Breastfeeding and anaesthesia: are they compatible?

Research findings on theeffect of epidural on breastfeeding are highly controversial. Epidurals are very effective pain management tools during labour in particular, and many factors can affect breastfeeding success. It is possible that the epidural is one of these factors — directly if the dose is high, or indirectly by increasing instrumental deliveries, the administration of synthetic oxytocin, the duration of labour, and so on.

No data available for certain agents

- Ketamine

There are currently no human studies evaluating the transfer of ketamine in breast milk.

- Volatile gases

No study measures the levels of volatile gases in breast milk following the administration of a volatile anaesthetic. Nevertheless, there is evidence that inhaled agents are rapidly excreted and have low bioavailability. This suggests that mothers may resume breastfeeding after inhalation anaesthesia without harmful effects for the infant [14].

- Neuromuscular blocking agents

To date, there are no studies evaluating the transfer of neuromuscular blocking agents in breast milk. It is presumed that these agents do not cross the blood-milk channel membranes and that they have low oral bioavailability, which reinforces their safety for breastfeeding mothers [15].

The CRAT
 

The CRAT is the reference centre for teratogenic agents. It states that "as a general rule, the duration of action of general anaesthetics is brief. For most of them, there is no measurement of their transfer into breast milk." [16]
 

According to the CRAT, "after general anaesthesia in a breastfeeding woman, breastfeeding may be resumed as soon as the mother is fully awake and able to care for her baby."

The American Society of Anesthesiologists

The American Society of Anesthesiologists has published the following recommendations for breastfeeding mothers who need to undergo surgery [17]:

+ All anaesthetic and analgesic medications pass into breast milk; however, they are only present in small amounts and at very low concentrations considered clinically insignificant.
 

+ Narcotics and/or their metabolites may be transferred into breast milk at slightly higher levels; therefore, steps should be taken to reduce narcotic requirements by adding other analgesics where appropriate, and by avoiding medications that are more likely to be transferred into breast milk.

+ As pain hinders successful breastfeeding, breastfeeding individuals should not avoid analgesics following surgery. Despite an excellent safety record, breastfeeding individuals who require narcotic analgesics should always monitor the baby closely for signs of sedation: difficulty waking and/or slowed breathing.

+ Where possible, spinal or epidural anaesthesia comprising a local anaesthetic and a long-acting narcotic should be used for a caesarean section in order to reduce overall postoperative analgesic requirements.
 

+ Mothers should resume breastfeeding as soon as possible after surgery, as anaesthetic medications are present in very small amounts in breast milk. It is not recommended for women to "pump and dump". If needed, you can take a breastfeeding-compatible food supplement to support your lactation. 
 

+ Where possible, day surgery is preferable to avoid disrupting normal routines [18]. The breastfeeding parent should be cautious when bed-sharing or when falling asleep whilst feeding their baby in a chair, as they may not be as responsive as usual.

In summary, meperidine should be avoided in breastfeeding mothers. Hydromorphone and morphine should be used with caution, under supervision. No data are available on ketamine to determine whether it can be used concurrently with breastfeeding. The other compounds can in principle be used for breastfeeding mothers. 
 

Given that data are limited, a general principle is that the mother may resume breastfeeding once she is awake, stable and alert following anaesthesia.