Anesthesia and breastfeeding
Abstract
The importance of breastfeeding with its positive impact on the wellbeing of the mother-infant pair is well established. Anesthesiologists should encourage the promotion of lactation by being willing to give reassurance during the preoperative period and preparing a plan that does not interfere with safe breastfeeding. There is concern regarding the transfer of drugs into breast milk, which may lead to inconsistent advice from many health professionals and to early discontinuation. However, evidence shows that most anesthetic drugs are safe in terms of transfer into breast milk, and hence, compatible with breastfeeding, which should be resumed after anesthesia as soon as the mother is alert and feels well enough to hold her infant, without the need to “pump and dump”. This review provides pharmacokinetic information on commonly used anesthesia drugs and their passage into breast milk, to help practitioners discuss risks and benefits with the mother, emphasizing that anesthesia should not interfere with the benefits of breastfeeding. Four practical clinical scenarios are presented: pregnant women concerned about the effect of epidural analgesia on subsequent breastfeeding, spinal anesthesia for c-section and lactation, patients who will receive general anesthesia during cesarean section, and finally women who are breastfeeding and require anesthesia for elective or urgent surgery. Neuraxial anesthesia allows for better pain control and immediate skin-to-skin contact at the time of childbirth. Also, it interferes the least with the woman’s ability to care for her infant. Regional techniques, opioid-sparing techniques and outpatient surgery are preferred. Drugs such as opioids and longer-acting benzodiazepines should be administered cautiously, particularly in repeat doses.
References
OMS. Estrategia mundial para la alimentación del lactante y el niño pequeño [Internet]. Ginebra: OMS; 2003 [cited 2020 Nov 24]. Available at: https://www.who.int/nutrition/publications/gs_infant_feeding_text_spa.pdf
Sankar MJ, Sinha B, Chowdhury R, Bhandari N, Taneja S, Martines J, et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):3-13. doi: https://doi.org/10.1111/apa.13147
World Health Organization (WHO). Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: 2017 [cited 2020 Sep 23]. Available at: https://apps.who.int/iris/bitstream/handle/10665/259386/9789241550086-eng.pdf?sequence=1
Brown CR, Dodds L, Legge A, Bryanton J, Semenic S. Factors influencing the reasons why mothers stop breastfeeding. Can J Public Health. 2014;105(3):e179-85. doi: https://doi.org/10.17269/cjph.105.4244
Ministerio de Salud. Informe técnico encuesta nacional de lactancia materna en la atención primaria (ENALMA), en colaboración con Comité Nacional de lactancia materna (CONALMA). Chile 2013 [cited 2020 Nov 4]. Available at https://www.minsal.cl/sites/default/files/INFORME_FINAL_ENALMA_2013.pdf
Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet. 2016;387(10017):475-90. doi: https://doi.org/10.1016/S0140-6736(15)01024-7
Aedo C. Economic Evaluation of prolonging the Postnatal Period. Rev Chil Pediatr. 2007;78(1):10-50. doi: http://dx.doi.org/10.4067/S0370-41062007000600003
Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125:e1048-56. doi: https://doi.org/10.1542/peds.2009-1616
Sankar MJ, Sinha B, Chowdhury R, et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):3-13. doi: https://doi.org/10.1111/apa.13147
Dalal PG, Bosak J, Berlin C. Safety of the breast-feeding infant after maternal anesthesia. Paediatr Anaesth. 2014;24:359-71. doi: https://doi.org/10.1111/pan.12331
UK Drugs in Lactation Advisory Service (UKDILAS). UK Medicines Information Specialist Pharmacy Service, 2018 [cited 2021 Mar 4]. Available at: https://www.sps.nhs.uk/articles/ukdilas, acceso 20 noviembre 2020.
Drugs and lactation database (LactMed) [internet]. 2019 [cited 2020 Sep 20]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK501922/
e-lactancia.org. APILAM: Asociación para la promoción e investigación científica y cultural de la lactancia materna; 2002 [cited 2020 Nov 20]. Available at: http://e-lactancia.org
Chestnut DH. Labor epidural analgesia and breastfeeding. Anesthesiology. 2017(4);127:593-5. doi: https://doi.org/10.1097/ALN.0000000000001794
Lim G, Facco FL, Nathan N, Waters JH, Wong CA, Eltzschig HK. A review of the impact of obstetric anesthesia on maternal and neonatal outcomes. Anesthesiology. 2018;129(1):192-215. doi: https://doi.org/10.1097/ALN.0000000000002182
Cobb B, Liu R, Valentine E, Onuoha O. Breastfeeding after anesthesia: A review for anesthesia providers regarding the transfer of medications into breast milk. Transl Perioper Pain Med. 2015;1(2):1-7. doi: https://doi.org/10.31480/2330-4871/023
Gyanesh P, Radhika K, Sinha M, Haldar R. Postdural puncture headache after caesarean section: are preventive strategies worse than the cure? Rev Bras Anestesiol. 2015;65(1):82-83. doi: https://doi.org/10.1016/j.bjane.2014.04.002.
