Considerations in the Breastfeeding Patient

 

Transfer of Medications into Breast Milk

  • “Pump and Dump” postop is outdated and no longer recommended

  • All anesthetic/analgesic drugs transfer to breast milk

    • Passive diffusion most common

    • Highly lipid soluble, less protein-bound, low MW, or higher pKa drugs have greater penetration into breast milk

  • Relative infant dose (RID) reflects relative neonatal drug exposure via breast milk

    • RID <10% considered safe

    • Almost all anesthetic drugs have RID <<10%

  • Drugs not recommended in breastfeeding mothers:

    • Codeine, Tramadol (metabolized by CYP2D6 - ↑ risk if “ultra-metabolizer” mother breastfeeds “slow metabolizer” neonate)

    • Meperidine, high-dose morphine (low dose ok)

    • See https://www.ncbi.nlm.nih.gov/books/NBK501922/ for more info on specific agents

  • Minimize opioids/sedatives

    • Multimodal analgesia, regional techniques when possible

    • Pain interferes with successful breastfeeding → treat appropriately

    • Monitor patient & infant for sedation, respiratory depression

  • Resume breastfeeding as soon as possible postop (when patient is awake, alert, and able to hold infant)

https://pubs.asahq.org/anesthesiology/article/127/4/A15/19790/Anesthesia-amp-Breastfeeding-More-Often-Than-Not

Maintaining Supply of Breast Milk

  • Surgical stress often causes ↓ supply

  • Maintenance of adequate hydration

    • No prolonged fasting, encourage carbohydrate-containing clear fluids until 2 hrs preop

    • IV fluids (+/- dextrose) while NPO

    • PONV prophylaxis (ex Ondansetron, Metoclopramide, TIVA)

  • If possible, avoid drugs which may ↓ supply

    • Antihistamines

    • Anticholinergics

    • Phenylephrine

  • Where possible, breastfeed or pump immediately pre- and post-op

  • Consider pumping (and dumping) during prolonged surgery to maintain breast milk production & ↓ engorgement, risk of clogged ducts, & mastitis