Analgesia and anesthesia for the breastfeeding mother: ABM Guidelines

The Academy of Breastfeeding Medicine has developed guidelines of Analgesia and Anesthesia for the Breastfeeding
Mother. The focus of this protocol is on anaesthesia and analgesia for breastfeeding mothers outside the postpartum period.

Major 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 the medication, the gestational and postpartum age of the child, and the potential for adverse effects on the breastfeeding infant.


• Anaesthetic 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.


• Mothers with the healthy term or older infants can generally resume breastfeeding as soon as they are awake, stable, and alert.


• 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.


• Infants at risk for apnea, hypotension, or hypotonia may benefit from a brief interruption of breastfeeding (6–
  12 hours) after maternal anaesthesia. 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.


• The most concerning the class of medications used for anaesthesia 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.


• Regional anaesthesia- Regional anaesthesia, including spinal, epidural, or peripheral nerve block, should be considered whenever possible, whether for intraoperative anaesthesia or postoperative analgesia.


• Analgesics-Opioid analgesics. Opioids may be continued postoperatively for pain but should be used with caution and for the shortest reasonable course in a breastfeeding mother. All opioids transfer into breast milk in varying amounts, and differences in breast milk concentration along with variation in oral availability make certain types of these medications more or less safe for a breastfeeding mother.


• Non-opioid analgesics should generally be the first choice for pain management in breastfeeding postpartum women, as they do not impact maternal or infant alertness.

1. Acetaminophen/paracetamol and ibuprofen are safe and effective for analgesia in postpartum mothers.


2. Ketorolac is commonly used for postpartum analgesia, especially after cesarean section, despite a Food and Drug Administration black box warning (in the United States) against the use of this medicine for breastfeeding women. Milk levels after oral administration are quite low, but levels have not been measured after parenteral administration.


3. Diclofenac suppositories are available in some countries and commonly used for postpartum analgesia. Milk levels are extremely low.


4. Cyclooxygenase-2 inhibitors such as celecoxib may have some theoretical advantages if maternal bleeding is a concern; this must be balanced with higher cost and possible cardiovascular risks, which should be minimal with short-term use in healthy young women.

1. Both pain and opioid analgesia can have a negative impact on breastfeeding outcomes; thus mothers should be encouraged to control their pain with the lowest medication dose that is fully effective. Opioid analgesia postpartum may affect babies' alertness and suckling vigor. However, when maternal pain is adequately treated, breastfeeding outcomes improve. Mothers should be encouraged to adequately control their pain, especially after cesarean birth or severe perineal trauma requiring repair. (II-2)

1. Parenteral medications (may be intravenous or intramuscular)

• Meperidine/pethidine should be avoided due to reported neonatal sedation when given to breastfeeding mothers postpartum, in addition to the concerns of cyanosis, bradycardia, and the risk of apnea that have been noted with intrapartum administration.


• The administration of moderate to low doses of intravenous or intramuscular morphine is preferred to meperidine/pethidine as a passage to milk and oral bioavailability are least with this agent.


• When patient-controlled intravenous analgesia (PCA) is chosen after cesarean section, morphine or fentanyl is preferred over meperidine/pethidine.


• Levels of butorphanol in human milk have been reported with approximately 0.5% of the weight-adjusted maternal dose* transferred into human milk. These appear minimal and probably are of no concern to a breastfeeding neonate in the first week postpartum. The use of butorphanol during labor has been reported to produce sinusoidal fetal heart rate patterns and irritability in newborns.


• Levels of nalbuphine in human milk are quite low. In one study the levels of nalbuphine in milk average only 42 µg/L with an estimated weight-adjusted relative infant dose (RID) of 0.59%.


• Hydromorphone (approximately seven to 11 times as potent as morphine) is sometimes used for extreme pain in a PCA, intramuscularly, intravenously, or orally. Following a 2 mg intranasal dose, levels in milk were quite low with a weight-adjusted RID of about 0.67%. This correlates with about 2.2 µg/day via milk. This dose is probably too low to affect a breastfeeding infant, but this is a strong opioid, and some caution is recommended.

1. Oral medications

• Hydrocodone has been used frequently in breastfeeding mothers worldwide. Less than 3.7% of the weight-adjusted maternal dose (RID) reaches the infant per day. Higher doses (10 mg of hydrocodone) and/or more frequent administration may lead to neonatal sedation and should be used with great caution.


