Review of Evidence on Alcohol and Health (2025)
Chapter: 8 Maternal Alcohol Consumption During Lactation
8
Maternal Alcohol Consumption During Lactation
This chapter discusses the last three of the eight questions in the Statement of Task (Box 8-1).
BACKGROUND
Breastfeeding and/or the feeding of human milk is the gold standard for infant nutrition for almost all healthy infants, and most expert groups recommend exclusive breastfeeding through age six months and continued breastfeeding along with appropriate complementary foods as long as mutually desired by mother and child (AAFP, 2024; ACOG, 2018; Critch et al., 2014; HHS and ODPHP, 2024; Meek and Noble, 2022; WHO and UNICEF, 2003). These recommendations reflect benefits to both maternal and infant health. Human milk provides all essential and conditionally essential nutrients in amounts adequate to meet an infant’s needs. It also provides a complex array of biologically active components, maternal cells, and microbes that contribute enzymatic, hormonal, and immunomodulatory functions to the developing infant (Smilowitz et al., 2023). Although the underlying mechanisms remain unclear, exclusive breastfeeding is associated with some protection against selected illnesses such as inflammatory bowel disease, diabetes, asthma, and obesity (as reviewed by Meek and Noble, 2022). Having been breastfed may also affect neurodevelopmental outcomes such as intelligence (Horta et al., 2015; Victora et al., 2015) and risks of attention-deficit and hyperactivity disorder (Tseng et al., 2019a) and autism spectrum disorder (ASD; Tseng et al., 2019b).
Breastfeeding is also associated with positive maternal outcomes, though study findings are less consistent than those for infants. Although some studies report a positive association between breastfeeding and postpartum weight loss, this relationship is complicated by the duration of breastfeeding, maternal age, maternal body mass index (BMI), and parity (Feltner et al., 2018; Jiang et al., 2018). Perhaps the most consistent evidence relates to breast cancer, such that people who have lactated have decreased risk of breast cancer compared to those who have not, and this association is even stronger with exclusive breastfeeding and longer breastfeeding durations (Chowdhury et al., 2015; Feltner et al., 2018; Unar-Munguía et al., 2017).
Breastfeeding may be contraindicated under some conditions, such as certain viral or microbial infections, when there is a risk for potentially harmful agents entering human milk (Meek and Noble, 2022). Illicit drugs such as opioids and cocaine can also pass into milk and might negatively affect infant neurodevelopment (Meek and Noble, 2022). With respect to cannabis and alcohol, which are legal in some or all U.S. states, respectively, and although their bioactive components (tetrahydrocannabinol/THC and ethanol, respectively) enter milk after maternal use, their putative effects on lactation, milk composition, and infant outcomes are understudied, and research results have been inconsistent (Castro-Navarro et al., 2024; Haastrup et al., 2014; Metz and Borgelt, 2018). Nonetheless, use of alcohol and cannabis products during breastfeeding is generally discouraged.
BIOLOGICAL PLAUSIBILITY
It is plausible that maternal alcohol consumption during lactation might be associated with changes in postpartum weight gain or loss, milk quality (composition) and quantity, and infant developmental milestones. With respect to postpartum weight change, alcohol has a high metabolizable
energy content (7 kilocalorie/gram), and thus its consumption might reduce weight loss by promoting neutral or positive energy balance. This is because ethanol can be metabolized directly for energy or converted into fatty acids and stored in adipose tissue when energy needs are met by other nutrients (Wilson and Matschinsky, 2020). Postpartum weight retention predicts obesity later in life, future cardiometabolic risk, and prepregnancy obesity in subsequent pregnancies (McKinley et al., 2018; Rooney and Schauberger, 2002; Sundaram et al., 2014). These outcomes are particularly important given current estimates from 2015 to 2018 that nearly 70 percent of U.S. women 20 years and older are overweight or obese (CDC, 2019). An established literature shows that consumed alcohol quickly distributes throughout the body, including the mammary gland. There is consistent and strong evidence that maternal alcohol consumption equivalent to 0.5–2.0 U.S. drinks/day during lactation leads to ethanol concentrations in milk that are essentially equivalent to those in the blood (Kesäniemi 1974; Lawton, 1985). The rapid appearance of ethanol in milk following maternal alcohol consumption during breastfeeding has been well established (Argote-Espinosa et al., 1992; Backstrand et al., 2004; Chien et al., 2005, 2009; da-Silva et al., 1993; Flores-Huerta et al., 1992; Kesäniemi, 1974; Lawton, 1985; Mennella, 1997; Mennella and Beauchamp, 1991, 1993). Alcohol concentrations in human milk peak at 30 to 90 minutes after alcohol consumption (as reviewed by Hutchinson et al., 2021).
