Elsevier

Environmental Research

Volume 151, November 2016, Pages 321-338
Environmental Research

Tobacco smoking and breastfeeding: Effect on the lactation process, breast milk composition and infant development. A critical review

https://doi.org/10.1016/j.envres.2016.08.002Get rights and content

Abstract

Approximately 10% of women report smoking during pregnancy. The number of breastfeeding women who relapse back to smoking is even greater. Smoking may cause adverse changes to the milk’s composition by not only reducing its protective properties, but also by affecting the infant’s health. The pathophysiological mechanisms underlying these adverse effects are not entirely known.

This article is a review of previous reports about the effects of smoking on the lactation process, breast milk composition and infant development. A systematic search for English language articles published until 2015 was made, using a MEDLINE data. The key search terms were “smoking and breastfeeding”, “smoking and lactation”, “smoking and milk composition”, “nicotine and breast milk”.

Studies have shown that nicotine levels in breast milk of women who smoke are three times higher than those in the plasma levels. Breast milk volume is reduced and the duration of lactation period is shorter. Smoking causes adverse changes to the milk’s composition by not only reducing its protective properties, but also affecting infants’ response to breastfeeding and to breast milk.

Introduction

Smoking is one of the most serious contemporary threats of civilization. Exposure to environmental tobacco smoke (ETS) has been linked to a number of health effects. ETS exposure is associated with adverse impacts on male and female reproduction, perinatal and postnatal manifestations of developmental toxicity, respiratory diseases, cardiovascular diseases and cancers (Haroun et al., 1999).

Over 5300 compounds have been identified in tobacco smoke. ETS or secondhand smoke, means exposure to a mixture of compounds from the smoke of burning tobacco products and smoke exhaled by the smoker. Classes of compounds include carbon and nitrogen oxides, amides, imides, lactams, lactones, aldehydes, ketones, carboxylic acids, alcohols, phenols, esters, amines, N-nitrosamines, N-heterocyclics, nitriles, nitro compounds, anhydrides, carbohydrates, ethers, hydrocarbons and metals (IARC, 2012). The principal tobacco alkaloid and major psychoactive component in smoke is nicotine. It is responsible for the addictive properties of tobacco smoke (Hukkanen et al., 2005). There are over 70 carcinogens in tobacco smoke that have been evaluated by the International Agency for Research on Cancer – IARC (IARC, 2004). Sixteen of them (among others: N′-nitrosonornicotine, 2-naphthylamine, formaldehyde, benzene, arsenic, beryllium, nickel compounds, chromium VI, cadmium, polonium-210) are classified as Group 1 - carcinogenic to humans. Moreover, there are other carcinogens in tobacco smoke that have not been evaluated by the IARC Monographs program (IARC, 2012).

In spite of documented evidence on the harmful effects of smoking on the fetus and infants, a considerable number of women continue to smoke during pregnancy and lactation. In the United States (US), 10.7% of pregnant women smoke (Centers for Disease Control and Prevention, 2012). It is estimated that in Europe this problem also affects more than 1 in 10 pregnant women (Euro-Peristat, 2013). As there is a tendency to quickly return to tobacco smoking after an interval of smoking cessation during pregnancy with 50–80% relapsing to smoking within six months after delivery. The US Surgeon General (SG), the American Academy of Pediatrics (AAP) and the World Health Organization (WHO) have recommended exclusive breastfeeding (with the exception of infants of HIV positive mothers) during the first 6 months (Centers for Disease Control and Prevention, 2002, Butte et al., 2002, Gartner et al., 2005). Thus the number of women smoking while breastfeeding represent a significant population of women and infants at risk.

Breast milk of mothers who smoke is a significant contributor to infant exposure to ETS constituents. Women who are less educated, have lower socioeconomic status and who began smoking at a younger age may not recognize or be aware of the adverse effects of tobacco smoking on fetal development, low birth weight, premature infants and increased complications of pregnancy such as placental abruption (Centers for Disease Control and Prevention, 2012, Euro-Peristat, 2013).

This article is a review of previous reports on the impact of smoking on the lactation process, breast milk composition and infant development. A systematic search for English language articles published until 2015 was made, through a MEDLINE search using the terms “smoking and breastfeeding”, “smoking and lactation”, “smoking and milk composition”, “nicotine and breast milk”. Additional studies were identified through a search of the Cochrane and Scopus database, through discussions with experts, and by hand-searching of reference lists from major review articles. This review aims to describe the literature available with particular reference to the impact of tobacco smoking during breastfeeding and nicotine consumption on the lactation process, milk changes in composition and dangers/risks on the well-being and health status of children as well as to discuss the necessary future directions of research in this matter.

