Breast-feeding, anesthesia and analgesics: What’s safe?

Moms can safely continue breast-feeding even just after waking from anesthesia and while taking most pain medications, according to a newly expanded clinical guidance, “Clinical Protocol No. 15: Analgesia and Anesthesia for the Breastfeeding Mother,” from the Academy of Breastfeeding Medicine (ABM).

In general, mothers who are beyond the postpartum stage do not need to avoid breast-feeding or to pump and discard breast milk while taking analgesics or receiving local or general anesthesia. The protocol was published in the journal Breastfeeding Medicine.

Sarah Reece-Stremtan, M.D., an anesthesiologist and acute pain medicine specialist at Children’s National Health System, co-chairs ABM’s protocol committee and is the lead author of the expanded protocol. A specialist in the intersection of anesthesia, pain medicine and breast-feeding medicine, Dr. Reece-Stremtan led the drafting of the recommendations.

“The key recommendation in this protocol is after waking up from anesthesia, most moms can breast-feed right away,” says Dr. Reece-Stremtan. “The standard thinking has been ‘pump and dump’ – discarding the breast milk for 24 hours after anesthesia. As an outdated practice, it is not evidence-based and is potentially harmful for babies. The evidence shows that this breast milk is safe.”

The authors’ main note of caution relates to opioids: “The most concerning class of medications used for anesthesia and analgesia in breast-feeding mothers is opioids, as these medications transfer into breast milk,” they write. “Judicious use of opioids for short periods is likely to be safe for most breast-feeding mothers and infants.”

The protocol recommendations cover pain medications, brief procedures, regional and general anesthesia and perioperative considerations. They provide more granular detail about specific anesthesia and analgesic agents.

For each recommendation, the protocol notes the strength or weakness of the evidence base. The authors note there is little rigorous information in the scientific literature about anesthesia or procedural sedation in breast-feeding mothers.

“For obvious reasons, it is unethical to conduct randomized, controlled clinical trials for this area, so we rely on expert opinion and on observational studies that do exist,” says Dr. Reece-Stremtan.

The protocol is intended to be relevant to a broad range of medical fields, from anesthesiology to general pediatrics, and to help any physician who may care for a new mother.

For instance, it includes a perioperative plan with suggestions that surgeons or physicians can share with their patients to make things easier for a breast-feeding mom who needs local or general anesthesia – and safer for their babies. “It’s important to acknowledge that medication isn’t the only or even the most important thing,” says Dr. Reece-Stremtan. Tips to aid breast-feeding can ease the minds of mothers and their physicians alike.

Dr. Reece-Stremtan has long been interested in breast-feeding and has seen a need for more education about where her areas of expertise, pediatric anesthesia and pain medicine, intersect. Few physicians specialize in this area, so she often gives talks to other clinicians on the topic.

“I know that most anesthesiologists do not encounter this scenario often, so many have questions about the impact of anesthesia agents on breast-feeding,” says Dr. Reece-Stremtan. “Likewise, general pediatricians, neonatal specialists and other health professionals who care for moms and newborns may have limited knowledge about the safety of pain medicine or anesthesia for breast-feeding infants.”

In developing this new set of recommendations, ABM’s protocol committee aimed to provide practical clinical guidance for two scenarios: Postpartum, and moms and babies who are past that stage. The committee divided a previous ABM protocol into these two areas and expanded them to offer clinicians more complete guidance that is clinically relevant yet concise. Dr. Reece-Stremtan attributes this expansion to a growing appreciation of the importance of breast-feeding to both individual and public health. She is helping to finalize ABM’s new birth-postpartum protocol on anesthesia and analgesics, which will be published in early 2018.

To build on these protocols, Dr. Reece-Stremtan is helping the Academy develop a set of free patient education materials that will inform mothers about the use of pain medications or the need for anesthesia while breast-feeding, so they can feel at ease that they are doing the best thing for their baby’s health.