• Recent cases have raised concern about the use of codeine. Some mothers may rapidly metabolize codeine to morphine, which can lead to toxic levels of morphine in the infant. Codeine should be used with caution, although it is probably safe in the majority of breastfeeding mothers.


• Several studies now suggest that oxycodone may be useful in some patients postpartum. Less than 3.5% of the weight-adjusted maternal dose (RID) transfers into human milk. Prolonged and frequent administration may lead to neonatal sedation. There is also the rare mother who is an ultrarapid metabolizer, whose babies are at higher risk for central nervous system depression [see Analgesics 1(i) below].


• Several recent studies of buprenorphine suggest that approximately 1.9% of the weight-adjusted maternal dose is transferred to the infant daily. Buprenorphine has a long half-life and should be used with some caution in infants who have not been previously exposed to the drug. Mothers treated continually for addiction may continue to breastfeed using this medication as long as the infant is tolerant to the current dose.

1. Epidural/spinal medications

• Single-dose opioid medications (e.g., neuraxial morphine) should have minimal effects on breastfeeding because of eligible maternal plasma levels achieved. Extremely low doses of morphine are effective.


• A continuous post-cesarean epidural infusion may be an effective form of pain relief that minimizes opioid exposure. A randomized study that compared spinal anaesthesia for elective cesarean with or without the use of postoperative extradural continuous bupivacaine found that the continuous group had lower pain scores and a higher volume of milk fed to their infants.

Anesthesia/Sedation for Surgery in Breastfeeding Mothers

1. The implications of drugs used in anesthesia in postpartum mothers depend on numerous factors, including the age of the infant, the stability of the infant, the length of lactation, and the ability of the infant to clear small quantities of anaesthetic medications. Anaesthetic agents will have little or no effect on older infants but could potentially cause problems in newborn infants, particularly those who are premature or suffer from apnea. (III)


2. Mothers with a normal term or older infants can generally resume breastfeeding as soon as they are awake, stable, and alert. Resumption of normal mentation is a hallmark that these medications have redistributed from the plasma compartment (and thus generally the milk compartment) and entered adipose and muscle tissue where they are slowly released. The exception could be a drug that is highly lipid soluble, in which breast tissue may function as a fat compartment, acting as a drug reservoir. For women who undergo postpartum tubal ligation, interruption of breastfeeding is not indicated as the volume of colostrum is small; hence the dose to the infant is low as well. In addition, the levels of medication in the maternal plasma and milk are low once mothers resume normal mentation. For maternal safety, regional anaesthesia is recommended for this procedure in preference to a general anaesthetic.


3. Mothers who have undergone dental extractions or other 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)


4. Mothers who have undergone plastic surgery, such as liposuction, where large doses of local anaesthetics (lidocaine/xylocaine or lignocaine) have been used should probably pump and discard their milk for 12 hours prior to resuming breastfeeding.


5. (III) The maternal dose and the ability of the infant to clear small amounts of medications that can cause cardiorespiratory effects is of primary concern before returning to breastfeeding. Infants subject to apnea, hypotension, or hypotonia should probably be protected by a few more hours of interruption from breastfeeding (12–24 hours) prior to resuming nursing.(III)

Information About Specific Agents Used for Anesthesia and Analgesia

Anaesthetic Agents

1. Drugs used for anaesthetic induction such as propofol, midazolam, etomidate, or thiopental enter the milk compartment only minimally, as they have extraordinarily brief plasma distribution phases (only minutes), and hence their transport to milk is low to nil.


2. Little or nothing has been reported about the use of anaesthetic gases in breastfeeding mothers. However, they too have brief plasma distribution phases, and milk levels are likely nil. A recent series of case reports suggest that xenon maintenance after propofol induction allows for breastfeeding immediately after surgery.


3. The use of ketamine in breastfeeding mothers is unreported. Following the use of ketamine, many adult patients may exhibit dissociative anaesthetic effects. This is often suppressed with the addition of midazolam or other benzodiazepines. The emergent reactions are apparently age-dependent and appear to occur more frequently in adults (30–50%) and less frequently in children (5–15%).


4. For specific local anesthetics for epidural use (such as bupivacaine and ropivacaine), see general comments about epidural analgesia/anesthesia. These and other local anesthetics are poorly absorbed orally so should be safe in postpartum breastfeeding mothers. Milk levels of bupivacaine and ropivacaine are exceedingly low.

