Anesthesia, analgesia and sedation during lactation is known to be safe in most clinical situations. Previously, standard advice was to pump and dump, however current evidence indicates that most classes of medications are safe (1,2). Most mothers who undergo general anesthesia or sedation may safely resume breastfeeding as soon as they are awake and can safely hold their baby. The following statements support breastfeeding after anesthesia:
The 2019 American Society of Anesthesiologists (ASA)’s “Statement on Resuming Breastfeeding after Anesthesia” (1)
An editorial from 2018 called “Pump and Dump: Anesthesiologists Lead the Feed” (3)
The 2017 Infographic from the ASA entitled “Anesthesia & Breastfeeding: More Often Than Not, They Are Compatible” (4)
Per the ASA’s statement and infographic, “A general principle is that a mother can resume breastfeeding once she is awake, stable, and alert after anesthesia has been given” (1, 4). This principle was also used in the Academy of Breastfeeding Medicine (ABM) protocol (5).
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 stored for later administration. If additional high doses of opioids are used postoperatively with the parent of a high-risk infant, the lactating parent can continue to express and save milk. This milk can be used when the infant is older or mixed/diluted with unexposed milk to decrease the amount of medication exposure.
During anesthesia, a variety of medications from different classes may be used in combination. Anesthesiologists may hesitate to recommend resumption of breastfeeding after anesthesia due to the number of medications administered. Medications for anesthesia and sedation are almost always given via the intravenous route and demonstrate very little oral bioavailability. Therefore, even if small amounts of anesthetic agents reach the milk compartment, they will exert little to no effects on the nursing infant. Further reading on the relative infant dose (RID) can be found in the ASA statement (1, 5-12). For more information on how medications enter human milk, please see the section on Pharmacology FAQ.
ABM Clinical Protocol #15 includes further details about a breastfeeding plan that addresses specific challenges in the preoperative, intraoperative, and postoperative periods (5). For more detailed information and references on specific medications, please refer to LactMed, e-lactancia, Infant Risk, or Mother to Baby.
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.
- Lidocaine, ropivacaine, and bupivacaine: These are large, polarized molecules that do not transfer easily into milk and are not well absorbed via the oral route (5, 13). There is no absolute indication to pump and dump.
Hypnotics are used to induce anesthesia.
- Propofol, etomidate, and thiopental: These medications have a brief plasma distribution phase that limits their transfer into milk and they have limited oral bioavailability. While infants should be monitored for sedation, there is no absolute indication to pump and dump once the parent is alert enough to pump or directly feed.
- Ketamine: Ketamine does have limited oral bioavailability. While some evidence indicates that its short-term use in nursing mothers does not adversely affect breastfed infants, the Academy of Breastfeeding Medicine’s protocol advises prudence and close monitoring of infants after using larger doses of ketamine(5, 14). While infants should be monitored closely for sedation, there is no absolute indication to pump and dump once the parent is alert enough to pump or directly feed.
Inhalational anesthetics are used to maintain general anesthesia during surgery.
- Nitrous oxide, sevoflurane, isoflurane, and desflurane: These medications 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 (5, 14). While data is limited for this class of medication, there is no absolute indication to pump and dump once the parent is alert enough to pump or directly feed.
Neuromuscular Blocking (NMB) Agents
NMB agents are used to facilitate endotracheal intubation and to maintain optimal surgical/operating conditions.
- Succinylcholine, rocuronium, cisatracurium and vecuronium: These medications are mostly distributed in the extracellular fluid compartment, have low lipid solubility, and poor oral bioavailability (5, 14). There is no absolute indication to pump and dump once the parent is alert enough to pump or directly feed.
Reversal Agents & Anticholinergics
These medications are used to safely reverse the effects of NMBs.
- Glycopyrrolate or atropine plus neostigmine: These medications are used to reverse the effects of NMBs. There is no absolute indication to pump and dump with these medications once the parent is alert enough to pump or directly feed.
- Sugammadex: 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 (5, 14). There is no absolute indication to pump and dump once the parent is alert enough to pump or directly feed.
