The breastfeeding surgical patient: 1.8 ce

Deborah Dumphy

In the United States, more than 10 million women are either pregnant or breastfeeding at any given time. (1) Of the women currently pregnant, over 70% will initially choose to breastfeed. (2) The breastfeeding surgical patient may present a unique situation for members of the perioperative team. All members of the surgical health care team should be informed when a surgical patient is breastfeeding.

In American culture, the ethical and social issue of breastfeeding often can trigger value-laden conflict among staff members. Perioperative nurses must become self-aware of any potential biases that they may have toward patients who are breastfeeding. Identifying personal beliefs about breastfeeding before the breastfeeding surgical patient arrives in the care setting requires professionalism. The goal of evaluating self biases is to ensure that the breastfeeding surgical patient and her infant both receive a comfortable environment of care that safely meets their needs.

The beliefs and knowledge surrounding breastfeeding are highly variable. Common myths associated with breastfeeding include that

* breastfeeding needs to cease for 24 hours to seven days after a surgical procedure,

* breast milk can be replaced with formula feedings without ill effect on the breastfed infant,

* breastfeeding can be resumed without difficulty after the mother has ceased breastfeeding for a considerable amount of time, and

* breast milk is one of two equally nutritive infant feedings.

The focus of this article is to enhance awareness of breastfeeding issues by dispelling the myths related to breastfeeding and surgical patients and ensuring that perioperative nurses have the resources to provide appropriate evidenced-based care.

PRACTICE IMPLICATIONS

The most prevalent concern regarding breastfeeding and surgery is the potential transfer of anesthesia-related medications, postoperative pain medications, and antibiotics into the breast milk and, subsequently, to the nursing infant. Often, medical staff members who are uninformed of current evidence to the contrary inaccurately instruct the breastfeeding patient to discontinue breastfeeding for a long period of time after the surgical procedure. (3-7) Disruption in breastfeeding can result in deterioration of the milk supply and, ultimately, may result in permanent discontinuation of breastfeeding. (4,5,8)

The American Academy of Pediatrics (AAP) policy statement on breastfeeding recommends that "human milk ... as species-specific ... be the only milk infants receive ... for the first year of life and beyond for as long as mutually desired." (9(p499) The AAP Committee on Drugs reports that a common reason for the discontinuation of breastfeeding is physician advice to stop breastfeeding when the patient is taking a medication, but this advice may not be warranted. (3) Most medications are presumed "safe" with limited bioavailability to the breastfed infant. (3-5,10) According to Hale, "Most drugs are quite safe in breastfeeding mothers ... [while the] risks of not breastfeeding and instead using infant formulas are much higher for the infant." (5(p9)) The identified risks of feeding an infant artificial milk rather than breast milk are supported and documented in medical and nursing research databases. (5,9,11) The risks include increased rates of acute diseases, such as

* bacteremia;

* diarrheal illness, including rotavirus gastroenteritis;

* meningitis;

* otitis media; and

* respiratory infections.

Other risks for artificially fed infants compared to breastfed infants include immune system disorders such as Crohn's disease, ulcerative colitis, childhood onset diabetes, lymphoma, and possible impairment of antibody response to oral and parenteral vaccines. (5,9,11) Artificial milk also increases an infant's ingestion of lead, aluminum, manganese, iodine, and other heavy metals up to 80 times compared to breast milk. (9,11)

Careful attention to medications that are not considered safe is imperative for the safety of the breastfed infant (Table 1). In determining medication uses for a patient who is breastfeeding, pertinent considerations include the age and condition of the infant and the medication's

* half-life,

* lipodensity,

* molecular weight,

* oral bioavailability,

* dosing frequency, and

* cumulative effects with other medications. (4,5,8,11)

The age and condition of the infant are deemed the most important criteria. (5) Preterm infants; infants with a history of bradycardia or apnea; neonates (ie, newborn infants or infants in their first 28 days (12)); and low-birth-weight infants may be more sensitive to maternal medication use. (5,11) In these instances, all maternal medications should be reviewed by the neonatologist or pediatric specialist caring for the infant before any medication is used. (11)

With the exception of a few medications, the shorter the half-life, the faster the medication will exit from the breast milk. (5,11) Additionally, the higher the lipodensity and the smaller the molecular weight of the medication, the greater the chance of transfer from maternal plasma to breast milk. (5,11) Medications that are low in protein binding transfer more readily into breast milk. (5,11)

Maternal medications should be reviewed to make sure the AAP has deemed them safe for the breastfed infant before administration to the breastfeeding mother. (5,11) Of important consideration is the possibility of active metabolites in the medication and the effect of the metabolite on the breastfed infant. (5,11) An example of a medication with an active metabolite and a long half-life is meperidine. (5) The maternal medication also should be reviewed for the possibility of reducing breast milk production, which can occur with some medications, including some diuretics and antihistamines.