Maternal alcohol consumption might also affect content of other milk constituents and/or milk production via myriad mechanisms that affect milk synthesis and letdown, including systemic (e.g., hormonal) and local (e.g., gene expression within the epithelial cell; metabolite availability) factors (Heil and Subramanian, 1998; Probyn et al., 2013; Vilaró et al., 1987). Maternal alcohol consumption may influence the presence of olfactory and other sensory molecules in human milk (Lan et al., 2021; Spahn et al., 2019), and those characteristics may negatively affect infant feeding behavior (Mennella and Beauchamp, 1991, 1993), which in turn might affect infant milk demand and thus maternal milk output (Mennella, 1997, 1999).
It is also biologically plausible that maternal alcohol consumption during lactation might affect infant development because the brain continues its exponential development during this time with substantial changes in synaptic formation and pruning along with circuitry consolidation as sensory, motor, recognition, and language skills develop. There are some differences between infant and adult brain function (e.g., the excitatory/inhibitory circuitry switch), but at the biochemical level, alcohol would be expected to interact with its protein targets and redirect their activity similarly across the lifespan, including during infancy. In other words, there is no reason to believe that infants respond differently than adults to alcohol’s effects on the central nervous system and other organ systems. In fact, the
effects in infants may be magnified and more long-lasting precisely because those processes are developing and are therefore malleable.
Although it has been suggested that infant exposure may constitute “less than 2 percent of the alcohol consumed” by the mother (Hutchinson et al., 2021), mechanistic relevance is the actual alcohol concentration in the infant’s circulation, as this drives the strength of alcohol’s protein interactions and thus its biological impact. Additionally, the neonatal liver poorly catabolizes alcohol compared with that of adults (Pikkarainen and Räihä, 1967). As such, alcohol’s effect on an infant may persist longer than an equivalent adult exposure. Finally, it should also be considered that alcohol consumption during the pre-conceptual period by both females and males may have detrimental effects across the perinatal period and beyond.
PRIOR DGA RECOMMENDATIONS
2010
The 2010 Dietary Guidelines Advisory Committee (DGAC) was the last to conduct a systematic review on the topic of breastfeeding and lactation (DGAC, 2010). The committee concluded:
Moderate, consistent evidence shows that when a lactating mother consumes alcohol, alcohol enters the breast milk and the quantity of milk produced is reduced, leading to reduced milk consumption by the infant. Although limited, evidence suggests that alcohol consumption during lactation is associated with altered postnatal growth, sleep patterns, and/or psychomotor patterns of the offspring.
In response, the 2010–2015 DGA stated:
Because of the substantial evidence clearly demonstrating the health benefits of breastfeeding, occasionally consuming an alcoholic drink does not warrant stopping breastfeeding. However, breastfeeding women should be very cautious about drinking alcohol, if they choose to drink at all. If the infant’s breastfeeding behavior is well established, consistent, and predictable (no earlier than at 3 months of age), a mother may consume a single alcoholic drink if she then waits at least 4 hours before breastfeeding. Alternatively, she may express breast milk before consuming the drink and feed the expressed milk to her infant later. (USDA and HHS, 2010)
2015
The 2015 DGAC indirectly considered the association between alcohol consumption during breastfeeding and maternal and infant health in its review of evidence for a relationship between “dietary patterns, foods and
nutrients, and health outcomes” (DGAC, 2015). The committee’s conclusion was the same as that of the 2010 DGAC. The 2015–2020 DGA stated: “Women who are breastfeeding should consult with their healthcare provider regarding alcohol consumption” (USDA and HHS, 2015).
