Breastfeeding can have long-lasting effects on a child and maternal health. Benefits of breastfeeding include prevention of child infections and malocclusion (i.e., imperfect teeth positioning), increases in intelligence and probable reduction in the incidence of diabetes.1 Making breastfeeding universal could prevent an estimated 823,000 annual deaths in children younger than five years old and 20,000 annual deaths from breast cancer.1 That said, there are many substances that can affect a mother’s ability to breastfeed and/or can be transmitted to the infant with dangerous effects.2 Thus, it is important for medical providers to assess a new mother’s breastfeeding status before prescribing medications. Specifically, anesthesia providers should account for the effects of anesthetic drugs on a mother and child before, during and after a procedure.
Anesthesia can affect a mother’s ability to breastfeed in a variety of ways. Generally, a mother can resume breastfeeding once she is awake, stable and alert after anesthesia induction.3 However, anesthetic agents used during and after labor can have adverse effects on breastfeeding initiation.4 Research shows that longer labors, instrumented deliveries, Cesarean section and separation of mother and infant after birth may increase risk of difficulty with breastfeeding initiation.5-7 Anesthesia used during labor may influence any one of these factors,8 and some anesthetic drugs can directly make breastfeeding more difficult.5 A study by Zuppa et al., for example, found that epidural anesthesia in labor reduced likelihood of successful breastfeeding initiation in mothers who received hands-off care after delivery.9 However, the same study found that a good start to lactation was guaranteed by hands-on care after delivery, regardless of whether or not anesthesia was administered during labor.9 This indicates that proper pre- and postpartum care may outweigh any deleterious effects intraoperative anesthesia may have on breastfeeding.4,9 Indeed, pain and suffering during labor can inhibit proper initiation of breastfeeding, suggesting that the reduction in pain caused by anesthesia could ultimately balance out the effects of the drug itself.4 Overall, the effects of anesthesia on initiation of breastfeeding are often conflicting and not well studied.4
The effects of anesthetic drugs on a newborn, however, are more concrete. If anesthesia is administered neuraxially (i.e., injected into fatty tissue or cerebrospinal fluid surrounding spinal nerve roots), it will not affect the infant.3 Thus, even opioids such as fentanyl and morphine can be used safely for labor or Cesarean section in patients who intend to breastfeed, as long as they are administered as intrathecal or epidural anesthetics.3 However, anesthesiologists are still responsible for understanding pharmacokinetics, limiting dosage and monitoring vital signs in mothers and infants.3 For general anesthesia and postpartum pain management, anesthesiology practitioners should avoid codeine and meperidine and should use hydromorphone with caution.3 Low-dose morphine can be used safely postpartum,3 but all opioids used for labor can affect the newborn’s normal reflex to suckle at the breast after birth.4 The ability to cross the blood-milk duct membranes differs among anesthetic agents, and an anesthesia provider should ensure that infants will not be affected before administering medication to a breastfeeding mother.2 Though data on drug transfer to breast milk are limited10 and special precautions are rarely warranted for routine anesthetic drugs,11 anesthesiologists must be aware of the potential harm of postoperative medications.3
Initiation and continuation of breastfeeding are important to maternal and child health. Anesthesia providers should be aware of the effects anesthetic drugs can have on a mother’s ability to breastfeed and on a child’s development. That said, the literature on anesthesia in breastfeeding is profoundly lacking. Future studies should assess the effects of various types of local and general anesthesia on breastfeeding initiation and breast milk concentrations. Without information on anesthesia’s relationship to breastfeeding, it could be difficult for an anesthesiologist to make decisions about a breastfeeding mother’s perioperative care.
1. Victora CG, Bahl R, Barros AJD, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lancet. 2016;387(10017):475–490.
2. National Institutes of Health. Drugs and Lactation Database (LactMed). Bethesda, MD: National Library of Medicine (US); 2006–2019.
3. Cobb B, Liu R, Valentine E, Onuoha O. Breastfeeding after Anesthesia: A Review for Anesthesia Providers Regarding the Transfer of Medications into Breast Milk. Translational Perioperative and Pain Medicine. 2015;1(2):1–7.
4. Montgomery A, Hale TW, The Academy of Breastfeeding Medicine. ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2012. Breastfeeding Medicine. 2012;7(6):547–553.
5. Rajan L. The impact of obstetric procedures and analgesia/anaesthesia during labour and delivery on breast feeding. Midwifery. 1994;10(2):87–103.
6. Tamminen T, Verronen P, Saarikoski S, Goransson A, Tuomiranta H. The influence of perinatal factors on breast feeding. Acta Paediatrica Scandinavica. 1983;72(1):9–12.
7. Patel RR, Liebling RE, Murphy DJ. Effect of operative delivery in the second stage of labor on breastfeeding success. Birth (Berkeley, Calif.). 2003;30(4):255–260.
8. Howell CJ. Epidural versus non-epidural analgesia for pain relief in labour. The Cochrane Database of Systematic Reviews. 2000(2):Cd000331.
9. Zuppa AA, Alighieri G, Riccardi R, et al. Epidural analgesia, neonatal care and breastfeeding. Italian Journal of Pediatrics. 2014;40(1):82.
10. Nitsun M, Szokol JW, Saleh HJ, et al. Pharmacokinetics of midazolam, propofol, and fentanyl transfer to human breast milk. Clinical Pharmacology and Therapeutics. 2006;79(6):549–557.
11. Chu TC, McCallum J, Yii MF. Breastfeeding after Anaesthesia: A Review of the Pharmacological Impact on Children. Anaesthesia and Intensive Care. 2013;41(1):35–40.