Analgesics

1. Opioid analgesics

• Morphine is still considered an ideal analgesic for breastfeeding mothers due to its limited transport to milk and its poor oral bioavailability in infants.


• The transfer of meperidine/pethidine into breastmilk is low (1.7–3.5% of maternal weight-adjusted dose). However, meperidine/pethidine and its metabolite (normeperidine) are consistently associated with dose-related neonatal sedation. Transfer into milk and neonatal sedation have been documented for even up to 36 hours after a single dose. Meperidine/pethidine should be avoided during labor and in postpartum analgesia (except, perhaps, within 1 hour prior to delivery). Infants of mothers who have been exposed to repeated doses of meperidine/pethidine should be closely monitored for sedation, cyanosis, bradycardia, and possibly seizures.


• Although there are no published data on remifentanil, this esterase-metabolized opioid has a brief half-life even in infants (<10 minutes) and has been documented to produce no fetal sedation even in utero. Although its duration of action is limited, it could be used safely and indeed may be ideal in breastfeeding mothers for short painful procedures.


• Fentanyl levels in breast milk have been studied and are extremely low after 2 hours and generally below the limit of detection.


• Sufentanil transfer into milk has not been published, but it should be similar to that of fentanyl.


• Nalbuphine and butorphanol levels in breastmilk are very low. At this time they would only be indicated in the specific situations mentioned previously. If these agents are used, observe the mother and infant for psychotomimetic reactions (3%).


• Hydrocodone has been used frequently in breastfeeding mothers. Occasional cases of neonatal sedation have been documented, but these are rare and generally dose-related. Doses in breastfeeding mothers should be kept at the minimum necessary to control pain. Frequent dosing throughout the day may lead to sedative effects in the breastfed infant.


• A recent report of a neonatal death following the use of codeine suggests that the use of codeine in breastfeeding mothers should be monitored closely. Although rare, rapid metabolizers of codeine are known, and levels of morphine following the use of codeine may be significantly elevated thus putting the infant at risk. Use caution with codeine in breastfeeding mothers.


• Oxycodone levels in milk are known and average approximately 58 µg/L (range, 7–130 µg/L) (RID = 1.5– 3.5%). Oxycodone may not be significantly safer for the rare mother who is an ultrarapid metabolizer, as it is also a substrate for CYP2D6. A recent retrospective study showed that one in five breastfed infants with mothers medicated with oxycodone experienced central nervous system depression. The strong concordance between maternal and infant symptoms may be used to identify babies at higher risk. It is important to follow these infants carefully for drowsiness.


• Regardless of the opioid, always consider the dose used. Many mothers undergoing chronic pain therapy in various pain clinics may use exceedingly high doses of hydrocodone, oxycodone, methadone, and other opioid analgesics. Those infants of mothers with exceedingly high doses should be closely monitored for sedation and apnea. If the infants are exposed in utero, the risk, initially, is probably somewhat less because of tolerance of the infant.

1. Non-steroidal anti-inflammatory drug analgesics

Use of non-steroidal anti-inflammatory drugs (NSAIDs) alone after vaginal birth or in combination with opioids after cesarean birth can improve pain control by assisting with some of the pain due to uterine cramping. NSAIDs are generally safe for breastfeeding and can help minimize the total dose of opioid needed to control pain. (III)

1. Ibuprofen is considered an ideal, moderately effective analgesic. Its transfer to milk is low to nil.


2. Ketorolac is a potent analgesic in breastfeeding mothers and is increasingly popular when used postpartum. Its primary benefit is excellent analgesia, with no sedative properties. In addition, the transfer of ketorolac into milk is extremely low. However, its use in postsurgical patients with haemorrhage may be somewhat risky as it inhibits platelet function, although this is somewhat controversial. It should not be used in patients with a history of gastritis, aspirin allergy, or renal insufficiency. If there is no risk of haemorrhage, it carries few complications for breastfeeding mothers and their infants. However, the Food and Drug Administration now has a black box warning against use of ketorolac in breastfeeding women.


3. Celecoxib transfer into milk is extraordinarily low (<0.3% of the weight-adjusted maternal dose). Its short-term use is safe.


4. Naproxen transfer into milk is low, but gastrointestinal disturbances have been reported in some infants following prolonged therapy. Short-term use (1 week) is probably safe.

For further reference log on to :

http://www.e-lactancia.org/media/papers/AnalgesiaAnestesiaBM-ABMProtocol15-BFM2017_gGSR5Rn.pdf