The breastfeeding surgical patient: 1.8 ce

AORN Journal,  April, 2008  by Deborah Dumphy

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TABLE 1

Considerations in the
Transfer of Maternal Medications
into Breast Milk (1-4)

Higher transfer              Lower transfer

High concentrations          Low concentrations in
in maternal plasma           maternal plasma

High oral bioavailability;   Low oral bioavailability
also high transfer
if lipid soluble

Low molecular weight         High molecular weight

Low in maternal              High in maternal protein
protein binding              binding

1. Hale TW. Anesthetic medications in breastfeeding
mothers. J Hum Lact. 1999;15(3):185-194.

2. Hale TW. Medications and Mothers' Milk. 12th
ed. Amarillo, TX: Hale Publishing; 2006.

3. Ting PH. Breastfeeding and anesthesia. AnesthesiologyInfo.com.
http://www.anesthesiologyinfo.com
/articles/01052002.php. Accessed February 4, 2008.

4. Riordan J. Breastfeeding and Human Lactation.
3rd ed. Boston, MA: Jones and Bartlett Publishers;
2005.

TABLE 2
Lactation Risk Category

L1: Safest

* Medication that has been taken by a large number of breastfeeding
  mothers without any observed increase in adverse effects in their
  infants.

* Controlled studies in breastfeeding women fail to demonstrate a
  risk to their infants, and the possibility of harm to the breastfed
  infant is remote.

* The product is not orally bioavailable to an infant.

L2: Safer

* Medication that has been studied in a limited number of
  breastfeeding women without an increase in adverse effects in their
  infants.

* The evidence of a demonstrated risk that is likely to follow use of
  this medication in a breastfeeding woman is remote.

L3: Moderately safe

* There are no controlled studies in breastfeeding women; however, the
  risk of untoward effects to a breastfed infant is possible, or
  controlled studies show only minimal, nonthreatening adverse
  effects.

* Medications should be given only if the potential benefit justifies
  the potential risk to the infant.

* New medications that have no published data are automatically
  categorized as moderately safety regardless of how safe they may be.

L4: Possibly hazardous

* There is positive evidence of risk to a breastfed infant or to
   breast milk production, but the benefits from use in a
   breastfeeding mother may be acceptable despite the risk to the
   infant (eg, if the medication is needed in a life-threatening
   situation or for a serious disease for which safer medications
   cannot be used or are ineffective).

L5: Contraindicated

* Studies in breastfeeding mothers have demonstrated significant and
  documented risk to their infants based on human experience, or the
  medication has a high risk of causing significant damage to an
  infant.

* The risk of using the medication in breastfeeding women clearly
  outweighs any possible benefit from breast feeding.

* The medication is contraindicated in women who are breastfeeding an
  infant.

Adapted with permission from Hale TW. Medications and Mothers' Milk.
12th ed. Amarillo, TX: Hale Publishing; 2006:15.

TABLE 3

Commonly Used Anesthesia-Related Medications

Alfentanil (eg, Alfenta)

Lactation risk category (LRC): L2
Alfentanil has not been reviewed by the American
Academy of Pediatrics (AAP). Transfer of alfentanil
to human milk is low and at levels probably too
low to produce sedation in breastfeeding infants. (1,2)

Atropine (eg, Belladona)

LRC: L3

The AAP reports that atropine usually is compatible
with breastfeeding, but the medication can transfer
into breast milk and infants are extremely sensitive
to these medications. It is best to avoid atropine-containing
medications for the breastfeeding mother. (1,2)

Bupivacaine (eg, Marcaine)

LRC: L2

Bupivacaine has not been reviewed by the AAP.
One study reports that the transfer levels of bupivacaine
in breast milk is below the limit of detection. (1,2)

Diazepam (eg, Valium)

LRC: L3; L4 for chronic use

The AAP reports that the effects of diazepam are unknown;
however, there may be concern for the breastfed
infant because of the medication's long half-life
and active metabolite. Diazepam is not recommended
for long-term therapy, but if it is used long term, the
infant must be observed for somnolence and poor
breastfeeding. Research studies on single-dose therapy
(ie, induction of surgery, dental extraction) indicate
minimal or no untoward effects. (1,2) In single-dose
maternal therapy with newborns or preterm infants,
however, "a cautious approach would be to wait a
period of 6 to 8 hours before resuming nursing." (3)

Fentanyl (eg, Sublimaze)

LRC: L2

The AAP reports that fentanyl usually is compatible
with breastfeeding. Studies indicate that although
the medication enters breast milk, it does so in minimal
amounts resulting in negligible amounts transferred
to the infant; however, the medication is not
eliminated as rapidly from the infant's system as
from the maternal system. The transfer to the infant
in most situations is minimal and "probably clinically
unimportant" as the bioavailability of the
medication is low. (2(p343))

