Breastfeeding when baby has surgery

… How long before & after general anesthesia is it safe for baby to nurse?

Compiled by Kelly Bonyata, IBCLC

Many times, when baby is scheduled to undergo surgery, the mother is told “no breastfeeding after midnight the night before surgery” or “no breastfeeding less than 8 hours prior to surgery.” Many moms are understandably concerned about this, since withholding nursing from a baby or young child for this amount of time will frequently result in a miserable time for all concerned. Not only is baby hungry, but mom and baby’s most useful comforting tool – nursing – is also gone.

The most current studies say that babies can safely breastfeed 4 hours prior to surgery. Breastfeeding may be safely resumed when your baby leaves the recovery room.

Make sure you talk to the surgeon and anesthesiologist beforehand about this— if needed, share the Academy of Breastfeeding Medicine’s Clinical Protocol (linked below) with your health care provider.

General Information on surgery/hospitalization and the breastfed baby

• Breastfeeding the Hospitalized Baby by Cyndi Egbert
• Babies and Children in the Hospital is a nice pamphlet by LLLI (No. 527-24). It may be obtained through the LLLI web site or from your local Leader.

Additional Information on anesthesia and the breastfed baby

The Academy of Breastfeeding Medicine. ABM Clinical Protocol #25: Recommendations for Preprocedural Fasting for the Breastfed Infant: “NPO” Guidelines. Breastfeed Med. 2012 Jun;7:197-202.

From Table 1. Summary of Fasting Recommendations to Reduce the Risk of Pulmonary Aspiration

Ingested Material                    Minimum Fasting Period (hours)
Clear liquids                                        2
Human breastmilk                            4
Infant formula                                    6
Non-human milks                             6

FAQ: Infant Anesthesia and Breastfeeding from LLL

Children’s Hospital Boston: Dietary Guidelines for Surgery. This is widely considered to be among the best anaesthesia departments in the US.
From the guidelines:

Clear Liquids: stop 2 hours before surgery/procedure/sedation
Breast Milk: stop 4 hours before surgery/procedure/sedation
Formula and Fortified Breast Milk (Children over the age of 12 months must stop formula at midnight before surgery/procedure): stop 6 hours before surgery/procedure/sedation

American Society of Anesthesiologists: Practice Guidelines for Preoperative Fasting (effective 2017) Although the American Society of Anesthesiologists is a conservative 4 hours, this is still much better than the commonly heard “no nursing for 8 hours before surgery.”
From the guidelines:

Breast milk may be ingested for up to 4 hours before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia.

Mohrbacher N. Breastfeeding Answers Made Simple. Amarillo, Texas: Hale Publishing, 2010: p 317.
Page 317:

“A Cochrane Review of the research stated: ‘…clear liquids up to a few hours before surgery did not increase the risk of regurgitation during or after surgery. Indeed there is added benefit of a more comfortable preoperative experience….’ (Brady, Kinn, O’Rourke, Randhawa, & Stuart, 2005). U.S. researchers wrote: ‘…after nearly 15 years of practice worldwide, the relative safety and benefits of [the following guidelines]… are well established’ [Cook-Sather & Litman, 2006):

• Light meal: 6 hours
• Formula: 4 hours
• Human milk: 3 hours
• Clear liquids: 2 hours”

References (most recent listed first)

Lawrence R and Lawrence R. Breastfeeding: A Guide for the Medical Profession, 8th ed. Philadelphia, PA: Elselvier 2016, p. 517.

“Instructions to breastfeeding mothers should limit the amount of breastfeeding after 4 hours and permit feeding on a prepumped breast (i.e., empty breast), predominantly for comfort… An infant who requires surgery or rehospitalization can and should be breastfed postoperatively in most cases… The infant who is hospitalized is already traumatized by the separation, the strange surroundings and people, and the underlying discomfort of the disease process itself. If the infant is to be fed orally, feeding should be at the breast as often as possible… The infant should not be subjected to the added trauma of being weaned from the breast when the infant needs the security and intimacy of nursing most, unless weaning is absolutely unavoidable.”