Section snippets

Nicotine and cotinine in breast milk

Simultaneous maternal smoking and breastfeeding significantly increases absorption of nicotine by the infant compared to this only being exposed to tobacco smoke (Luck and Nau, 1985, Dahlström et al., 1990, Schulte-Hobein et al., 1992). Studies of pharmacokinetics of nicotine have shown that its half-life in milk (t1/2=97±20 min) is longer than the half-life in serum (t1/2=81±9 min); however, the difference between these two values was not statistically significant (Luck and Nau, 1985). When

Effect of smoking on the lactation process

Among women who smoke reduced production of milk and shorter lactation periods are observed (Clements et al., 1997, Scott and Binns, 1999, Horta et al., 2001, Knudsen et al., 2001, Letson et al., 2002). Hopkinson et al. (1992) have shown that the daily amount of milk up to 2 weeks after birth was 406±262 mL/day in smoking mothers, while in the control group of non-smoking mothers 514±338 mL/day. Between weeks 2 and 4 after initiation of lactation, the amount of milk produced by non-smoking women

Tobacco smoke impair breast milk taste and composition

Infants of mothers smoking during pregnancy are usually born with lower birth weights by 150–250 g than infants of non-smoking women (Fried, 1993). The results of studies on weight gain of breastfed babies of smoking mothers are varied (Schulte-Hobein et al., 1992, Schwartz-Bickenbach et al., 1987, Little et al., 1994, Nafstad et al., 1997, Boshuizen et al., 1998, Visscher et al., 2003, Shenassa et al., 2015). Nevertheless, there are reports indicating that nicotine in breast milk may suppress

Exposure to tobacco smoke through breast milk and the infant development

Infants exposed to the harmful effect of smoking by their mothers run a higher probability of suffering from otitis media, and from lower and upper respiratory tract infections – 2.9, 8.2 and 15.3 times higher, respectively. However, it has been shown in the case of SHS exposure that breastfeeding may reduce this risk (Yilmaz et al., 2009).

Nicotine in breast milk may affect the infants' heart rate variability. Power values of frequency domains (HRV) in male infants of mothers who smoke have

Discussion

ETS is a complex mixture of chemicals generated during burning of tobacco products. Chemicals present in ETS, among others, include mutagens, carcinogens and reproductive toxicants (Haroun et al., 1999). To date, over 70 compounds in tobacco smoke have been identified by IARC as carcinogens. 16 of them are listed as carcinogenic to humans (Group I) (IARC, 2012). There are reports about the transfer of some of them (for example tobacco-specific nitrosamines: NNN, NNK, BaP) into milk (LaVoie et

Conflict of interest statement

The authors declare that there is no conflict of interest.

References (144)

  • G.S. Maritz et al.

    Chronic maternal nicotine exposure during gestation and lactation and the development of the lung parenchyma in the offspring. Response to nicotine withdrawal

    Pathophysiology

    (2003)
  • S. Nakauchi et al.

    Early postnatal nicotine exposure causes hippocampus-dependent memory impairments in adolescent mice: association with altered nicotinic cholinergic modulation of LTP, but not impaired LTP

    Neurobiol. Learn Mem.

    (2015)
  • C. Agostoni et al.

    Earlier smoking habits are associated with higher serum lipids and lower milk fat and polyunsaturated fatty acid content in the first 6 months of lactation

    Eur. J. Clin. Nutr.

    (2003)
  • American Academy of Pediatrics Committee on Drugs

    The transfer of drugs and other chemicals into human milk

    Pediatrics

    (2001)
  • A.N. Andersen et al.

    Suppressed prolactin but normal neurophysin levels in cigarette smoking breast-feeding women

    Clin. Endocrinol.

    (1982)
  • E. Avila-Tang et al.

    Assessing secondhand smoke using biological markers

    Tob. Control.

    (2013)
  • P. Bachour et al.

    Effects of smoking, mother’s age, body mass index, and parity number on lipid, protein, and secretory immunoglobulin A concentrations of human milk

    Breast. Med

    (2012)
  • A. Baheiraei et al.

    The effects of maternal passive smoking on maternal milk lipid

    Acta Med. Iran.

    (2014)
  • N.L. Benowitz et al.

    Nicotine chemistry, metabolism, kinetics and biomarkers

    Handb. Exp. Pharmacol.

    (2009)
  • C.A. Blake et al.

    Nicotine blocks the suckling-induced rise in circulating prolactin in lactating rats

    Science

    (1972)
  • H. Boshuizen et al.

