Breastfeeding and anesthetics (and other medications used during anesthesia)

July 28, 2011. Posted in: Medications & Vaccines

Information on selected anesthetics and related medications

The information summarized below is only a general overview of selected medications. For detailed information on the specific drugs or for information on drugs not listed here, please review the references listed below with your health care provider.

Info on selected anesthetics
Name of medication
AAP approved?*
Pregnancy Risk Category**
Notes
     Local anesthetics
Articaine (Septocaine) NR - NR
Bupivacaine (Marcaine) NR C L2
Lidocaine (Xylocaine)
Approved
C L2
Mepivacaine (Carbocaine, Polocaine) NR C L3  
Procaine HCL (Novocaine) NR C L3
     General anesthetics
Halothane (Fluothane)
Approved
C L2  
Isoflurane (Forane) NR - NR 1
Ketamine NR - NR  
Methohexital (Brevital) Approved B L3
Nitrous oxide NR - L3
Sevoflurane (Ultane) NR B L3
Thiopental (Pentothal)
Approved
C L3
Other medications often used during anesthesia
Sedatives
Diazepam (Valium) Concern D L3; L4 for chronic use
Midazolam (Versed) Concern D L3
Propofol (Diprivan) NR B L2 more
Triazolam (Halcion) NR X L3
Narcotic Analgesics
Alfentanil (Alfenta) NR C L2
Fentanyl (Sublimaze) Approved B L2
Hydromorphone (Dilaudid) NR C L3
Morphine Approved B L3
Reversal Medication
Flumazenil (Romazicon) NR C NR 2
Naloxone (Narcan) NR C NR 3
Steroids
Decadron (Dexamethasone) NR C NR more
Stimulants
Epinephrine (Adrenaline) NR C L1
Anti-nausea
Promethazine (Phenergan) NR C L2
*  Per the AAP Policy Statement The Transfer of Drugs and Other Chemicals Into Human Milk, revised September 2001.

** Per Medications’ and Mothers’ Milk by Thomas Hale, PhD (2004 edition).

 Lactation Risk Categories  Pregnancy Risk Categories
  • L1 (safest)
  • L2 (safer)
  • L3 (moderately safe)
  • L4 (possibly hazardous)
  • L5 (contraindicated)
  • A (controlled studies show no risk)
  • B (no evidence of risk in humans)
  • C (risk cannot be ruled out)
  • D (positive evidence of risk)
  • X (contraindicated in pregnancy)
NR: Not Reviewed. This drug has not yet been reviewed by Hale.
  1. Isoflurane (Forane) is used for c-sections and directly in newborns. Induction of and recovery from isoflurane anesthesia are rapid, so the majority of the medication is out of the body (and milk) very quickly. More here.
  2. Flumazenil (Romazicon) is used directly in children aged 12 months and up.
  3. Naloxone (Narcan) is used directly in newborns and children.

 

References

Table 6: Maternal Medication Usually Compatible With Breast-Feeding, from the AAP Policy Statement The Transfer of Drugs and Other Chemicals Into Human Milk, revised September 2001.

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Links for additional information

@

@ other websites

Some references regarding anesthesia (for mom) and breastfeeding

Andersen LW, Qvist T, Hertz J, Mogensen F. Concentrations of thiopentone in mature breast milk and colostrum following an induction dose. Acta Anaesthesiol Scand 1987 Jan;31(1):30-2. “Concentrations of thiopentone in mature breast milk and colostrum following anaesthesia induction… may be regarded as negligible and therefore non-toxic for the nursing infant.”

Baka NE, Bayoumeu F, Boutroy MJ, Laxenaire MC. Colostrum morphine concentrations during postcesarean intravenous patient-controlled analgesia. Anesth Analg. 2002 Jan;94(1):184-7.

Borgatta L, Jenny RW, Gruss L, Ong C, Barad D. Clinical significance of methohexital, meperidine, and diazepam in breast milk. J Clin Pharmacol 1997 Mar;37(3):186-92. “The amounts of methohexital, meperidine and diazepam excreted into breast milk do not warrant interruption of breast-feeding.”

Hirose M, Hosokawa T, Tanaka Y. (PDF) Extradural buprenorphine suppresses breast feeding after caesarean section. Br J Anaesth. 1997 Jul;79(1):120-1.

Hirose M, Hara Y, Hosokawa T, Tanaka Y. The effect of postoperative analgesia with continuous epidural bupivacaine after cesarean section on the amount of breast feeding and infant weight gain. Anesth Analg. 1996 Jun;82(6):1166-9.

Lie B, Juul J. Effect of epidural vs. general anesthesia on breastfeeding. Acta Obstet Gynecol Scand. 1988;67(3):207-9.

Kanto J. Risk-benefit assessment of anaesthetic agents in the puerperium. Drug Saf. 1991 Jul-Aug;6(4):285-301. “The different anaesthetic agents are excreted in the milk in amounts so low that detrimental effects on the neonate should not be expected.”

Nitsun M, Szokol JW, Saleh HJ, Murphy GS, Vender JS, Luong L, Raikoff K, Avram MJ. Pharmacokinetics of midazolam, propofol, and fentanyl transfer to human breast milk. Clin Pharmacol Ther. 2006 Jun;79(6):549-57. “The amount of midazolam, propofol, and fentanyl excreted into milk within 24 hours of induction of anesthesia provides insufficient justification for interrupting breast-feeding.”

Ortega D, Viviand X, Lorec AM, Gamerre M, Martin C, Bruguerolle B. Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery. Acta Anaesthesiol Scand 1999 Apr;43(4):394-7. “Our study does not reveal any adverse reactions related to the excretion of local anesthetics into breast milk. This study documents the magnitude of excreted lidocaine, bupivacaine and PPX in breast milk, and indicates that the use of both lidocaine and bupivacaine for epidural anaesthesia is safe with regard to breast-feeding.”

Schneider P, Reinhold P. Anesthesia in breast feeding. Which restrictions are justified? Anasthesiol Intensivmed Notfallmed Schmerzther 2000 Jun;35(6):356-74. From the abstract: “Thus it will be possible to anesthetize a breast-feeding mother with minimal risks for the child without giving up the advantages of mother milk. Through careful selection of appropriate drugs even elective operations don’t need to be postponed and breastfeeding can be continued as soon as in the immediate postoperative period.”

Sener EB, Guldogus F, Karakaya D, Baris S, Kocamanoglu S, Tur A. Comparison of neonatal effects of epidural and general anesthesia for cesarean section. Gynecol Obstet Invest. 2003;55(1):41-5.

Spigset O. Anaesthetic agents and excretion in breast milk. Acta Anaesthesiol Scand (Denmark), Feb 1994, 38(2) p94-103. “Most anaesthetics are rapidly cleared from the mother, and, consequently, it should be possible to allow suckling as soon as practically feasible after surgery.”

Wittels B, Glosten B, Faure EA, et al. Postcesarean analgesia with both epidural morphine and intravenous patient-controlled analgesia: neurobehavioral outcomes among nursing neonates. Anesth Analg. 1997 Sep;85(3):600-6.

Medications and Mothers’ Milk by Thomas Hale, PhD

Clinical Therapy in Breastfeeding Mothers by Thomas Hale, PhD

Breastfeeding: A Guide for the Medical Profession by Ruth Lawrence, MD