Maxwell LG and Yaster M. Perioperative management issues in pediatric patients. Anesthesiol Clin North Am 2000 Sep; 18(3); 601-632.

FASTING GUIDELINES: The classic literature and texts of anesthesiology have been replete with the mantra of the association of gastric fluid volume with the risk of aspiration pneumonia, and resulted in rigid guidelines that were “NPO after midnight” for adult and pediatric patients. Exhaustive recent examinations of many studies, including an ASA taskforce, have concluded that these associations, formerly considered iron-clad, are anything but. Because such rigid guidelines in children caused fussy, possibly hypoglycemic patients in the age of outpatient surgery, studies documenting no increase in gastric volume with liberalization of clear liquid administration have led to a relaxation of fasting guidelines in practice in the United States and the United Kingdom. This change in practice recently has been confirmed by the recommendations of the ASA taskforce. These guidelines can be summarized most easily as 8-6-4-2 (i.e., 8 hours solids, 6 hours formula, 4 hours breast milk, 2 hours clear liquids). This change in practice can result in decreased numbers of canceled cases, and in pediatric patients who are less irritable preoperatively and less dehydrated at the time of anesthesia induction. The liberalization, however, applies only to clear liquids, and communicating the correct guidelines to parents can be problematic, resulting in some patients who still consume formula and must be delayed and in others who still have been NPO since midnight. Patients undergoing emergency surgery, those with anatomic bowel obstruction, and those who are not NPO must have their risk for aspiration balanced against the urgency of the surgery. Most trauma patients and others requiring emergency surgery have delayed gastric emptying, reducing the utility of having to wait a prescribed period of time until induction of anesthesia. Those patients should have a rapid sequence induction in any case.

Ferrari LR et al. Preoperative fasting practices in pediatrics. Anesthesiology 1999 Apr; 90(4): 978-80.

“There is less agreement about breast milk feeding. Some institutions (36%) consider the composition of breast milk to be equivalent to that of a clear fluid, others (34%) equivalent to a solid, and the remaining institutions consider it “something else.” This is likely due to the paucity of data examining absorption of breast milk in healthy infants. Most institutions (77%) consider at least a 4-h fast for breast milk to be sufficient; only 23% allowed breast milk to be ingested less than 4 h before induction… In conclusion, this study shows the variation in fasting patterns and the difficulty in developing practice guidelines. It is far easier to simplify guidelines by making all patients NPO after midnight. This is not the optimal or safest practice for pediatric anesthesia, nor is it the accepted practice of the majority of clinicians. The question posed to the pediatric anesthesia community is “Can reasonable guidelines be developed that could be agreed on by the majority of practitioners?” Our results indicate that a “2-4-6-8 rule” represents the majority of institutions that provide anesthesia for children in North America. This restricts clear fluids for 2 h, breast milk for 4 h, formula for 6 h, and solid food for 8 h before induction of anesthesia. In elective surgical procedures, acceptance of this as a guideline deserves further discussion by the anesthesia community and would serve to simplify the current confusing and arbitrary policies that exist in different institutions.”

Emerson BM. Pre-operative fasting for paediatric anaesthesia. A survey of current practice. Anaesthesia 1999; 53(4) 326-330.

Abstract: There has recently been much debate about pre-operative fasting for paediatric anaesthesia. There is no consensus about the optimum fasting times for children undergoing elective surgery. In order to establish a standard for paediatric pre-operative fasting times, we undertook a postal survey, targeting members of the Association of Paediatric Anaesthetists resident in the United Kingdom and Ireland in 1995. One hundred and sixty-three questionnaires were dispatched, 131 (80%) were returned and 110 (67%) were complete. The results show that the following guidelines for duration of fast are acceptable to the majority of respondents-neonates: 2 h for clear fluids, 4 h for breast and formula milk; infants: 2 h for clear fluids, 4 h for breast milk, 6 h for formula milk and solids; children: 2 h for clear fluids, 6 h for milk and solids. We suggest that these times be used as guidelines and audited for pre-operative fasting in paediatric anaesthesia.

