Anesthesia and Sedation in Lactating Parents
by Anne Eglash MD, IBCLC, FABM
One of the more common controversies in healthcare is the issue of ‘pumping and dumping’ when a lactating parent receives either intravenous medications or undergoes general anesthesia. Individuals who undergo surgery for a cesarean birth are typically allowed to directly feed as soon as they are able. Other healthcare teams outside of labor and delivery often lack education about the importance of lactation, and how medications transfer into and out of human milk leading to erring on the side of caution. For example, lactating individuals undergoing a gallbladder removal, appendectomy, orthopedic surgery, or neurosurgery are often instructed to pump and dump for at least 24 hours due to concerns of IV medication effects for infants.
The article for this week is a consensus statement from the Association of Anaesthetists in the United Kingdom. I should mention that an equally excellent review is available from the Academy of Breastfeeding Medicine’s (ABM) Clinical Protocol #15.
The UK consensus statement states that there is no need to discard human milk after anesthesia, because once the individual is awake and alert, the anesthesia agents have left their brain, and therefore their milk. ABM cautions that if a lactating parent’s infant is at risk for apnea, low blood pressure or low tone, to consider a brief interruption of direct feeding, and to instead use stored human milk. They should express their milk for later use, when the infant is older and less vulnerable.
The most concerning medications used during surgery are opioids. Intravenous morphine is considered the safest opioid to use for lactating individuals because the transfer into human milk is low. If more than a few doses are used over time, the infant should be watched for sedation and poor feeding.
Codeine should be strictly avoided because it has higher levels in human milk, and individuals vary greatly in how they metabolize codeine. Codeine is metabolized into morphine and individuals who are ‘rapid metabolizers’ can generate high levels of morphine into their milk, making the milk unsafe for the infant.
Benzodiazepines are often used for conscious sedation. This type of anesthesia is typically used for procedures such as colonoscopies, minor orthopedic procedures, dental procedures, and biopsies. Often midazolam is used, which is very short acting, and has low levels in human milk, so it is safe to feed directly when awake and alert.
There are many more medications used during anesthesia and conscious sedation that are discussed in the UK consensus statement, and the ABM protocol. Check out the questions below to test yourself.
- Medications used to prevent individuals from moving during surgery (neuromuscular blocking agents) should not be used for lactating individuals, to avoid paralyzing the infant when feeding resumes.
- Lactating individuals should not be expected to fast before surgery, to avoid dehydration or a decrease in milk supply.
- Oxycodone and hydrocodone can cause sedation in infants receiving human milk. It is best to avoid more than a total of 30mg a day of either medication for lactating individuals.
- Although local anesthesia, such as numbing medication given for dental work, or medications used for a ‘spinal’ can transfer into human milk at low doses, it is considered safe to feed immediately after these procedures.
See the Answer
Breastfeeding has many health benefits for the mother and infant. Women who are breastfeeding may require anaesthesia or sedation. Concerns regarding the passage of drugs into breast milk may lead to inconsistent advice from professionals. This can sometimes result in the interruption of feeding for 24 hours or longer after anaesthesia, or expressing and discarding (‘pumping and dumping’) breast milk; this may contribute to early cessation of breastfeeding. However, there are data regarding the transfer of most anaesthetic drugs into breast milk. We advise that breastfeeding is acceptable to continue after anaesthesia and should be supported as soon as the woman is alert and able to feed, without the need to discard breast milk. We provide evidence-based information on the pharmacokinetics of drugs commonly used during anaesthesia so that professionals can undertake a risk-benefit discussion with the woman. We advise the development of local policies that aid logistical planning and guide staff to facilitate breastfeeding during the woman's hospital stay.
The UK consensus statement and the ABM protocol are generally in agreement with one another.
Just about all medications used for anesthesia and conscious sedation are safe during lactation. The major caution is for individuals with vulnerable infants, particularly if they take more than a few doses of narcotics or other sedating medications such as benzodiazepines. The medications used for muscle relaxation and paralysis during surgery rapidly leave human milk, so that once the lactating parent can move normally, the medication is no longer in the milk. Lactating individuals are asked to fast before surgery, however, limiting fasting to the shortest time is ideal, to prevent dehydration and a drop in milk production. Strategies such as planning the surgery for the early am, and preventing nausea and vomiting after the procedure with appropriate medication should be encouraged.