Jennifer Nopoulos, MSN-Ed, RN, CPAN
March 6, 2021
The peri-operative patient that is currently breast feeding their infant requires evidenced based teaching on when to resume breast feeding to ensure safety for their child. Pumping and "dumping" is an older concept likely borne from an abundance of caution and a dearth of evidence and is seldom necessary according to current available information (Cobb, Liu, Valentine & Onuoha, 2015). Advantages of breast feeding are well established, and as a surgical procedure can disrupt a mother's nursing pattern, returning to breast feeding is considered the best for both herself and her baby (Cobb, et al, 2015). Much of the evidence and research surrounding this topic involve newborns and the anesthesia a new mother may receive during delivery. The recommendations available are based on observation and testing medication levels in breast milk, and the following synopsis is comprised of this information.
General recommendations for mothers of normal term and older infants include allowing breast feeding as soon as the mother is sufficiently awake to be able to hold and nurse her baby. Vital signs should be stable, and the mother should be alert. Limited medications given for a short procedure should allow for wakefulness in a few hours. If there are any concerns, a single pump and discard can be done to clear any retained medications from the milk fat. If the child has issues such as apnea, was pre-mature or very small, substituting formula while breast milk is pumped and discarded for 12-24 hours is suggested by authors (Lawrence & Lawrence, 2012). Here are some specifics:
* Medications used for anesthesia induction, such as midazolam (Versed) or propofol have limited blood distribution, and little is transferred to breast milk. One study confirmed negligible concentrations of propofol two hours after birth (Cobb, et al., 2015). Anesthesia gases have the same short time blood distribution and are theorized to also have little concentration in breast milk. (Lawrence and Lawrence, 2012).
* The large molecules of local anesthetics do not move easily into lactation ducts, therefore this form of neuraxial anesthesia is ideal for nursing mothers (Cobb, et al, 2015). Although the use of local anesthetic blocks decrease the need for opioids and benefit the nursing mother (Berens, 2021), large amounts of local anesthetic, such as required in a procedure like liposuction, would require pumping and discarding for 12 hours (Lawrence & Lawrence, 2012).
* The non-opioid analgesics are preferred for the nursing mother. Acetaminophen is generally considered to be an acceptable medication to use while breastfeeding, as are short acting NSAIDs such as Ibuprofen, except when the baby has a ductal-dependent heart condition. Long acting NSAIDs such as Naprosyn should be avoided (Lawrence & Lawrence, 2012). Aspirin is theoretically contraindicated as it can cause Reye's Syndrome in children (Berens, 2021).
* Some opioids are contraindicated for the nursing mother, while others have been shown to be safe in most circumstances. Those to avoid include codeine, tramadol (Ultram), and meperidine (Demerol). Variances in drug metabolism may allow more of these opioids to enter breast milk and produce unwanted infant sedation. Meperidine has long-acting metabolites that may do the same. Better choices, if necessary, are morphine, oxycodone, or hydrocodone. The general rule is to avoid high doses of opioids, frequent dosing, or pro-longed use, and then replace with non-opioid analgesics as soon as possible (Berens, 2021). Authors disagree on breast feeding following the use of hydromorphone (Dilaudid), citing concerns about its extended half-life and potency (Cobb, et al. 2015).
* If opioids will be taken at home after discharge, the patient needs education on the recognition of untoward opioid effects on their infant such as increased sleepiness, difficulty breathing, difficulty feeding, or weakness (Berens, 2021). If these symptoms are observed nursing should be stopped immediately, formula should be used instead of breast milk, the infant monitored, and the provider notified.
Berens, P. (Jan 25, 2021). Overview of the postpartum period: Normal physiology and routine maternal care. Retrieved from https://www.uptodate.com/contents/overview-of-the-postpartum-period-normal-physiology-and-routine-maternal-care?sectionName=Safety%20of%20common%20analgesics%20in%20breastfeeding%20women&search=breast%20feeding%20after%20general%20anesthsia&topicRef=398&anchor=H428778289&source=see_link#H428778289
Cobb, B., Lui, R., Valentine, E., & Onuoha, O. (2015). Breastfeeding after anesthesia: A review for anesthesia providers regarding the transfer of medications into breast milk. Translational Perioperative Pain Medicine. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26413558/
Lawrence, R.M., & Lawrence R.A. (2012). The breast and the physiology of lactation. In Creasy and Resnik's maternal-fetal medicine: Principles and Practice, (8th ed.). Elsevier.