Greetings Lactnetters:
At our hospital, we were having frequent 'conflicts' with surgeons and/or
anaesthesiologists writing post op orders for breastfeeding mothers NOT to
breastfeed for 24-48 hours post anaesthesia. We met with one of our
anaesthesiologists to see if we could create a protocol for perioperative
breastfeeding. He did some research and wrote the following letter. He
asked me to post it to the list and get feedback, suggestions, whatever.
If approved, this will become dept. policy and this information will be
provided to BF mothers at their advance registration before admission to
the hospital:

Dear Colleagues:

after an extensive review of the literature and text search, I have come
to the following recommendations in regards to perioperative
breastfeeding. Please remember that any drug you give to a breastfeeding
mother will reach her infant in some quantity. In general, water-soluble
drugs are excreted in higher concentrations into colostrum, whereas lipid-
soluble drugs are excreted in greater concentrations into breast milk. It
is also possible that epidural narcotics are affecting a neonate's ability
to breastfeed although no good studies have been done to support or refute
this.

1.  Mothers should be allowed to breastfeed their babies through the
entire perioperative period, if logistically feasible, without pumping and
discarding irregardless of the anesthetic type (see below anesthetic
considerations).

2.  If it is likely that the patient will be unable to breastfeed directly
after surgery, then should pump and freeze a supply (of breastmilk) to use
in the immediate postoperative period.

3.  Regional anesthesia should be used in appropriate cases. Spinal
anesthesia may be more appropriate than epidural because of the decreased
local anesthetic load to the mother and, indirectly, to the infant.

4.  Breastfeeding mothers undergoing PPTL (Post partum tubal ligation)
should receive spinal without sedation. Remember, they are still at risk
for difficult airway and full stomach until 6 weeks postpartum.

5.  When general anesthesia is used, less is best. That is, use only what
is needed, no more. See below for more specific drug considerations.

6.  Specific/ Classes of medications:
        A.  Narcotics-codeine, meperidine, fentanyl, sufentanil, result in
insignificant levels (breastmilk concentrations 1-2% of mother's dose)
with therapeutic doses. Again, less is best.

        B.  Benzodiazipines-valium should be avoided as appreciable plasma
levels of active substances are found in the neonate for up to 10 days
after a single maternal dose. Midazolam disappears rapidly from breast
milk (within four hours) and may be used safely preoperatively in small
quantities.

        C.  Sedatives/ Hypnotics: Thiopental is found in breastmilk but
probably has insignificant effects on the newborn after a single
induction dose. The concentration of Propofol is very low in breastmilk
and rapidly cleared by the newborn, however, other researchers have noted
lower Apgars, hypotonia and evidence of cortical depression compared to
thiopental in neonates after elective C-section.

        D.  Inhaled anesthetics: the less lipid-soluble, the better, ie
low blood-gas solubility coefficient. All agents currently available may
be used safely.

        E.  Muscle relaxants: large, ionized molecules do not pass into
breastmilk.

        F.  Atropine and Antihistamines may cause decreased lactation.

        G.  Other medications: please refer to Medications and Mother's
Milk by Thomas Hale, PhD.

References: (I'm abbreviating these-hands getting tired)
Celleno, D. et al; "Neurobehavioral effects of propofol on the neonate
following elective c section induction. BrJAnaesth 62:649, 1989

Anderson, LW et al; "Concentrations of thiopentone in mature breast milk
and colostrum following and induction dose. ActaAnaesthesiolScan 31:30,
1987.

Leuschen, MP et al; "Fentanyl excretion in breast milk" ClinPharm 9:336,
1990.

Bader, AM, et al; "Maternal and Neonatal fentanyl and bupivacaine
concentrations after epidural infusion during labor. Anesthesia and
Analgesia *1:4, 1995.

Hale, Thomas, PhD; Medications and Mother's Milk, Fifth edition.

Shnider and Levinson; Anesthesia for Obstetrics, Third edition.

Chestnut; Obstetric Anesthesia Principles.

Abboud, TK, et al; "The influence of acidosis on the distribution of
lidocaine and bupivacaine into the myocardium and brain of the sheep"
AnesthAnalg 63:421, 1987.

Loftus, JR, et al; "Placental transfer and neonatal effects of epidural
sufentanil and fentanyl administered with bupivacaine during labor."
Anesthesiology, 1995.

Steer, PL, et al; "Concentrations of fentanyl in colostrum after an
analgesic dose" Canadian Journal of Anesthesia 39:3, 1992.

I know this is long. I'm assuming our hospital is not the only institution
where post op orders for breastfeeding mothers are inappropriate. I'm
looking forward to your reactions, thoughts, suggestions, whatever to this
approach.

Thanks!



Amy Mueller, BSN, RN, IBCLC
Traverse City
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