To clarify, do you mean as a PCA -- patient-controlled analgesia -- modality, which I have never heard of being used with ketamine before, or as ketamine just given IV?  It can be given in large-ish doses to provide analgesia and anesthesia, and it can also be given as an "ultra-low dose" infusion in various situations to help reduce narcotic requirements and in specific pain syndromes.  I would guess you are seeing it used as small boluses, to help moms tolerate painful repairs post-delivery.

Ketamine is an odd drug.  It's considered a "dissociative anesthetic" and is great in specific scenarios because it generally preserves respiratory drive and hemodynamics, unlike most other meds we use in anesthestic practice.  In resource-poor areas of the world, it can be used as the sole anesthetic.  I use it routinely in my peds anesthesia practice, but we almost never give it to infants unless in a dire emergency, because it has been shown in several animal model studies to be neurotoxic, inducing apoptosis in rapidly developing brains.  Ketamine has pretty good oral bioavailability -- approximately po 3-4:1 IV so it likely that some amount may be transferred into colostrum.  However, we know that colostrum volume is quite small and so babies are probably exposed to very small, sub-clinical amounts.

So in terms of immediate risk to a breastfeeding infant, I would say that there is minimal risk.  No risk of respiratory depression or hemodynamic derangements are seen even if I give this medication directly to an infant.  Just watch the infant -- very first sign I see when it takes effect is nystagmus, and after that, kiddos just lay still and breathe quietly.  Theoretical risks exist in terms of neurodevelopmental outcomes, but that is a very small risk, and we don't really know how much dose an infant may receive.  Like all other general anesthetics, I would say that if mom is awake enough to breastfeed, she should be encouraged to do so.

Just my $0.02.

-Sarah Reece-Stremtan MD (peds anesthesiologist and pain doc)

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