Halothane (eg, Fluothane)

LRC: L2

The AAP reports that halothane usually is compatible
with breastfeeding. (1)

Ketorolac (eg, Toradol)

LRC: L2

The AAP reports that ketorolac usually is compatible
with breastfeeding. (1) The US Food and Drug Administration,
however, requires a "black box"
warning against breastfeeding during maternal ketorolac
use of the injection or tablets." (4)

Lidocaine (eg, Xylocaine)

LRC: L2

The AAP reports that lidocaine usually is compatible
with breastfeeding. It has low bioavailability
to the infant with a low transfer into breast milk. (1,2)

Lorazepam (eg, Ativan)

LRC: L3

The AAP reports that the effects of lorazepam are
unknown; however, it "may be of concern" (1(p534)) in
the breastfed infant. One study reported a high rate
of neonatal respiratory depression, hypothermia,
and feeding issues. Other research studies indicate
that within 2 hrs of single-dose administration, the
breast milk medication level is too low to produce
neurobehavioral changes in the newborn in most
situations, and neonates are able to "metabolize
and excrete lorazepam roughly equivalent to the
maternal rate." (2(p186))

Meperidine (eg, Demerol)

LRC: L2; L3 if used in early postpartum

The AAP reports that meperidine usually is compatible
with breastfeeding although small amounts are
excreted directly into the maternal breast milk and
the metabolite has a long half-life. Neurobehavioral
depression in breastfed infants with maternal administration
of meperidine has been reported, including
infant sedation, poor sucking reflex, and
neurobehavioral delay. (1,2,5)

Midazolam (eg, Versed)

LRC: L3

The AAP reports the the effects of midazolam are
unknown, however they "may be of concern" in
the breastfed infant. There is a brief redistribution
half-life of 7 minutes. The medication and its
metabolite were undetected in breast milk 4 hrs
after maternal administration. (1,2)

Morphine (eg, Duramorph, Infumorph)

LRC: L3

The AAP reports that morphine usually is compatible
with breastfeeding. (1) "Overall, most studies
do not tend to suggest that morphine is a significant
hazard to breastfeeding infants as long as
the maternal doses are low to moderate, and the
infant is reasonably stable." (2(189)) Individual variations
may result, however, in an infant being
more vulnerable to morphine, resulting in pediatric
sedation. (1)

Natoxone (eg, Narcan)

LRC: L3

This medication has not been reviewed by the
AAP. Considerations include low oral bioavailability;
however, even small amounts present in
the infant of a narcotic-dependent mother could
potentiate withdrawal symptoms. (1)

Nitrous oxide

LRC: L3

Nitrous oxide has not been reviewed by the AAP. It
has an extremely short half-life, and there is an unlikely
chance of oral bioavailability in the breastfed
infant. (1,2)

Ondansetron (eg, Zofran)

LRC: L2

Ondansetron has not been reviewed by the AAP. (1)

Propofol (eg, Diprivan)

LRC: L2

Propofol has not been reviewed by the AAP.
Studies indicate that although the medication
enters breast milk, it does so in minimal amounts,
resulting in negligible amounts transferred to the
infant, and it is rapidly eliminated from the infant's
system. (1,2)

Thiopental sodium (eg, Pentothal)

LRC: L3

The AAP reports that thiopental usually is compatible
with breastfeeding. It is extremely short-acting
and studies indicate that although thiopental
enters breast milk, it does so in minimal
amounts, resulting in negligible amounts transferred
to the infant. (1,2)

Editor's note: This review of medications is for informational
purposes only. A thorough review of maternal medications to be
administered, frequency of administration, cumulative effects of
multiple medication use, the status of the breastfed infant, and
pediatric care provider approval are indicated before any medications
are administered to a breastfeeding surgical patient.

1. Hale TW. Medications and Mothers' Milk. 12th ed. Amarillo, TX: Hale
Publishing; 2006.

2. Hale TW. Anesthetic medications in breastfeeding mothers. J Hum Lact.
1999;15(3):185-194.

3. Valium. National Library of Medicine TOXNET.
http://www.toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~lmnImx:1.
Accessed February 25, 2008.

4. Ketorolac. National Library of Medicine TOXNET.
http://www.toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/-H7Ecr5:1.
Accessed February 25, 2008.

5. Riordan J, Gross A, Angeron J, Krumwiede B, Melin J. The effect of
labor pain relief medication on neonatal suckling and breastfeeding
duration. J Hum Lact. 2000;16(1):7-12.

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