Splinter WM. Preoperative fasting in children. Anesth Analg. 1999 Jul; 89(1): 80-9.

O’Hare B, Chin C, Lerman J, Endo J. Acute lung injury after instillation of human breast milk into rabbits’ lungs: effects of pH and gastric juice. Anesthesiology 1999 Apr;90(4):1112-8.

Feldman D. Pediatric anesthesia and postoperative analgesia. Pediatr Clin North Am 1998 Dec; 45(6): 1525-37

“Patients need to have fasted appropriately before surgery. Although no universal agreement exists among anesthesiologists when it comes to fasting, several accepted standards do exist. It is generally believed that, to minimize the risks of aspiration, an adult patient should be NPO approximately 8 hours before surgery. The rules differ slightly for pediatric patients. At Children’s Hospital of Buffalo, it is generally believed that children should have no solid food for at least 6 hours before surgery. Breast milk and other such semisolids are usually considered acceptable up to 3 hours before surgery; clear liquids are acceptable until 2 hours before surgery.”

O’Hare B, Lerman J, Endo J, Cutz E. Acute lung injury after instillation of human breast milk or infant formula into rabbits’ lungs. Anesthesiology 1996 Jun;84(6):1386-91.

See also correspondence in British Journal of Anesthesia, Vol. 74, no. 3, March 1995, p. 349 and Vol. 75, no. 3, September 1995, p. 375 for discussion of preoperative fasting for pediatric anesthesia. There is no mention of breastmilk, but it deals with the problem that many children end up fasting much longer than intended. The authors believe that a clear fluid drink should be “prescribed” 3 hours before surgery.

Litman RS, et al. Gastric Volume and pH in infants fed clear liquids and breastmilk prior to surgery. Anesth Analg. 1994;79:482-5.

In a prospective, blinded study, 24 breastfed infants nursed as usual 2
hours prior to surgery (feeding ended by 1 1/2 hours before anesthesia
induction). After induction of general anesthesia and tracheal intubation,
gastric fluid samples were aspirated and volume and pH were measured.
Sufficient gastric fluid for analysis was obtained from 8 (33 %) of the
infants. The volumes were great enough that the authors do not recommend
breastfeeding less than 3 hours before surgery. The majority of the
infants had residual gastric contents which were alkaline. Animal studies
suggest that this higher pH may confer an advantage in case of pumonary
aspiration. The formula fed infants in the study were safely able to
receive 2 – 8 ounces of clear liquids up to 2 hours prior to surgery.

Schreiner MS. Preoperative and postoperative fasting in children. Ped Clinics N. Am. 1994; 41(1):111-20.

“Until early 1990 perioperative oral fluid management for children could be
summarized as ‘Starve Preop: Feed Postop.’ Recent advances have reversed
the conventional wisdom and now allow children to drink clear liquids up
until 2 hours prior to surgery and to fast after surgery until they want to
eat. The pattern of gastric emptying of milk, formula and breast milk
needs further investigation…” The author’s recommendations are for clear
liquids to be stopped 2-3 hours before arrival at the hospital for day
surgery anesthesia, and breast milk 3 hours before. He refers to a 1987
study by Tomomosa (Gastroduodenal motility in neonates: response to human milk compared with cow’s milk formula. Pediatrics 1987; 80:434) that showed that 3 hours after a test meal, 75% of breastfed infants but only 17% of formula fed infants had entered a fasting state. “Breast milk clearly
empties faster than formula but slower than clear liquids.”

Nicholson SC, Schreiner MS. Feed the babies. Anesth Analg 1994;79:407-9.

Newell SJ, Chapman S, Booth IW. Ultrasonic assessment of gastric
empyting in the preterm infant. Archives of Disease in Childhood 1993;
69:32-36.