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/Reglan, and 5HT-3 antagonists (ondansetron/Zofran): These are the most commonly used medications during anesthesia and immediately postoperatively as anti-emetics. There is no absolute indication to pump and dump.
- Prochlorperazine, promethazine, and scopolamine: These are additional rescue medications. While they may cause maternal sedation, there are no reports of infant ill effects from breastfeeding (5). There is no absolute indication to pump and dump once the parent is alert enough to pump or directly feed.
- Haloperidol: This is another common prophylactic and rescue medication which has been shown to readily enter breast milk. Its impact on infant and child development is mixed. While there is no absolute indication to pump and dump, caution may be warranted in breastfeeding dyads. Breastfed infants should be closely monitored and providers should engage lactating individuals in shared decision making regarding the use of this medication (15, 16).
- American Society of Anesthesiologists. Statement on Resuming Breastfeeding after Anesthesia [press release]. ASA House of Delegates 2019. https://www.asahq.org/standards-and-guidelines/statement-on-resuming-breastfeeding-after-anesthesia.(Accessed June 13 2022).
- 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. PMID: 26413558; PMCID: PMC4582419.
- Dodd SE, Sharpe EE. Pump and Dump; Anesthesiologists Lead the Feed. Anesthesiology. 2018;128(5):1046-1047. DOI: https://doi.org/10.1097/ALN.0000000000002144
- Wanderer JP, Rathmell JP. Anesthesia & breastfeeding: more often than not, they are compatible. Anesthesiology. 2017;127(4):A15-A15. DOI: https://doi.org/10.1097/ALN.0000000000002144
- Reece-Stremtan S, Campos M, Kokajko L, Medicine AoB. ABM Clinical Protocol# 15: analgesia and anesthesia for the breastfeeding mother, revised 2017. Breastfeed Med. 2017;12(9):500-506. DOI: https://doi.org/10.1089/bfm.2017.29054.srt
- 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: https://doi.org/10.1177/0310057×1304100107
- 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. PMCID: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4582419/
- Dalal PG, Bosak J, Berlin C. Safety of the breast-feeding infant after maternal anesthesia. Paediatr Anaesth. 2014;24(4):359-371. DOI: https://doi.org/10.1111/pan.12331
- Smathers AB, Collins S, Hewer I. Perianesthetic considerations for the breastfeeding mother. J Perianesth Nurs. 2016;31(4):317-329. DOI: https://doi.org/10.1016/j.jopan.2014.09.006
- Allegaert K, van den Anker J. Maternal analgosedation and breastfeeding: Guidance for the pediatrician. Journal of Pediatric and Neonatal Individualized Medicine. 2015;4(1): e040117
- 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. DOI: https://doi.org/10.1089/bfm.2018.29087.ejm
- Hale TW. Anesthetic medications in breastfeeding mothers. J Hum Lact. 1999;15(3):185-194. DOI: https://doi.org/10.1177%2F089033449901500302
- Anderson PO. Local anesthesia and breastfeeding. Breastfeed Med 2021;16:173-4. DOI: https://doi.org/10.1089/bfm.2020.0384
- Anderson PO. General anesthesia while breastfeeding. Breastfeed Med 2021;16:275-7. PMID: 33781081 DOI: https://doi.org/10.1089/bfm.2021.000
- Yoshida K, Smith B, Craggs M, Kumar R. Neuroleptic drugs in breast-milk: a study of pharmacokinetics and of possible adverse effects in breast-fed infants. Psychol Med. 1998 Jan;28(1):81-91. doi: https://doi.org/10.1017/s0033291797005965 (Accessed October 28 2022).
- Schoretsanitis G, Westin AA, Deligiannidis KM, Spigset O, Paulzen M. Excretion of Antipsychotics Into the Amniotic Fluid, Umbilical Cord Blood, and Breast Milk: A Systematic Critical Review and Combined Analysis. Ther Drug Monit. 2020 Apr;42(2):245-254. doi: https://doi.org/10.1097/ftd.0000000000000692 (Accessed October 28 2022).