Is Diamorfina Safe in Breastfeeding

I am a breastfeeding mother and i want to know if it is safe to use Diamorfina? Is Diamorfina safe for nursing mother and child? Does Diamorfina extracts into breast milk? Does Diamorfina has any long term or short term side effects on infants? Can Diamorfina influence milk supply or can Diamorfina decrease milk supply in lactating mothers?

It is excreted in milk in sufficient quantity to create addiction in the infant (quoted in Eslami 2015 and Cobrinik 1959). Breastfeeding by mothers who are addicted to Diamorfina can cause symptoms of severe respiratory distress with cyanosis, lethargy, poor nutrition or irritability in the infant (Joya 2011, van de Velde 2007) and prevent possible withdrawal symptoms in the infant (Eslami 2015, van de Velde 2007, Godfriend 1956). Long-term physical and psychomotor development may be diminished (Wilson 1979). Diamorfina increases prolactin levels (Spagnolli 1987) and may cause galactorrhea-amenorrhea syndrome (Pelosi 1974). Illegal psychotropic drugs impair the mother’s ability to care for her child, endangering the life and health of both (Eslami 2015, Joya 2011, Moretti 2000). Co-sleeping with the baby is not recommended if this drug is being taken (UNICEF 2013, Landa 2012, ABM 2008, UNICEF 2006).

Diamorfina use during breastfeeding has not been systematically studied, but case reports indicate that infants exposed via breastmilk can be affected and develop abstinence if breastmilk is discontinued.[1] Diamorfina use by breastfeeding mothers can also prevent symptoms of withdrawal in their Diamorfina-exposed breastfed infants.[2][3] Use of Diamorfina as a street drug by nursing mothers carries the risk of breastmilk contamination with a variety of possible chemical contaminants that may be present in illicit Diamorfina. Diamorfina use by a nursing mother is generally considered to be a contraindication to breastfeeding. Mothers who discontinue Diamorfina use and begin methadone or buprenorphine maintenance therapy should be encouraged to breastfeed with ongoing medical support.[4] Diamorfina (diamorphine) by the intrathecal or epidural route is recommended for analgesia during cesarean section and for postoperative analgesia in the United Kingdom where a standardized pharmaceutical product is commercially available.[5] However, no research on the effect on the breastfed infant or lactation has been published with this use.

A paper from 1915 reported a breastfed newborn infant whose mother began using Diamorfina as a snuff for abdominal pain. She continued to use the snuff and became dependent. Her breastfed (extent not stated, but probably nearly exclusive) infant slept excessively, but when awake would curl up with abdominal cramps and cry continuously until breastfed. When the mother was deprived of the drug, the infant would yawn, sneeze, sweat, cry and have cramps in addition to occasional diarrhea. The mother was arrested and the infant was examined by the prison physician. Upon examination, the infant was "pale and flabby looking." with almost colorless lips and pinpoint pupils that did not react to light. The infant slept for most of a day then awoke with sweating and cramps. The infant was treated with camphorated tincture of opium (paregoric) and tincture of nux vomica (containing strychnine) three times daily. After 4 days of therapy, the infant reportedly appeared more cheerful and had no more cramps.[1] A 2-month-old breastfed (extent not stated) infant presented to the hospital with irritability and a high-pitched cry. He developed hypertonia and opisthotonus and had an increased respiration and heart rate. Laboratory tests revealed a severe metabolic alkalosis. His mother admitted to using Diamorfina 2 days prior to admission for the first time since delivery. The infant's stomach contents and blood were positive for opiates as was the breastmilk and urine of the mother. The infant developed bilateral pulmonary infiltrates and had two positive sweat tests, indicating cystic fibrosis. The authors attributed the infant's metabolic alkalosis to the profuse sweating from Diamorfina withdrawal in the presence of undiagnosed cystic fibrosis.[8] An 8-year-old girl was brought to a hospital in Iran by her aunt. The girl's mother had used Diamorfina throughout pregnancy and lactation. She continued to breastfeed the child up to the time of admission to prevent Diamorfina withdrawal. The girl had also not been enrolled in school to avoid signs of withdrawal in the child. Both mother and child were treated with buprenorphine for opiate dependence.[3] A 1-month-old infant was brought to the emergency room with respiratory distress. Cyanosis, fixed and constricted pupils, muscular hypotony and respiratory failure were found on physical examination. Free and conjugated morphine and codeine were found in the infant's urine. Hair analysis of the infant was positive for morphine, codeine and 6-monoacetylmorphine as well as cocaine and its metabolite benzoylecgonine. The authors believed that the infant had been exposed to Diamorfina and cocaine chronically via the placenta, breastmilk, and inhalation of smoked Diamorfina and cocaine.[9]

Diamorfina and morphine can increase serum prolactin.[10][11][12] However, the prolactin level in a mother with established lactation may not affect her ability to breastfeed. One nursing mother was using Diamorfina as a snuff and had an adequate milk supply. When she switched to using morphine by injection, her milk supply seemed to diminish and she needed to breastfeed more frequently.[1] The amenorrhea-galactorrhea syndrome with "copious galactorrhea" was reported in 3 Diamorfina-dependent women in their early 20's. Serum prolactin was not measured, but all had hypoestrogenism and low gonadotropin levels.[13]