Mitchell J, Jones W, Winkley E, Kinsella SM. Guideline on anaesthesia and sedation in breastfeeding women 2020. Anaesthesia. 2020;75:1482-93. doi: https://doi.org/10.1111/anae.15179
Stelwagen K, Singh K. The role of tight junctions in mammary gland function. J Mammary Gland Biol Neoplasia. 2014;19(1):131-8. doi: https://doi.org/10.1007/s10911-013-9309-1
Hotham N, Hotham E. Drugs in breastfeeding. Aust Prescr. 2015;38(5):156-9. doi: https://doi.org/10.18773/austprescr.2015.056
Askie LM, Duley L, Henderson-Smart DJ, Stewart LA; PARIS Collaborative Group. Antiplatelet agents for prevention of pre-eclampsia: a meta-analysis of individual patient data. Lancet. 2007;369(9575):1791-8. doi: https://doi.org/10.1016/S0140-6736(07)60712-0
EMA. Committee for Medicinal Products for Human Use (CHMP). Referral under Article 31 of Directive 2001/83/EC metamizole-containing medicinal products [internet]. 2018 [cited 2020 dic. 2]. Available at: https://www.ema.europa.eu/en/documents/referral/metamizole-article-31-referral-chmp-assessment-report_en.pdf
Shah RR. Metamizole (dipyrone)-induced agranulocytosis: Does the risk vary according to ethnicity? J Clin Pharm Ther. 2019;44(1):129-33. doi: https://doi.org/10.1111/jcpt.12768
Nitsun M, Szokol JW, Saleh HJ, Murphy GS, Vender JS, Luong L, et al Pharmacokinetics of midazolam, propofol, and fentanyl transfer to human breast milk. Clin Pharmacol Ther. 2006;79:549-57. doi: https://doi.org/10.1016/j.clpt.2006.02.010
Stuttmann R, Schäfer C, Hilbert P, Meyer MR, Maurer HH. The breast feeding mother and xenon anaesthesia: four case reports. Breast feeding and xenon anaesthesia. BMC Anesthesiol. 2010;10:1. doi: https://doi.org/10.1186/1471-2253-10-1
Koren G, Cairns J, Chitayat D, Gaedigk A, Leeder SJ. Pharmacogenetics of morphine poisoning in a breastfed neonate of a codeine-prescribed mother. Lancet. 2006;368:704. doi: https://doi.org/10.1016/S0140-6736(06)69255-6
U.S. Food and Drug Administration. FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommendations against use in breastfeeding women [internet]. 2017 [cited 2020 Nov 5 ]. Available at: https://www.fda.gov/drugs/fda-drug-safety-podcasts/fda-drug-safety-podcast-fda-restricts-use-prescription-codeine-pain-and-cough-medicines-and-tramadol
Palmer GM, Anderson BJ, Linscott DK, Paech MJ, Allegaert K. Tramadol, breast feeding and safety in the newborn. Arch Dis Child. 2018;103:2017. doi: https://doi.org/10.1136/archdischild-2017-313786
Lam J, Kelly L, Ciszkowski C, et al. Central nervous system depression of neonates breastfed by mothers receiving oxycodone for postpartum analgesia. J Pediatr. 2012;160:33-7; e2. doi: https://doi.org/10.1016/j.jpeds.2011.06.050
Edwards JE, Rudy AC, Wermeling DP, Desai N, McNamara PJ. Hydromorphone transfer into breast milk after intranasal administration. Pharmacotherapy. 2003;23(2):153-8. doi: https://doi.org/10.1592/phco.23.2.153.32081
Martin E, Vickers B, Landau R, Reece-Stremtan S, the Academy of Breastfeeding Medicine. ABM Clinical Protocol #28, Peripartum analgesia and anesthesia for the breastfeeding mother. Breastfeed Med. 2018;13:164-71 doi: https://doi.org/10.1089/bfm.2018.29087.ejm
Corda DM, Robards CB. Sugammadex and oral contraceptives: Is it time for a revision of the anesthesia informed consent? Anesth Analg. 2018;126(2):730-1. doi: https://doi.org/10.1213/ANE.0000000000002677
Bar-Oz B, Bulkowstein M, Benyamini L, Greenberg R, Soriano I, Zimmerman D, et al. Use of antibiotic and analgesic drugs during lactation. Drug Saf. 2003;26(13):925-35. doi: https://doi.org/10.2165/00002018-200326130-00002
Moretti ME, Lee A, Ito S. Which drugs are contraindicated during breastfeeding? Practice guidelines. Can Fam Physician. 2000;46:1753-7.