Of concern is not the simple presence of the medication, but a pharmacologically significant amount of the medication in the breast milk. (4) This also is an important consideration when multiple doses of the medication will be administered, such as for long-term pain therapy. Because most anesthetic medications generally have a short half-life, biotransfer to the breastfed infant often is minimized. (4,5) For example, midazolam frequently is administered as a premedication and propofol and fentanyl are used for anesthesia induction. Nitsun et al (6) report

   the amount of midazolam, propofol, and fentanyl excreted into milk
   within 24 hours of induction of anesthesia provides insufficient
   justification for interrupting breastfeeding. (6(p549))

   ... thus our data are supportive of the current opinion that
   breast-feeding may be resumed as soon after surgery and anesthesia
   with these three medications as the mother is physically and
   mentally able. (6(p555))

EVIDENCED-BASED PRACTICE RESOURCES

It is important for perioperative nurses reviewing medication information to use a reference that addresses current research on the breastfeeding patient. The Physicians' Desk Reference (PDR) and other standard medication manuals may not address the latest research on breast milk transfer and infant oral bioavailability of the particular medication. (5,11) In fact, the PDR has been cited as the poorest source of ac curate breastfeeding medication information. (5) The most commonly used medication reference that specifically deals with medications in breast milk is Medications and Mothers' Milk, 12th edition, by Thomas W. Hale, PhD. (5) Hale uses the lactation risk category to identify the level of medication risk to the breastfed infant (Table 2). Table 3 provides a summary of commonly used anesthesia-related medications and indicates the lactation risk category for each medication.

A complete and easy-to-navigate web site is the US National Library of Medicine TOXNET (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen? LACT). To access medication information on this site, the clinician types in the medication name and pertinent information for the lactating patient is provided instantly.

PREOPERATIVE NURSING CONSIDERATIONS

In the preoperative period, the nurse should engage the breastfeeding patient in an open dialogue regarding risks, benefits, and options; this will help ensure informed consent and patient satisfaction with the plan of care. (10) The nurse should assess and document data regarding the breastfeeding dyad (ie, the breastfeeding mother and breastfed infant), including the age, status, and weight of the infant and any breastfeeding concerns or problems. The nurse should ensure that the patient's pediatric health care provider has been notified of the perioperative plan of care, including medications to be administered and dosing frequency.

The nurse should determine whether the patient brought her infant with her to the hospital and whether a significant other is present to be a primary caregiver for the infant and to support the mother, particularly during the intraoperative period. The nurse should facilitate continuous rooming-in of the infant and significant other with the mother during the preoperative and postoperative period.

The preoperative nurse should document that the surgical patient is breastfeeding and inform the anesthesia care provider and the institution's lactation consultant, if one is avail able. When necessary, the preoperative nurse should seek assistance from a lactation consultant if any breastfeeding problems, questions, or concerns are identified. To find an internationally board certified lactation consultant (ie, IBCLC), the preoperative nurse should visit the International Lactation Consultants Association web site at http://www.ilca.org/falc.html.

The nurse should encourage the patient to breastfeed her infant immediately before the nurse administers preoperative medications that have been identified as compatible with breastfeeding. If breastfeeding is not an option at this time, the nurse should determine whether the patient brought her own breast pump and pump kit supplies. If the patient has her own breast pump, she should express her milk as she normally does.

If the patient does not have her own pump and supplies, the nurse should verify access to a hospital-grade electric breast pump and sterile pump kit. If the patient has not been expressing milk on her own in the past and is unfamiliar with the process, the preoperative nurse should be prepared to assist the patient with the process to maintain the patient's breast milk supply and demand. Current recommendations are for pumping both breasts simultaneously for 15 minutes, if using a hospital-grade electric bilateral breast pump. The nurse then should label and store the breast milk according to the standards for collection and storage of breast milk. (12)

INTRAOPERATIVE NURSING CONSIDERATIONS

The circulating nurse should ensure that all perioperative team members are aware that the patient is a breastfeeding mother and should document this on the intraoperative medical record. The length of the surgery and current breast milk production are critical to the risk of engorgement and resulting negative outcomes, such as increased risk of postoperative breast pain and decreased breast milk production. If the surgeon anticipates that the surgical procedure may extend beyond four hours, the circulating nurse should consider the risk of engorgement when planning intraoperative care for the patient. The preoperative team should weigh the benefits of expressing breast milk intraoperatively, which may slow the progress of the surgical procedure, against the potential negative effects of engorgement, breast pain, and decreased breast milk production in the postoperative period. The nurse should discuss with the surgeon and anesthesia care provider the need for using the electric breast pump intra-operatively to express breast milk after the four-hour time frame.

