Abstract
Case Report
A 26
She is otherwise healthy and her infant is now 13 months of age without any medical comorbidities.
How will you proceed?
A. Discuss plans for rescheduling the operation with the patient and surgeon.
B. Instruct the patient to express breast milk or feed her infant in the preoperative area before surgery and then express and discard her breast milk for 24 hours after her operation.
C. Instruct the patient to express breast milk or feed infant in the preoperative area before surgery and then express and discard her breast milk once after her operation.
D. Instruct the patient to express breast milk or feed infant in the preoperative area before surgery and resume feeding her infant once she is awake and alert after surgery.
Discussion
Human milk is the recommended source of nutrition for neonates and infants. 1 The World Health Organization (WHO) and the American Academy of Pediatrics (AAP) recommend exclusive breastfeeding until 6 months of age, with continued breastfeeding along with complementary foods for a year or longer (AAP) or up to 2 years and beyond (WHO). As more women choose to breastfeed and do so for a longer duration, questions related to the perioperative management of their lactation may be posed to surgeons, pediatricians, anesthesiologists, primary care doctors, and proceduralists of several specialties.
Historically, concerns about possible adverse effects to the infant and lack of rigorous pharmacological trials in lactating women led to the blanket recommendation that breast milk should be expressed and discarded for a period after anesthesia often phrased as “pump and dump.” This unnecessarily conservative advice by medical professionals is not congruent with the currently accepted recommendations and underestimates the impact on the maternal–infant dyad, which may include perioperative anxiety, mastitis, decreased milk supply, and ultimately undesired early weaning. 2 Discarding expressed milk is necessary in rare circumstances such as medications with long half-lives, variable metabolism, and some radioactive isotopes.
Although there are certainly medications that cross into breast milk and may negatively impact the infant, these medications are largely known and avoidable in a modern anesthetic. Multiple reviews of the literature and the majority of patient and provider experience indicate that it is safe for patients to breastfeed their infants or express breast milk without discarding as soon as they are awake and alert in the postanesthesia care unit (PACU) after a lactation-compatible anesthetic. 3 A safe anesthetic or sedation plan can be developed for most lactating patients, but requires education of patient and staff, communication, and advanced planning when possible.
Anesthesia, analgesia, and lactation
There is little human data regarding the transfer of anesthetic and analgesic medications into breast milk. 4 Recommendations are typically based on pharmacological properties of medications, studies of milk levels, animal data, and case reports. The pharmacological properties of medications including protein binding, lipid solubility, molecular weight, pKa, and maternal plasma drug levels influence which drugs will transfer into breast milk. 5 Most drugs administered to the mother pass from maternal plasma to breast milk by passive diffusion, and as plasma levels fall, they return to the plasma compartment by the same mechanism. 5
Multiple review articles conclude that receiving anesthesia should not affect the mother's ability to breastfeed or the safety of her milk once she is awake and alert. 3,6,7 Resumption of normal mentation is the hallmark that medications have redistributed from the plasma compartment (and milk compartment) and indicate a low plasma level of medication. 8 Commonly used medications in anesthesia and their compatibility are summarized in Table 1. Medications used in routine anesthesia care such as midazolam, propofol, etomidate, volatile anesthetics, paralytics, local anesthetics, and antiemetics are thought to be safe. An excellent resource for clinicians is the Drugs and Lactation Database (LactMed) website that is part of the National Library of Medicine's Toxicology Data Network. 9
Compatibility of Commonly Used Medications During Anesthesia with Breastfeeding
Limited studies available, recommend monitoring infant for adverse effects.
