Conscious Sedation and Breastfeeding: Recommendations for Patients

by Maurenne Griese, RNC, BSN. Reprinted with permission from the author.

As a lactation professional, I am often asked about the compatibility of breastfeeding with certain medications. I refer to both my experience and knowledge of the drug in question as well as what the medical literature has to say about the safety of the drug for both mother and baby.

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As a registered nurse working part-time for an oral surgery practice, I often administer drugs for IV conscious sedation for dental procedures, most commonly for wisdom tooth extractions. We also offer nitrous oxide sedation and oral sedation for patients who do not wish to be as sedated as they might be for IV sedation.

The majority of female patients we see in our clinic for IV sedation are of childbearing age. Some of our patients are breastfeeding mothers and they often have questions about what drugs for sedation are safe in terms of:

Safety for the baby
Safety for the mother
Effect on milk supply

Often times, discontinuing breastfeeding for a surgical or diagnostic procedure requiring sedation is the only alternative suggested to a nursing mother. Discontinuing breastfeeding is typically not necessary.

Today, many women, armed with knowledge and assertiveness, search for other ways or other practitioners who are willing to work with them as they have their procedure with sedation and continue nursing. They know that for most medications, very little of the drug is transferred to their milk. Additionally, very few medications have adverse effects in breastfed babies because the dose transferred to the milk is in such a low dose or it is poorly bioavailable to the infant.

Thomas Hale is one of the world’s expert on Pharmacology and Lactation. His book, Medication’s and Mother’s Milk, is an excellent reference for lactational pharmacology and a resource guide I use frequently. Dr. Hale has an informative article on his website that discusses how drugs enter human milk.

The medications often used for sedation procedures in dental offices include:

Triazolam (Halcion)
Diazepam (Valium)
Nitrous Oxide
Phenergan
Decadron
Fentanyl
Versed
Propofol

Many medical professionals use these same or similar drugs for other surgical or diagnostic procedures requiring sedation.

Oral Agents

Triazolam and diazepam are used as oral pre-operative sedatives, often taken one hour prior to a procedure with a sip of water. If a patient is breastfeeding, the oral sedative of choice would be triazolam with a half life of 1.5-5.5 hours compared to diazepam’s half life of 43 hours. Some pediatric concerns of poor suckling, lethargy and sedation have been reported with Valium. The milk to plasma ratio with Valium has been reported to be as high as 2.8.

Inhalation Agents

The inhalation agent of choice in dentistry is nitrous oxide blended with oxygen, also know as “laughing gas”. A nitrous oxide/oxygen blend helps to reduce anxiety and works as a sedative. In the dental office, the patient breathes the gas through a nasal mask. Patients describe a sense of well being and relaxation. It works quickly and wears off quickly, making it a good choice for breastfeeding mothers and breastfed babies. Its half life is less than 3 minutes.

Agents Used for IV Sedation include:

Benzodiazepines

Diazepam (Valium)
Midazolam (Versed)

Narcotic Analgesics

Alfentanil (Alfenta)
Fentanyl (Sublimaze)
Hydromorphone (Dilaudid)
Morphine

Barbiturates

Methohexital (Brevital)
Thiopental (Pentothal)

Sedative/Hypnotics

Propofol (Diprivan)

Reversal Medication

Flumazenil (Romazicon)
Naloxone (Narcan)

IV sedation is a great alternative for breastfeeding mothers undergoing surgical or diagnostic procedures. The IV medications listed above produce quick, effective sedation. Recovery time from these sedative agents is also short. The majority of patients tell us they were comfortable and do not remember much if anything about the procedure.

The IV medications listed above have a very short half life and the milk to plasma ratio is low for most of these drugs, except Valium and Morphine. The half lives of these drugs are quite long and the milk to plasma ratio is somewhat higher than the other drugs listed. Some references suggest using caution with these drugs, and some do not. My advice is to use caution when using these drugs with the breastfeeding mother, or even better, chose a more appropriate alternative besides diazepam or morphine.

Additional guidelines for care

Prior to surgery, encourage the mother to plan for assistance at home after surgery to allow time for recovery. Arrange for nursing her baby immediately prior to surgery. If her baby is exclusively fed from the breast, it is important to refer her to a lactation consultant to assist her with coordinating supplementary feedings and assisting with arrangements for a breast pump on a temporary basis. If necessary, she can express and freeze a supply of breast milk before surgery.

Postoperatively, the mother can safely nurse her baby once she feels more alert. Pain medication can be taken safely as prescribed. Most practitioners prescribe the exact same pain medications for postoperative pain relief as are prescribed for postoperative pain relief following a Cesarean birth.

Conclusion

It is important for the health care professional to inform the mother of the risks and benefits, possibilities and options given the evidence available about the safety of breastfeeding and using the medications discussed in this article. It is not appropriate for health care professionals to advise ALL mothers to discontinue breastfeeding or to “pump and dump” for surgical or diagnostic procedures requiring oral, inhalation or intravenous sedation because most medications used for oral, inhalation and IV sedation are compatible with breastfeeding. They have no effect on milk supply and very minimal or no effect on the infant.

With breastfeeding mothers, the health care professional should consider avoiding diazepam and morphine as sedative agents for a surgical or diagnostic procedure because of their long half life and higher milk to plasma ratio. Alternative medications that do not impact the breastfeeding relationship are readily available for sedation for surgical and diagnostic procedures.

Maurenne Griese graduated from the Northeast Louisiana University School of Nursing in 1989. She served as a US Army Nurse for 5 years and has experience in labor and delivery, mother baby nursing, childbirth and breastfeeding education and continuing education for health professionals. Maurenne has published in several nursing journals on the topics of perinatal nursing and breastfeeding. She runs a pregnancy and breastfeeding website and also speaks regularly to health care professionals about perinatal topics. Maurenne’s favorite lecture topic is how to optimize first feedings through minimal birth interventions. She also runs a breastfeeding retail station from her home and works part time as an RN for a private oral surgery practice. She is the proud mother of four breastfed children.

Excellent Online Resources:

Breastfeeding and anesthetics (& other medications used during anesthesia) @
Dental Work and Breastfeeding @
Breastfeeding when mom has surgery @
Breastfeeding in the Face of Surgery or Hospitalization by Becky Flora, IBCLC

References:

La Leche League. “The Breastfeeding Answer Book” (1997) by Nancy Mohrbacher, IBCLC and Julie Stock, BA, IBCLC

Medications and Mothers’ Milk by Thomas Hale, PhD 10th Edition (2002)

Handbook of Nurse Anesthesia by Nagelhout, Zaglaniczny and Haglund, 2nd Edition (2001)

Breastfeeding and Human Lactation by Jan Riordan and Kathleen Auerbach 2nd Edition (1999)

Drugs in Pregnancy and Lactation by G Briggs, R Freeman and S Yaffe 4th Edition (1994)