If the patient is unable to express breast milk herself intraoperatively, the circulating nurse will apply the sterile, breast-pump kit flange centrally to the surgical patient's breasts simultaneously and maintain a suction seal of the flanges to each breast. The nurse will hold the pump kit with the collection bottle vertical on the ventral-dorsal side of the patient for gravity flow of the expressed breast milk so that the milk will not leak from the flanges and potentially contaminate the surgical field. This is a difficult challenge intraoperatively so the perioperative team must weigh these risks against the benefits and risks of waiting to express breast milk postoperatively.

The plan of care should be developed with the patient and perioperative team members before the circulating nurse transfers the patient to the OR. The circulating nurse should ensure that the postanesthesia care unit (PACU) nurse is aware of the patient's breastfeeding status before the patient arrives in the PACU.

POSTOPERATIVE NURSING CONSIDERATIONS

As soon as possible after settling the patient in the PACU (eg, after obtaining initial vital signs, managing the airway, and managing postoperative pain), the PACU nurse should offer the postoperative patient the opportunity to breastfeed. (10) If breastfeeding is not an option, the PACU nurse should assist the patient in using the electric breast pump to express milk, adhering to standards for collection and storage of breast milk.

The PACU nurse should explain to the patient that postoperative pain can suppress lactation and should encourage pain management with medications identified as compatible with breastfeeding. (10) The nurse should inform the patient of any possible adverse medication effects for the infant and should ensure that the patient is aware of what infant behaviors to observe and report. When an inpatient stay is required, nursing staff members should ensure that continued rooming-in is allowed. An adult care giver should remain with the patient to provide primary care for the infant and to support the surgical patient with continued breastfeeding. (10)

MEDICATION SAFETY FOR THE BREASTFEEDING PATIENT AND HER INFANT

When caring for a breastfeeding surgical patient, perioperative nurses have a unique opportunity to support the maternal commitment to breastfeeding and the mother's goal to provide optimal nutrition and health benefits for her infant. As with most obliged responsibilities, this requires time and dedication to achieve the best outcome. The perioperative team plays a vital role in supporting maternal and infant safety. The nuances of medication safety with a breastfeeding surgical patient may be unfamiliar territory for perioperative nurses; however, evidence does not indicate that a breastfeeding patient must discontinue breastfeeding when undergoing surgery. Preparing a plan of care and obtaining necessary breast pump equipment and supplies in advance can help ensure positive outcomes for both the breastfeeding surgical patient and her infant.

Acknowledgement: The author thanks Michelle Byrne, PhD, RN, CNOR, associate professor of nursing, North Georgia College and State University, Dahlonega, GA, for her time, effort, and support of this manuscript.

REFERENCES

(1.) Nahum GG, Uhl K, Kennedy DL. Antibiotic use in pregnancy and lactation: what is and is not known about teratogenic and toxic risks. Obstet Gynecol. 2006;107(5):1120-1138.

(2.) Breastfeeding practices--results from the National Immunization Survey. Centers for Disease Control and Prevention. http://www.cdc.gov/breast feeding/data/NIS_data/data_2004.htm. Accessed February 25, 2008

(3.) American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. 2001;108(3):776-789.

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

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

(6.) Nitsun M, Szokol JW, Saleh HJ, et al. Pharmacokinetics of midazolam, propofol, and fentanyl transfer to human breast milk. Clin Pharmacol Ther. 2006; 79(6):549-557.

(7.) Ressel G; American Academy of Pediatrics. AAP updates statement for transfer of drugs and other chemicals into breast milk. Am Fam Physician. 2002; 65(5):979-980.

(8.) McCarter-Spaulding DE. Medications in pregnancy and lactation. MCN Am J Matern/Child Nurs. 2005;30(1):10-17.

(9.) Gartner LM, Morton J, Lawrence RA, et al; American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496-506.

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

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

(12.) Neonate. In: Webster's College Dictionary. New York, NY: Random House; 2001:887.

Storing Breast Milk

The perioperative nurse should encourage the mother to store the expressed breast milk in a sterile container, such as an emptied sterile water bottle from the hospital nursery or sterile, breast-milk collection container from the hospital special care nursery. The nurse must label the collection container with the patient's name, patient's identification number, and the date and time the milk was expressed. The nurse should also indicate on the label what, if any, maternal medications were administered.

The breast milk can be stored in an ice-filled or cold-packed cooler for transport home if the patient is expected to be discharged within eight hours. If it is going to be longer than eight hours before discharge or consumption of the breast milk by the infant, the nurse should store the expressed breast milk in a refrigerator or freezer. The hospital nursery department should have a breast milk-storage refrigerator or freezer. Many facilities now have breast-pump rooms with a breast milk-storage refrigerator or freezer. If a specified breast milk refrigerator or freezer is not available, the nurse should consult the facility administrator.

DEBORAH DUMPHY, RN, MSNED, IBCLC, RLC

Deborah Dumphy, RN, MSNed, IBCLC, RLC, is a clinical instructor and lactation consultant at North Georgia College and State University, Dahlonega, GA. Ms Dumphy has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.

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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