Analgesic medications are frequently used during the postoperative period. In lactating patients, nonopioid analgesics should be first-line for pain management as they are nonsedating for both mother and infant. Nonsteroidal anti-inflammatory drugs are generally safe for breastfeeding infants and transfer to breast milk is low. Ibuprofen is ideal, whereas naproxen and celecoxib are both considered safe. Intravenous ketorolac provides excellent analgesia without sedating side effects. Limited data on ketorolac is available, milk levels are low with usual intravenous dosage but higher dosages have not been studied. 9 Acetaminophen has low transfer into milk and should be used as part of a multimodal regimen. There is limited data on the safety of ketamine and breastfeeding. Given the safety profile of local anesthetics during lactation and opioid-sparing effect, consideration should be given to regional techniques for primary anesthesia and postoperative analgesia whenever possible. 3,6,7,9
When opioid medications are needed, short acting medications are preferred. Fentanyl as a single intravenous dose has been shown to be safe. The exposure of the infant for 24 hours is rarely >1%–2% of the original maternal dose. 10 If the mother is receiving a longer acting intravenous opioid such as morphine or hydromorphone, caution should be used and close monitoring is recommended with repeated maternal doses. Oral opioid use should be limited to the shortest reasonable course and infants should be monitored closely for sedation while mothers are taking these medications. Hydrocodone has commonly been used in breastfeeding mothers with rare dose-related cases of neonatal sedation. Recommendations include limiting the dose to a maximum of 30 mg per day. 11 Oxycodone is also used frequently postpartum and postoperatively in lactating women and rarely can lead to infant sedation. A maximum total daily dose of 30 mg is also recommended. 9
Opioid medications to avoid while breastfeeding include meperidine, codeine, and tramadol. Meperidine and its metabolite normeperidine have long half-lives with wide ranges of levels reported in breast milk. Studies have shown that exposed infants are at higher risk of respiratory depression. 3,12 Codeine is a prodrug that is metabolized to morphine by the hepatic enzyme system CYP2D6. Tramadol is also metabolized by CYP2D6 into O-desmethyltramadol (M1). Mothers who are ultrarapid metabolizers may have larger than expected blood concentrations of morphine (for codeine) and M1 (for tramadol), which could increase risk of neonatal depression. There has been one infant death related to codeine use in the breastfeeding mother. 13 Therefore, the U.S. Food and Drug Administration issued a Drug Safety Communication warning against the use of codeine and tramadol in breastfeeding mothers.
In certain circumstances when opioids are required for the mother, it may be judicious to interrupt breastfeeding briefly (6–12 hours), for example, for preterm infants or those at risk for apnea, hypotension, or hypotonia. Mothers can still express their breast milk during this time frame and either store the milk until the infant is older or dilute the breast milk with fresh milk not containing any medications. 8
In preparation for surgery, preoperative providers should inform patients to pump and store breast milk for missed feedings that may occur during surgery. This quantity will vary depending on the type and length of surgery, but patients should prepare for at least one missed feeding. Patients should be instructed to bring their breast pump, breast milk storage containers, and a cooler with ice packs. The American Society of Anesthesiologists preoperative fasting guidelines should be used preoperatively, which would allow clear liquids up until 2 hours before surgery. Unnecessary prolonged fasting should be avoided. Patients should breastfeed or pump close to the time of surgery to avoid painful overfilling of breasts. After surgery, patients can breastfeed or pump as soon as they are awake, alert, and able in the recovery room. If the patient is hospitalized after surgery and will not be with the child every feeding, the patient should pump every 3–4 hours.
Answer: D
In this instance, the mother is scheduled to undergo a short procedure and should be able to resume breastfeeding in the recovery room after anesthesia. The infant is healthy with no significant medical issues. The patient should feed the infant or express breast milk as close to the operative time as possible. The anesthesiologist should avoid incompatible medications and select from any number of the medications that are safe while breastfeeding. Postoperatively, the patient can breastfeed or pump as soon as she is awake, alert, and able, and the surgeon can prescribe medications for postoperative pain that are compatible with breastfeeding. Even though it is a short procedure, banking some extra milk in advance of the day of surgery is advisable for possible missed feedings.
Footnotes
Author Disclosure Statement
No competing financial interests exist.