I would urge some caution and careful review of the medications and dosages that this mom is receiving, and remind everyone it is impossible to say that giving all this breastmilk to an extremely premature infant is "fine."  While the commonly used medications used for adult sedation are usually safe for a breastfeeding infant when mom has had brief exposures, we would expect that she likely has high plasma levels of the various meds, especially if her renal function is poor.

In general, fentanyl, hydromorphone, and morphine are usually OK because they have poor oral bioavailability, but it is difficult to say it is fine when mom is likely receiving a LOT.

Benzodiazepines (we often see midazolam used as an infusion) may be more problematic because they have good oral bioavailability and infants may get significant exposure from breastmilk.  And in situations such as you describe, where mother is likely not experiencing *pain* but rather *discomfort* from intubation and mechanical ventilation, it is possible she is receiving more benzos than opioids.

Additionally, with emerging yet equivocal evidence for the effects of some of these medications (particularly benzos) on infants' developing brains, I would be cautious about unnecessary exposure.

But if she receiving propofol, we would usually think that is fine as it is rapidly cleared through redistribution and likely has NO effect when taken in orally (ie, through breastmilk).  And I don't think we have any data yet on dexmedetomidine, my personal favorite for sedation, though it does have good oral bioavailability and can exert profound hemodynamic changes.

Again, be careful here, mom may be receiving enormous amounts of sedative medications, and baby is very very young.  Can donor milk be used until mom is extubated and meds cleared from her system?  Milk should certainly be removed at frequent intervals and perhaps it can be labeled and frozen, and used later/mixed with completely "untainted" milk in small amounts when baby is older so that it is not completely wasted.

Best of luck to mom and team in this difficult situation!
-Sarah Reece-Stremtan MD (peds anesthesiologist and pain doc who does a lot of sedation consults in our NICU/PICU)

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