Schreiner MS. Should children drink before discharge from day surgery? Anesthesiology. 1992 Apr; 76(4): 528-33.

Abstract: The ability to drink clear liquids without vomiting after anesthesia and surgery is a commonly used criteria for discharge of pediatric day surgery patients. We hypothesized that the ability to drink as a prerequisite for discharge would not affect the frequency of vomiting, delay discharge, or increase the frequency of readmission of children for dehydration after day surgical procedures. We randomized 989 patients between the ages of 1 month and 18.0 yr to one of two groups. The 464 “mandatory drinkers” were required to demonstrate the ability to drink clear liquids without vomiting prior to discharge from the hospital, whereas 525 “elective drinkers” were allowed but not required to drink. Other than the discharge criteria, the patients were managed in an identical fashion; the minimum volume of intravenous fluids received by all patients was adequate to supply a calculated 8-h fluid deficit prior to discharge from the hospital. There were no differences between the two groups in the incidence of vomiting in the operating room, the postanesthesia care unit, or after discharge from the hospital. However, in the day surgery unit, only 14% of the elective drinkers vomited compared to 23% of the mandatory drinker group (P less than 0.001). The mandatory drinkers had a more prolonged stay in the day surgical unit, averaging 101 +/- 58 min (mean +/- SD) compared to 84 +/- 40 min for elective drinkers (P less than 0.001). No patient in either group required admission to the hospital for persistent vomiting on the day of surgery, and no patient required readmission for vomiting or dehydration after discharge from the day surgery unit.

Spear R. Anesthesia for premature and term infants: perioperative implications. J Pediatr 1992:120(2 pt 1): 165-75.

Schreiner MS. Ingestion of liquids compared with preoperative fasting in pediatric outpatients. Anesthesiology. 1990 Apr; 72(4): 593-7.

Abstract: The preoperative fast is often an unpleasant preoperative experience that might be alleviated by allowing children to drink clear liquids. The authors compared gastric fluid volume and pH in two groups of children, one of whom was permitted clear liquids until 2 h before surgery (study group) and the other followed routine preoperative fasting orders (control group). The study group was not limited in the quantity of clear liquid allowed with the exception that the last intake prior to surgery was limited to 8 ounces. The study group (n = 53) averaged 5.9 +/- 5 yr and weighed 23.6 +/- 17 kg, while the control group averaged 7.3 +/- 4.6 yr and weighed 29 +/- 17.7 kg (P = NS). Gastric contents were aspirated following induction of anesthesia. Gastric fluid volume averaged 0.44 +/- 0.51 ml/kg for study group and 0.57 +/- 0.51 ml/kg in the control group (P = 0.12). Of the study patients, 48% had a measured gastric fluid volume greater than or equal to 0.4 ml/kg compared with 58% of the control patients (P = 0.77). Eighty three patients had sufficient gastric fluid for pH determination; of these 34/35 (97%) in the study group and 44/48 (92%) in the control group had a gastric fluid pH less than or equal to 2.5. Using a linear analog scale parents rated the children in the study group to be less irritable (P less than 0.001) and to have had a better overall preoperative experience (P less than 0.01) compared with the control patients.

Cavell B: Gastric emptying in infants fed human milk or infant formula. Acta Paediatr Scand 1981; 70:639.

Abstract: Gastric emptying of meals of human milk or infant formula was studied in 17 healthy infants aged 4 weeks to 6 months using a marker dilution technique. In the 24 studies performed gastric emptying followed a biphasic pattern in 11 and a linear pattern in 12 studies. The average gastric half-emptying time for meals of human milk was 48 min, and for meals of infant formula 78 min. After 1 hour an average of 29.5 ml of human milk and 22.7 ml of infant formula per 0.1 m2 of body surface area had emptied from the stomach.

Pildes RS, Blumenthal I, Ebel A. Stomach emptying in the newborn. Pediatrics 1980; 66:482-483.