Kratom and Breastfeeding

Summary of use during lactation

Kratom (Mitragyna speciosa) is a tree native to tropical Southeast Asia. Kratom leaves contain psychoactive substances that produce analgesic, euphoric and stimulant effects. The best studied of these substances are mitragynine and 7-hydroxymitragynine. Both have partial mu- and kappa-opioid agonist properties. Corynantheidine is another ingredient with high affinity for adrenergic receptors. Many other chemically similar substances with similar effects have been identified in kratom leaves. Cases of opioid withdrawal syndrome necessitating opioid replacement treatment have been reported in newborn infants whose mothers used kratom during pregnancy.[1-6] Little information is available on the use of kratom during breastfeeding. There is some suggestion that breastfeeding might help lessen neonatal withdrawal symptoms, although it should not be expected to replace direct opioid replacement treatment of the withdrawing infant.[3-5] Withdrawal symptoms can occur in breastfed infants when maternal administration of an opioid analgesic is stopped, or when breastfeeding is stopped. Nursing mothers should generally avoid using kratom due to unknown infant health effects from exposure to multiple central nervous system acting substances in breastmilk.

Drug levels in milk and infant serum

The main psychoactive substance in kratom leaves is mitragynine, which has a bioavailability estimated to be about 21% and a half-life of 3 to 9 hours.[7] Maternal Levels. Relevant published information was not found as of the revision date. Infant Levels. Relevant published information was not found as of the revision date.

Effects in breastfed infants

An infant was born to a mother who took kratom tea 3 to 4 times daily (dose not specified), acetaminophen, methocarbamol, diphenhydramine, valacyclovir, ranitidine, loratadine, albuterol and a low dose of citalopram during pregnancy. She rapidly discontinued kratom in the hospital and was discharged after 7 days. Her infant was breastfed frequently, but was noted to be jittery and to have increased tone with handling within 6 to 8 hours of birth. The infant was admitted to the NICU for irritability, sleeplessness between feeds and excessive sucking at 22 hours of age and was treated with morphine for narcotic withdrawal. She was discharged home on day 12 on oral morphine. At 1 month of age, she continued to be irritable with stretches of prolonged crying, mostly during the daytime, but was feeding well and gaining weight. The time necessary to wean her off morphine was slightly longer than 2 months. This prolonged withdrawal syndrome in the infant might be as a result of sustained in utero exposure.[4] In this case, breastfeeding did not appear to be helpful in eliminating kratom withdrawal symptoms, even when the mother was still taking kratom. A woman was taking 18 to 20 grams of kratom powder 3 times daily throughout her pregnancy for back pain and mood disorder. She delivered a female infant at 37 weeks and 5 days. On postpartum day 2 the infant developed feeding intolerance, jitteriness, irritability, and emesis. The infant was transferred to the NICU and treated for neonatal opioid withdrawal with a continuous intravenous morphine infusion up to a maximum dose of 10 mcg/kg per hour. By postpartum day 7 the morphine had been converted to the oral route, and then stopped. The infant was transferred back to care with her mother and began breastfeeding shortly thereafter. Meanwhile, on postpartum day 2 the mother began weaning off kratom and was also started on 10 mg of oral morphine 3 times daily. Her morphine and kratom doses were then alternatingly decreased until she was no longer taking either substance after 4 weeks. No further neonatal opioid withdrawal symptoms were reported during this time.[3] The combination of breastfeeding with maternal kratom and morphine use might have helped alleviate the infant’s withdrawal syndrome. An infant was born to a mother who was taking kratom in an unspecified dose during pregnancy. The mother had a negative urine drug screen on admission indicating that no other opioids were used just prior to delivery. The infant was breast- and bottle-fed. On postnatal day 1, the infant developed increased fussiness, jitteriness, sneezing, increased respiratory rate, and poor feeding, but symptoms were mild and did not require opioid treatment.[5]

Effects on lactation and breastmilk

Relevant published information was not found as of the revision date.

References

1. Trakulsrichai S, Tongpo A, Sriapha C, et al. Kratom abuse in Ramathibodi Poison Center, Thailand: A five-year experience. J Psychoactive Drugs 2013;45:404–8.24592666 PubMed
2. Eldridge WB, Foster C, Wyble L. Neonatal opioid withdrawal syndrome due to maternal kratom use. Pediatrics 2018;142:e20181839.30404789 PubMed
3. Mackay L, Abrahams R. Novel case of maternal and neonatal kratom dependence and withdrawal. Can Fam Physician 2018;64:121–2.29449242 PubMed
4. Murthy P, Clark D. An unusual cause for neonatal opioid withdrawal syndrome. Paediatr Child Health 2019;24:12–4.30792593 PubMed
5. Love JS, Moss MJ, Thompson JA, et al. A case series of maternal kratom use and newborns with neonatal opioid withdrawal symptoms. J Med Toxicol 2020;16:166. doi:10.1007/s13181-020-00759-7
6. Wright ME, Ginsberg C, Parkison AM, et al. Outcomes of mothers and newborns to prenatal exposure to kratom: A systematic review. J Perinatol 2021;41:1236–43.33589723 PubMed
7. Ya K, Tangamornsuksan W, Scholfield CN, et al. Pharmacokinetics of mitragynine, a major analgesic alkaloid in kratom (Mitragyna speciosa): A systematic review. Asian J Psychiatr 2019;43:73–82.31100603 PubMed