2020
The 2020 DGAC did not review evidence regarding alcoholic beverage consumption by people who are lactating (DGAC, 2020). The 2020–2025 DGA stated:
Not drinking alcohol also is the safest option for women who are lactating. Generally, moderate consumption of alcoholic beverages by a woman who is lactating (up to one standard drink in a day) is not known to be harmful to the infant, especially if the woman waits at least two hours after a single drink before nursing or expressing breast milk. (USDA and HHS, 2020)
REVIEW
Approach
The committee initially conducted an evidence scan as detailed in Chapter 2. This initial scan spanned January 1, 2019, to September 23, 2023, and only two papers were identified (Gibson and Porter, 2020a,b). Because there had not been a systematic literature search by any DGAC on breastfeeding and alcohol since 2010, the committee then conducted the same systematic search to identify all eligible papers published between January 1, 2010, and April 18, 2024. All search terms are provided in Appendix J. A total of 5,731 publications were initially identified (see Figure 8-1 for the PRISMA framework). Of these, 1,014 publications were removed prior to screening: 971 were found to be duplicates, and there were 43 supplemental records.
Of the 4,717 publications remaining, 4,700 were excluded: 70 by single review and 4,630 by dual review. Reasons for exclusion included being duplicates (n = 70), intervention studies not associated with alcohol (n = 858), having outcomes that were not applicable (n = 562), wrong population (n = 646), or study types that did not match the include/exclusion criteria (n = 126). An additional 2,438 studies were excluded for other reasons. The remaining 17 publications were retrieved for assessment; of these, one was excluded because it was an intervention not related to alcohol, three were excluded due to inappropriate study type, and one was excluded for other reasons. This resulted in a total of 12 publications being identified. Following removal of six papers published prior to 2010, the collection of eligible studies for review included the two identified in the initial evidence scan combined (Gibson and Porter, 2020a,b) with the four
NOTES: The diagram shows the number of primary articles identified from the two primary article searches and each step of screening. The literature dates include articles with the publications between 2010 and 2024. n = number; NLM = National Library of Medicine; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
additional publications identified in the second systematic search (Gibson and Porter, 2018; Mennella and Pepino, 2010a; Schneider et al., 2013; Wilson et al., 2017).
Upon careful review of these papers and several recent reviews on the topic, committee members determined that the search strategy may not have identified all eligible studies and began handsearching the literature for additional pertinent studies. These included reviews of the references cited in the previously retrieved studies and several recent reviews on the topic. PubMed was also searched for papers that referenced all these studies. This
process identified one additional paper (Mennella and Pepino, 2010b). In sum, the committee identified a total of seven studies published since 2010 (two from the initial scan, four from the second systematic search, and one from handsearching) that could be used to address the three questions posed in the Statement of Task.
Because the systematic searches identified so few relevant studies, the committee concluded that there were insufficient publications to warrant meta-analyses (including grading of evidence) for any of the questions posed in the Statement of Task, particularly publications evaluating the impact of chronic, moderate maternal alcohol consumption. All the identified studies related to milk composition and milk production were small-scale intervention studies evaluating the effects of acute alcohol consumption—though sometimes at levels above what is considered to be “moderate consumption” (one drink/day). Because of the relative dearth of data published since 2010, it was determined that all seven studies should be included in this chapter and not just those focused on moderate alcohol consumption. Consequently, this chapter is a systematic review with narrative synthesis of the studies identified from the literature searches for each health outcome.