    Maternal smoking during lactation: relation to growth during the first year of life in a Dutch birth cohort

    Am. J. Epidemiol.

    (1998)
  • J.E. Bruin et al.

    Fetal and neonatal nicotine exposure and postnatal glucose homeostasis: identifying critical windows of exposure

    J. Endocrinol.

    (2007)
  • N.F. Butte et al.

    Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life

    WHO Report Geneva

    (2002)
  • Centers for Disease Control and Prevention

    US Public Health Service Women and Smoking: A Report of the Surgeon General

    (2002)
  • Centers for Disease Control and Prevention, US, 2012. Tobacco Use and Pregnancy. http://www cdc...
  • T. Chajek-Shaul et al.

    The effect of acute and chronic administration of nicotine on lipoprotein lipase activity

    Int. Angiol.

    (1987)
  • C.M. Chen et al.

    Maternal nicotine exposure during gestation and lactation induces kidney injury and fibrosis in rat offspring

    Pediatr. Res.

    (2015)
  • B. Chilmonczyk et al.

    Environmental tobacco smoke exposure during infancy

    Am. J. Public Health

    (1990)
  • S.Y. Chou et al.

    Association between exposure to environmental tobacco smoke (ETS) and breastfeeding behavior

    (2008)
  • M. Clements et al.

    Influences on breastfeeding in southeast England

    Acta Paediatr.

    (1997)
  • B. Cross

    The hypothalamus and the mechanism of sympathetic-adrenal inhibition of milk ejection

    J. Endocrinol.

    (1995)
  • A. Czarnywojtek et al.

    The influence of radioiodine therapy on ocular changes and their relation to urine cotinine level in patients with Graves' Ophthalmopathy

    Neuro. Endocrinol. Lett.

    (2013)
  • A. Dahlström et al.

    Nicotine exposure in breastfed infants

    Acta Paediatr.

    (2004)
  • A. Dahlström et al.

    Nicotine in breast milk influences heart rate variability in the infant

    Acta Paediatr.

    (2008)
  • A. Dahlström et al.

    Nicotine and cotinine concentrations in the nursing mother and her infant

    Acta Paediatr. Scand.

    (1990)
  • D. Dempsey et al.

    Accelerated metabolism of nicotine and cotinine in pregnant smokers

    J. Pharmacol. Exp. Ther.

    (2002)
  • D.A. Dempsey et al.

    Nicotine metabolism and elimination kinetics in newborns

    Clin. Pharmacol. Ther.

    (2000)
  • D.A. Dempsey et al.

    CYP2A6 genotype but not age determines cotinine half-life in infants and children

    Clin. Pharmacol. Ther.

    (2013)
  • J.G. Dorea

    Maternal smoking and infant feeding: breastfeeding is better and safer

    Matern. Child Health J.

    (2007)
  • B. Ermis et al.

    Influence of smoking on human milk tumor necrosis factor-α, interleukin-1β, and soluble vascular cell adhesion molecule-1 levels at postpartum seventh day

    Pediatr. Int.

    (2009)
  • İ. Etem Pişkin et al.

    Effect of maternal smoking on colostrum and breast milk cytokines

    Eur. Cytokine Netw.

    (2012)
  • Euro-Peristat, 2013. European Perinatal Health Report 2010, Health care pregnant Women babies Eur. 2010 2013.http://www...
  • R. Fant et al.

    Nicotine dependence in women

    J. Am. Med. Women’s. Assoc.

    (1996)
  • K.E. Farsalinos et al.

    Tobacco-specific nitrosamines in electronic cigarettes

    Comp. Liq. Aerosol Lev.

    (2015)
  • B.B. Ferguson et al.

    Determination of nicotine concentrations in human milk

    Am. J. Dis. Child.

    (1976)
  • J.D. Ferreira, et al.

    Pregnancy, maternal tobacco smoking, and early age leukemia in Brazil

    Front. Oncol.

    (2012)
  • P. Fried

    Prenatal exposure to tobacco and marijuana: effects during pregnancy, infancy, and early childhood

    Clin. Obstet. Gynecol.

    (1993)
  • J.F. Frøen et al.

    Adverse effects of nicotine and interleukin-1beta on autoresuscitation after apnea in piglets: implications for sudden infant death syndrome

    Pediatrics

    (2000)
  • K. Gamieldien et al.

    Postnatal expression of cytochrome P450 1A1, 2A3, and 2B1 mRNA in neonatal rat lung: influence of maternal nicotine exposure

    Exp. Lung Res.

    (2004)
  • L.M. Gartner et al.

    Breastfeeding and the use of human milk

    Pediatrics

    (2005)
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