Beilin Y, Bodian CA, Weiser J, Hossain, S, Arnold I, Feierman DE, et al. Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study. Anesthesiology. 2005;103:1211-7. doi: https://doi.org/10.1097/00000542-200512000-00016
Halpern SH, Ioscovich A. Epidural analgesia and breast-feeding. Anesthesiology. 2005;103:1. doi: https://doi.org/10.1097/00000542-200512000-00002
Lee A, McCarthy R, Toledo P, Jones MJ, White N, Wong C. Epidural labor analgesia—fentanyl dose and breastfeeding success: a randomized clinical trial. Anesthesiology. 2017;127:614-24. doi: https://doi.org/10.1097/ALN.0000000000001793
Chang ZM, Heaman MI. Epidural analgesia during labor and delivery: Effects on the initiation and continuation of effective breastfeeding. J Hum Lact. 2005;21(3):305-26. doi: https://doi.org/10.1177/0890334405277604
Hobbs AJ, Mannion CA, McDonald SW, Brockway M, Tough SC. The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum. BMC Pregnancy Childbirth. 2016;16:90. doi: https://doi.org/10.1186/s12884-016-0876-1
Brown A, Jordan S. Impact of birth complications on breastfeeding duration: an internet survey. J Adv Nurs. 2013;69(4):828-39. doi: https://doi.org/10.1111/j.1365-2648.2012.06067.x
Yousefshahi F, Davari-Tanha F, Najafi A, Kaveh M, Rezaei-Hemami M, Khashayar P, et al. Effects of Intrathecal opioids in cesarean section on breastfeeding and Newborns’ weight Gaining. J Fam Reprod Health. 2016;10(4):176-83.
Oliveira MR, Santos MG, Aude DA, Lima RM, Módolo NS, Navarro LH. Should maternal anesthesia delay breastfeeding? A systematic review of the literature. Braz. J. Anesthesiol. 2019;69(2):184-96. doi: https://doi.org/10.1016/j.bjane.2018.12.006
Roofthooft E, Joshi GP, Rawal N, Van de Velde M, & PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy and supported by the Obstetric Anaesthetists’ Association. PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia. 2021;76(5):665-80. doi: https://doi.org/10.1111/anae.15339
Abdel-Aleem M, Osman A, Morsy K. Effect of coadministration of dexamethasone with intrathecal morphine on postoperative outcomes after cesarean delivery. Int J Gynaecol Obstet. 2012;116(2):158-61. doi: https://doi.org/10.1016/j.ijgo.2011.10.002
Imeh A, Olaniyi O, Simeon O, Omotola O. Dexamethasone versus a combination of dexamethasone and ondansetron as prophylactic antiemetic in patients receiving intrathecal morphine for caesarean section. Afr Health Sci. 2014;14(2):453-9. doi: https://doi.org/10.4314/ahs.v14i2.23
Crenshaw JT Healthy Birth Practice #6 Keep mother and baby together- It’s best for mother, baby and breastfeeding J Perinat Educ. 2014;23(4):211-7. doi: https://doi.org/10.1891/1058-1243.23.4.211
Guala A, Boscardini L, Visentin R, Angellotti P, Grugni L, Barbaglia M, et al. Skin-to-skin contact in cesarean birth and duration of breastfeeding: a cohort study. Scient World J. 2017;2017:1940756. doi: https://doi.org/10.1155/2017/1940756
Ghaffari S, Dehghanpisheh L, Tavakkoli F, Mahmoudi H. The effect of spinal versus general anesthesia on quality of life in women undergoing cesarean delivery on maternal request. Cureus. 2018;10(12):e3715. doi: https://doi.org/10.7759/cureus.3715
Karasu D, Yilmaz C, Ozgunay SE, Cansabuncu S, Korfali G. A comparison of the effects of general anaesthesia and spinal anaesthesia on breastfeeding. C R Acad Bulg Sci. 2018;71:993-1000. doi: https://doi.org/10.7546/CRABS.2018.07.17
United Nations International Children's Emergency Fund (UNICEF). Breastfeeding during the COVID-19 pandemic. Tips on keeping your baby healthy and safe [internet]. 2021 [cited 2021 Mar 25]. Available at: https://www.unicef.org/ eap/breastfeeding-during-covid-19
Wanderer JP, Rathmell JP. Anesthesia & breastfeeding: more often than not, they are compatible. Anesthesiology. 2017;127(4):A15-A15. doi: https://doi.org/10.1097/ALN.0000000000001867
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