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ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2017
Abstract
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .
Background
THERE IS LITTLE RIGOROUS INFORMATION in the scientific literature about anesthesia or procedural sedation in breastfeeding mothers. Recommendations in this area typically focus on pharmacologic properties of anesthetic agents, limited studies of milk levels, and rare infant effects. In addition to medication concerns, additional perioperative considerations may impact a breastfeeding dyad’s continued breastfeeding success when a mother undergoes anesthesia or sedation. Despite the lack of controlled studies regarding outcomes of breastfeeding in mothers receiving anesthesia, multiple review articles conclude that most mothers may safely breastfeed immediately following anesthesia. (IV) (Quality of evidence [levels of evidence IA, IB, IIA, IIB, III, and IV] is based on levels of evidence used for the National Guidelines Clearing House and is noted in parentheses.) Most recommendations for breastfeeding in the perioperative setting come from expert opinion rather than from extensive studies or trials. Up-to-date information on specific medications can be found on the United States National Library of Medicine website LactMed, with additional resources listed in Table 1 .
Table 1
Resources of Information About Medications
| Resource | Sponsor | Website and contact information |
|---|---|---|
| LactMed | U.S. National Library of Medicine | https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm |
| E-Lactancia | Association for Promotion and Cultural and Scientific Research of Breastfeeding, Spain | www.e-lactancia.org |
| Infant Risk Center | Texas Tech University Health Sciences Center, TX | www.infantrisk.org and +1 806-352-2519 |
| Breastfeeding and Human Lactation Study Center | University of Rochester, NY | +1 585-275-0088 |
| Mother to Baby | Organization of Teratology Information Specialists | https://mothertobaby.org and +1 866-626-6847 |
| Motherisk | Hospital for Sick Children, Toronto Canada | www.motherisk.org and +1 877-439-2744 |
Medication guidelines discussed in this protocol may be extended to mothers in the immediate postpartum period; however, specific considerations for this population are detailed in ABM Protocol #28, Peripartum Anesthesia and Analgesia for the Breastfeeding Mother. The focus of this protocol is on anesthesia and analgesia for breastfeeding mothers outside the postpartum period.
Recommendations
General principles
Medications
The implications of medications used in breastfeeding mothers depend on numerous factors, including the amount of medication that passes into breast milk, the oral absorption of medication, the gestational and postpartum age of the child, and the potential for adverse effects on the breastfeeding infant. Anesthetic agents cause little or no effects for older infants, but could potentially cause problems in neonates, particularly those who are preterm and/or suffer from preexisting apnea.
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Mothers with healthy term or older infants can generally resume breastfeeding as soon as they are awake, stable, and alert. (IV) Resumption of normal mentation is a hallmark that medications have redistributed from the plasma compartment (and thus generally the milk compartment) and entered adipose and muscle tissue where they are slowly released.
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Infants at risk for apnea, hypotension, or hypotonia may benefit from a brief interruption of breastfeeding (6–12 hours) after maternal anesthesia. In this situation, mothers can express and store her milk in small amounts to be used when the infant is older, or it can be mixed with fresh milk containing no medications to dilute the milk with medications present.
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The most concerning class of medications used for anesthesia and analgesia in breastfeeding mothers is opioids, as these medications transfer into breast milk and may cause infant sedation or apnea. Judicious use of opioids for short periods is likely to be safe for most breastfeeding mothers and infants. (IV)
Brief procedures
Mothers who have undergone dental extractions or other short procedures requiring the use of single doses of medication for sedation and analgesia can breastfeed as soon as they are awake and stable. Although shorter-acting agents such as fentanyl and midazolam may be preferred, single doses of meperidine/pethidine or diazepam are unlikely to affect the breastfeeding infant. (III) Local anesthetics given by injection or topical application are considered safe for breastfeeding mothers. (IV)
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