Results
Lactation and Postpartum Weight Loss
No studies published since 2010 addressed the question of maternal alcohol consumption during breastfeeding and postpartum weight loss. Thus, the committee was unable to evaluate this association.
Lactation and Human Milk Composition and Quantity
The committee did not identify any reports since 2010 that provided information on potential changes to milk components other than ethanol after maternal alcohol consumption, although one publication found that when people who are breastfeeding consume small amounts of alcohol, ethanol appears in the milk they produce (Schneider et al., 2013). These researchers investigated the effect of nonalcoholic beer on the ethanol concentration of human milk. Nonalcoholic beverages are of interest because some people who are lactating consume them to avoid alcohol consumption. However, nonalcoholic beverages may still contain small amounts (~0.5–1.2 percent volume) of ethanol. The researchers enrolled 15 breastfeeding women who abstained from alcohol consumption for at least five days and then consumed 1.5 liters of nonalcoholic beer containing 0.42 percent ethanol within a period
of one hour. Complete breast expressions were obtained prior to drinking the nonalcoholic beer (left breast only), from both breasts immediately following beer consumption, and again one and three hours later. Only two of the 105 milk samples collected immediately after beverage consumption had detectable ethanol concentrations, and only one of these had a quantifiable concentration (0.21 milligram/deciliter).
Closely related to the effect of maternal alcohol consumption on milk composition is the impact on milk quantity, which includes milk synthesis, output, and infant milk consumption. These outcomes are distinct and difficult to assess, and thus researchers often rely on proxy measurements (e.g., breastfeeding patterns or duration) and/or circulating levels or effects of lactation-related hormones (e.g., prolactin, oxytocin). The committee identified two papers relevant to this question (Mennella and Pepino, 2010a,b). Mennella and Pepino (2010a) studied 28 exclusively breastfeeding women, seven of whom had a family history of alcoholism; none had alcohol dependence or practiced lifetime alcohol abstinence. Women were randomized to consume 0.4 gram/kilogram body weight of alcohol in orange juice or an equal volume of orange juice in two sessions one week apart. Thirty-five minutes thereafter, the women expressed milk using an electronic pump, and this was reported as “milk yield.” Blood prolactin concentrations were analyzed ~10 minutes before and multiple times after beverage consumption. Participants also recorded how often and at what times of day they nursed their infants. Alcohol consumption magnified the prolactin response to breast pumping regardless of family history of alcoholism. However, compared to those without such a history, women with a family history of alcoholism had a blunted circulating prolactin response to milk expression after consuming both the control and alcohol-containing beverages. There were no associations of family history group or alcohol consumption with amount of milk pumped. Women with family histories of alcoholism reported nursing their infants more frequently than those who did not—particularly in the late afternoon and early morning. Using this same alcohol consumption model, these investigators (Mennella and Pepino, 2010b) also examined the effect of milk expression using a breast pump on ethanol pharmacokinetics and reported that pumping before maternal alcohol consumption reduced breath alcohol concentrations, and pumping after alcohol consumption altered the time curve of breath alcohol concentrations. The data suggest that the act of breastfeeding (or expressing milk) may affect alcohol pharmacokinetics.
Finding 8-1: There was insufficient evidence to determine any association between maternal alcohol consumption at any level during lactation and milk composition or milk production.
Conclusion 8-1: The committee determined that no conclusion could be drawn regarding any associations between maternal alcohol consumption during lactation and milk composition or milk production.
Infant Development
At sufficient levels, alcohol can damage the developing brain through multiple mechanisms including alterations in axonogenesis, synaptogenesis, neuronal expansion and survival, myelination, and neuroinflammation. These changes redirect the brain’s developmental trajectory and cause permanent deficits in multiple behavioral and cognitive domains. However, it is unknown whether quantities of alcohol in human milk can reach a threshold to alter infant brain development. Determining the answer is challenging because the dosage for that threshold is unknown for humans and is likely individualized due to variation in genetics, nutritional status, and external socioeconomic factors. Another challenge is that many people (13.5 percent, Gosdin et al., 2022) consume alcohol during pregnancy as well as during lactation, and it is difficult to disentangle the consequences of prenatal versus lactational alcohol exposure.
