000;164(1): 45-67.
Centers for Disease Control. Health objectives for the nation: Cigarette
smoking among adults 1993. MMWR 1994; 43:925-930.
Laurberg, P. et al. Iodine nutrition in breast-fed infants is impaired
by maternal smoking. J Clin Endocrinol and Metab 2004; 89:181-87.
Mackay, J. and Eriksen, M. The Tobacco Atlas. Geneva, Switzerland:
World Health Organization, 2002.
Mohrbacher, N. and Stock, J. THE BREASTFEEDING ANSWER BOOK, 3rd Edition.
Schaumburg, IL: La Leche League International, 2003.
Mullen, P.D. et al. Postpartum return to smoking: Who is at risk and
when. Am J Health Promot 1997; 11(5):323-30.
Nafstad, P. Breastfeeding, maternal smoking and lower respiratory
tract infections. Eur Respir J 1996; 9:2623-29.
Nylander, G. et al. Amming. Effekt av royking og utdanning [Breastfeeding.
Effects of smoking and education]. Tidsskrift for den Norske laegeforening
1989;109:970-3.
Smoking and Breastfeeding. LLLI, 2004. Publication No. 1487-27.
Starling, J. et al. Breastfeeding success and failure. Aust Paediatr
J 1979; 15:271-74.
Ward, S. Addressing nicotine addiction in women. J Nurse Midwifery
1999; 44(1): 3-18.
Widstrom, A.M. et al. Somatostatin levels in plasma in non-smoking
and smoking breastfeeding women. Acta Paediatrica Scandinavica
1991; 80:13-21.
THE WOMANLY ART OF BREASTFEEDING, 7th Edition. Schaumburg, IL: La
Leche League International, 2004.
Woodward, A. Acute respiratory illness in Adelaide children: Breastfeeding
modifies the effect of passive smoking. Journal of Epidemiol Community
Health 1990; 44: 224-30.
Helpful Web sites
La Leche League International
www.lalecheleague.org
World Health Organization
www.who.int/health_topics/tobacco/en/
The International Cancer
Alliance
www.icare.org
American Lung Association
Freedom From Smoking
www.lungusa.org/ffs/
American Cancer Society
www.cancer.org
Dana Villamagna, MSJ,
is a freelance journalist and LLL Leader on Leader Reserve in Richmond,
Virginia, USA where she lives with her husband, Drew, and two daughters,
Olivia (6) and Elena (2)..
Page last edited Sun Oct 14 09:32:26 UTC 2007.
