Safety of the breast‐feeding infant after maternal anesthesia

Abstract

There has been an increase in breast-feeding supported by the recommendations of the American Academy of Pediatrics and the World Health Organization. An anesthesiologist may be presented with a well-motivated breast-feeding mother who wishes to breast-feed her infant in the perioperative period. Administration of anesthesia entails acute administration of drugs with potential for sedation and respiratory effects on the nursing infant. The short-term use of these drugs minimizes the possibility of these effects. The aim should be to minimize the use of narcotics and benzodiazepines, use shorter acting agents, use regional anesthesia where possible and avoid agents with active metabolites. Frequent clinical assessments of the nursing infant are important. Available literature does suggest that although the currently available anesthetic and analgesic drugs are transferred in the breast milk, the amounts transferred are almost always clinically insignificant and pose little or no risk to the nursing infant.

Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk

“…hydrophilic opioid) has an oral bioavailability of 30% and its metabolite, morphine-6-glucoride, is pharmacologically active and has a bioavailability of 4%. 6 This information is relevant because morphine is known to be expressed in breast milk and studies have reported adequate sedation in 50% of infants (AS 50 ) with morphine serum concentrations of 125 ng/ml. 11 Feilberg et al reported a peak morphine concentration of 82 ng/ml in breast milk 30 minutes after a 4mg bolus of morphine given in the epidural space.…”

“…Thus, if mothers medicate themselves at the beginning of breastfeeding, the drug levels are usually negligible if the next feeding is 2-3 hours later. 6,24 Meperidine should be avoided due to a theoretical higher risk of neonatal respiratory sedation if taken by breastfeeding mothers in the postpartum period. There are reports of cyanosis, bradycardia, and apnea after its administration.…”

“…Neostigmine and glycopyrrolate are quaternary ammonium compounds, which do not penetrate the blood-brain barrier and are not expected to cross into milk ducts. 6,21 Of note, neonatal abdominal cramping has been reported in myasthenia gravis patients taking cholinesterase inhibitors while lactating, but serum breast milk cholinesterase levels were undetectable.…”

“…This review highlights the most recent medical literature concerning breastfeeding and the perioperative use of common medications by anesthesia providers during the intraoperative, intrapartum, postoperative and postpartum periods. 6 The review is focused only on opioid-naïve patients as evidence addressing recommendations in opioid-tolerant lactating mothers remain non-existent. Information presented in this review is written on the premise that data is limited and most medications administered in this patient population have not been rigorously screened by the FDA for safety and efficacy.…”

“…This suggests that mothers can resume breastfeeding after inhalational anesthesia without deleterious effects to the infant. 6,17 • Opioids: Intravenous fentanyl, morphine, and hydromorphone are commonly used opioids for general anesthesia. Fentanyl, approximately one hundred times more potent than morphine, is highly lipophilic and has the ability to be stored in breast tissue.…”