The committee identified one study (Wilson et al., 2017) that assessed the effect of maternal alcohol consumption during breastfeeding on infant sleep, which is critical for brain development and represents a time of active synaptogenesis and pruning to create and stabilize neurocircuitries. In a longitudinal survey of Australian women (Wilson et al., 2017), self-reported alcohol use during lactation was not associated with differences in maternally reported measures of infant sleep, including frequency or duration.
Four studies were identified that addressed the association between maternal alcohol consumption during lactation and offspring cognition and behavior (Gibson and Porter, 2018, 2020a,b; Wilson et al., 2017). Wilson et al. (2017) also assessed child development at eight weeks and 12 months of age using a parental report tool, the Ages and Stages Questionnaire (ASQ-3), and the ASQ Social-Emotional. Compared to children born to mothers who abstained, the investigators found no associations between maternal alcohol use during lactation and infant outcomes at eight weeks of age, including gross and fine motor skills, problem solving, personal-social interactions, and communication skills. At 12 months of age, there was an association only with personal-social interactions and these scores were improved in the abstainers(ORadj = 2.43, 95%CI [1.43, 4.13]; p = 0.001).
Gibson and Porter (2018) assessed cognitive measures at six to seven years of age in an Australian cohort (Longitudinal Study of Australian Children) recruited during infancy. Maternal alcohol consumption in the year prior to recruitment was assessed using the Alcohol Use Disorders Identification
Test-Concise (AUDIT-C) tool. Although an association was found between maternal AUDIT-C scores and nonverbal reasoning at six to seven years of age for children whose mothers had never breastfed, this association did not hold up at age 10 years nor was it found for children whose mothers reported alcohol consumption at the time of first assessment during lactation. There were no associations with vocabulary or early literacy and numeracy. Moreover, the study design did not distinguish between maternal alcohol consumption during pregnancy versus during lactation. In contrast, a follow-up study (Gibson and Porter, 2020a) of this cohort found no association between maternal alcohol consumption and measures of physical, emotional, and social functioning at 6 to 7 years or 10 to 11 years of age, as assessed using the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales.
An additional follow-up study (Gibson and Porter 2020b) evaluated academic performance during school in third and fifth grades. No associations were found between maternal alcohol consumption and academic outcomes. Nonetheless, for mothers who had breastfed at any time, their AUDIT-C scores were negatively associated with the offsprings’ scores with respect to third grade writing (β = −1.56, 95%CI [−2.52, −0.60]; padj = 0.01), spelling (β = −2.06, 95%CI [−3.31, −0.81]; padj <0.0001), and grammar/punctuation (β = −2.11, 95%CI [−3.59, −0.64]; padj = 0.01), and spelling in fifth grade (β = −1.58, 95%CI [−2.74, −0.43]; padj = 0.03). The authors concluded that these reductions in scores were likely attributed to maternal alcohol consumption during breastfeeding, as associations were not observed when considering number of drinking days per pregnancy trimester nor were associations observed in children who were never breastfed. A limitation of these studies is that the infants were recruited from birth to one year, and the AUDIT-C tool assesses alcohol consumption in the entire past year. In addition, Gibson and Porter (2020b) relied on retrospective recall. Thus, the infant’s alcohol exposure during pregnancy and lactation was not differentiated.
One study found no association between alcohol use during lactation and infant sleep as assessed using maternal report. Several observational studies found inconsistent findings on the association between maternal alcohol consumption during lactation and infant and child developmental milestones.
Finding 8-2: There was insufficient evidence to determine an association between maternal alcohol consumption at any level during lactation and infant development.
Conclusion 8-2: The committee determined that no conclusion could be drawn regarding the association between maternal alcohol consumption during lactation and infant development.
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