Overview of Anesthesia, Analgesia, & Sedation to Lactating People
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Medications and Anesthesia Overview of Anesthesia, Analgesia, & Sedation to Lactating People

Overview of Anesthesia, Analgesia, & Sedation to Breastfeeding Women

Provision of anesthesia, analgesia, and sedation to breastfeeding women remains a somewhat controversial area for both healthcare professionals and mothers, despite multiple review articles recommending safe continuation of breastfeeding in most clinical situations. Like most medications, agents used in the perioperative setting and for sedation and analgesia are largely understudied in breastfeeding women. However, a closer examination of the specific classes and types used for anesthesia, analgesia, and sedation reveals that these medications may generally be safely used without a need for interruption in breastfeeding.

During anesthesia, a variety of medications from different classes may be used in combination. Likely some of the hesitation by anesthesiologists to recommend continuation of breastfeeding afterwards stems from the sheer number of medications administered. As part of anesthesia and sedation, virtually all medications are given via the intravenous route, and demonstrate very little bioavailability if ingested orally. So even if small amounts of anesthetic agents reach the milk compartment, they will exert little to no effects on the nursing infant.

Most mothers who undergo general anesthesia or sedation are able to safely resume breastfeeding as soon as they are awake. If there is concern about exposure for a particular infant with prematurity or another underlying medical condition, especially with regards to opioids, milk can be expressed in the recovery area and then ongoing if additional high doses of opioids are used; the milk can be saved and used when the infant is older, or mixed/diluted with unexposed milk to decrease the amount of medication transfer.

Beyond medications used during sedation and anesthesia and for analgesia, other factors including fasting guidelines and institutional policies may affect a breastfeeding dyad’s ability to continue breastfeeding uninterrupted during the perioperative period. ABM’s protocol includes a breastfeeding plan that addresses specific challenges in the preoperative, intraoperative, and postoperative periods.

Local Anesthetics

Are considered safe, and their use should be encouraged as a way to decrease the need for additional analgesics. These are used for local infiltration, regional anesthesia, and increasingly as intravenous adjuncts. Medications such as lidocaine, ropivacaine, and bupivacaine are large, polarized molecules that do not transfer easily into milk and are not well absorbed via oral route.

Hypnotics

Largely considered safe. This category includes propofol, etomidate, and thiopental, usually used as single doses to induce anesthesia. These medications all have a very brief plasma distribution phase that limits their transfer into milk, and they all have limited oral bioavailability. Ketamine is the one medication in this class that does have some oral bioavailability. Some evidence indicates that its use in nursing mothers does not adversely affect breastfed infants after short-term use in the mother.  The Academy of Breastfeeding Medicine’s protocol advises prudence when using doses that provide anesthesia and monitoring breastfeeding infants afterward.

Inhalational Anesthetics

Considered safe although there is no data available. These include nitrous oxide, sevoflurane, isoflurane, and desflurane, which are used to maintain general anesthesia during surgery. These agents diffuse freely into and out of plasma but all have brief distribution phases and no oral bioavailability.

Neuromuscular Blocking (NMB) Agents

Considered safe. These medications are used to facilitate endotracheal intubation and to maintain optimal surgical/operating conditions. Succinylcholine, rocuronium, and vecuronium are most commonly used. These medications are mostly distributed in the extracellular fluid compartment, have low lipid solubility, and poor oral bioavailability.

Reversal Agents & Anticholinergics

Considered safe. These medications are used to safely reverse the effects of NMBs, and typically consist of either glycopyrrolate or atropine, plus neostigmine. Sugammadex is a newer reversal medication with a different mechanism of action that does not require concurrent administration of an anticholinergic, and it also appears to be safe.

Anti-Emetics

Considered safe. Nausea and vomiting are the most common post-operative side effects of anesthesia and may significantly impact a patient’s ability to breastfeed. Dexamethasone, metoclopramide, and 5HT-3 antagonists such as ondansetron are the most commonly used medications during anesthesia and immediately postoperatively. Prochlorperazine, promethazine, and scopolamine are additional rescue medications that may cause maternal sedation although there are no reports of infant ill effects from breastfeeding.

References

  1. Chu TC, McCallum J, Yii MF. Breastfeeding after anaesthesia: A review of the pharmacological impact on children. Anaesth Intensive Care. 2013;41(1):35-40. doi: 20110853 [pii].
  2. 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.
  3. Dalal PG, Bosak J, Berlin C. Safety of the breast-feeding infant after maternal anesthesia. Paediatr Anaesth. 2014;24(4):359-371. doi: 10.1111/pan.12331 [doi].
  4. Kundra S, Kundra S. Breastfeeding in the perioperative period. Journal of Obstetric Anaesthesia and Critical Care. 2011;1(1):46-47.
  5. Allegaert K, van den Anker J. Maternal analgosedation and breastfeeding: Guidance for the pediatrician. Journal of Pediatric and Neonatal Individualized Medicine. 2015;4(1):1-6.
  6. Dumphy D. The breastfeeding surgical patient. AORN J. 2008;87(4):759-66; quiz 767-70.
  7. Smathers AB, Collins S, Hewer I. Perianesthetic considerations for the breastfeeding mother. J Perianesth Nurs. 2016;31(4):317-329. doi: 10.1016/j.jopan.2014.09.006 [doi]
  1. Martin E, Vickers B, Landau R, et al. ABM Clinical Protocol #28, Peripartum analgesia and anesthesia for the breastfeeding mother. Breastfeed Med 2018;13:164-71. PMID: 29595994
  2. Reece-Stremtan S, Campos M, Kokajko L, et al. ABM Clinical Protocol #15: Analgesia and anesthesia for the breastfeeding mother, revised 2017. Breastfeed Med 2017;12:500-6. PMID: 29624435
  3. Anderson PO. Local anesthesia and breastfeeding. Breastfeed Med 2021;16:173-4. PMID: 33370542
  4. Anderson PO. General anesthesia while breastfeeding. Breastfeed Med 2021;16:275-7. PMID: 33781081

References

  1. Chu TC, McCallum J, Yii MF. Breastfeeding after anaesthesia: A review of the pharmacological impact on children. Anaesth Intensive Care. 2013;41(1):35-40. doi: 20110853 [pii].
  2. 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.
  3. Dalal PG, Bosak J, Berlin C. Safety of the breast-feeding infant after maternal anesthesia. Paediatr Anaesth. 2014;24(4):359-371. doi: 10.1111/pan.12331 [doi].
  4. Kundra S, Kundra S. Breastfeeding in the perioperative period. Journal of Obstetric Anaesthesia and Critical Care. 2011;1(1):46-47.
  5. Hale TW. Anesthetic medications in breastfeeding mothers. Journal Of Human Lactation: Official Journal Of International Lactation Consultant Association. 1999;15(3):185-194. http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=10578796&site=ehost-live.
  6. Allegaert K, van den Anker J. Maternal analgosedation and breastfeeding: Guidance for the pediatrician. Journal of Pediatric and Neonatal Individualized Medicine. 2015;4(1):1-6.
  7. Dumphy D. The breastfeeding surgical patient. AORN J. 2008;87(4):759-66; quiz 767-70.
  8. Smathers AB, Collins S, Hewer I. Perianesthetic considerations for the breastfeeding mother. J Perianesth Nurs. 2016;31(4):317-329. doi: 10.1016/j.jopan.2014.09.006 [doi]