Statement on Resuming Breastfeeding after Anesthesia

Developed by: Committee on Obstetric Anesthesia
Last Amended: October 23, 2024 (Original Approval: October 23, 2019)

The American Society of Anesthesiologists (ASA) offers this statement to provide anesthesiologists with evidence-based information so they may appropriately counsel nursing patients undergoing surgery who are concerned about adverse neonatal effects from medication exposure via breastmilk. The committee reviewed existing guidelines and data on the concentration of anesthetic drugs in breast milk to produce the overview and recommendations included in this statement.^1-7 

Background:
In the past it was recommended that lactating patients discard breastmilk (“pump and dump”) immediately after surgery before resuming breastfeeding. This outdated recommendation was made before data was available on the accumulation of drugs in breastmilk yet is still widely circulated on the internet, creating considerable confusion among patients and providers.  Although many lactating patients presenting for surgical procedures are prepared to “pump and dump,” patients routinely ask their anesthesiologist for information and recommendations on when they may safely resume breastfeeding. Anesthesiologists should be prepared to discuss current recommendations for breastfeeding safety following anesthesia.⁸ 

Anesthesia Drugs and Breastmilk:
A commonly accepted method used to express infant exposure to maternal medications via consumption of breastmilk is the relative infant dose (RID).⁹ The RID provides an indication of relative exposure by taking into account maternal and infant weight, concentration of drug in breastmilk, absorption of the drug, thereby indicating the percentage of drug in the infant relative to mother.  RID levels less than 10% are generally considered safe for the infant.  While certain opioids (i.e., codeine and tramadol) and certain drug classes (i.e., amphetamines, chemotherapy agents, ergotamines and statins) are not recommended in breastfeeding patients, nearly all anesthetic drugs have RID values significantly less than 10% (see Table).  An exception is morphine, which has an RID of approximately 9%. Even so, countless women who are breastfeeding have received morphine following surgical procedures without incident.  Despite an excellent safety record, it makes sense to attempt to reduce opioid requirements in lactating patients by using a multimodal approach to treat postoperative pain.¹⁰ Further, because pain interferes with successful breastfeeding, patients should not avoid pain medicines after surgery when needed. The FDA advises that breastfeeding persons not receive the prodrugs codeine or tramadol, both of which are metabolized to their active forms by the CYP2D6 enzyme. Due to pharmacogenetic variability, there is a risk of neonatal opioid overdose if an “ultra-metabolizer” mother breastfeeds a “slow metabolizer” neonate¹¹. 

Recommendations:
The following recommendations are suggested for lactating women requiring surgery:

1. All anesthetic and analgesic drugs can transfer into breastmilk; however, only small amounts are present in very low concentrations which are considered clinically insignificant.
2. Opioids and/or their metabolites may transfer in slightly higher levels into breastmilk; therefore, steps should be taken to lower opioid requirements by adding other classes of analgesics when appropriate and avoiding drugs that are more likely to transfer (i.e., have a higher RID).
3. Because pain interferes with successful breastfeeding, patients should not avoid pain medicines after surgery. Despite an excellent safety record, breastfeeding persons who require opioid pain medicines should monitor for potential signs of sedation: difficult to wake and/or slowed breathing. Additional consideration for when to resume breastfeeding postoperatively should be given to patients with neonates or infants at high risk for apnea (e.g. prematurity)³.
4. When possible, spinal or epidural anesthesia consisting of local anesthetic and a long-acting opioid, should be used for cesarean delivery to reduce overall post-operative pain medication requirements. 
5. Patients should resume breastfeeding as soon as desired after surgery¹¹ because anesthetic drugs appear in such low levels in breastmilk. It is not recommended that patients “pump and dump” and rather they should “sleep and keep”¹³.

References:

1. World Health Organization. Guideline: Protecting, promoting and supporting Breastfeeding in Facilities providing maternity and newborn services. ISBN: 978-92-4-155000-6. Accessed at: http://www.who.int/nutrition/publications/guidelines/breastfeeding-facilities-maternity-newborn/en/. 
2. Eidelman AI, Schanler RJ. Breastfeeding and the use of human milk. Section on Breastfeeding. American Academy of Pediatrics. Pediatrics 2012; 129: e827-41.
3. Reece-Stremtan S, Campos M, Kokajko L. ABM Clinical Protocol #15: Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2017. Breastfeeding Medicine 2017; 12(9):500-506. 
4. Dalal PG, Bosak J, Berlin C. Safety of the breast-feeding infant after maternal anesthesia. Pediatric Anesthesia 2014; 24: 359-71.
5. LactMed. TOXNET Toxicology Data Network. US National Library of Medicine. NIH. HMS. Bethesda, MD. Accessed at: https://toxnet.nlm.nih.gov/cgi-bin/sis/search2.
6. de Swiet’s Medical Disorders in Obstetric Practice, 5th Ed. Edited by Powrie RO, Greene MF, Camann W. 2010 Blackwell Publishing Ltd. 806 pgs. ISBN: 978-1-405-14847-4.
7. Statement on Sugammadex during pregnancy and Lactation, Society for Obstetric Anesthesia and Perinatology, 2019, Accessed at www.soap.org.
8. Mitchell J, Jones W, Winkley E, Kinsella SM. Guideline on anaesthesia and sedation in breastfeeding women 2020. Anaesthesia 2020;75:1482–1493.
9. Ilett KF, Kristensen JH. Drug use and breastfeeding. Expert Opin Drug Saf 2005; 4: 745-68. 
10. Sutton CD, Carvalho B. Optimal pain management after cesarean delivery. Anesthesiol Clin 2017; 35: 107-24.
11. FDA Drug Safety Communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. 2018. Accessed at: https://www.fda.gov/Drugs/DrugSafety/ucm549679.htm. 
12. Optimizing support for breastfeeding as part of obstetric practice. ACOG Committee Opinion No. 756. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;132:e187-96. (https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2023/02/duration-of-breastfeeding-update) Accessed 4.1.2024
13. Kraus MB, Dodd SE, Sharpe EE. "Sleep and Keep": Dispelling Myths of "Pump and Dump" from an Anesthesiologist's Perspective. J Womens Health (Larchmt). 2020 Oct;29(10):1243-1245. doi: 10.1089/jwh.2019.7970. Epub 2019 Aug 13. PMID: 31408398. 
    
     

Table. Relative Infant Dose (RID) of Anesthesia Medications and Recommendations

* Mean RID is an estimated average from multiple sources reviewed.
# Mustafa HJ, Wong HL, Al-Kofahi M, Schaefer M, Karanam A, Todd MM. Bupivacaine Pharmacokinetics and Breast Milk Excretion of Liposomal Bupivacaine Administered After Cesarean Birth. Obstet Gynecol. 2020 Jul;136(1):70-76. doi: 10.1097/AOG.0000000000003886. PMID: 32541292.
§ LactMed. Toxicology Data Network. US National Institute of Child Health and Human Development. NIH. HMS. Bethesda, MD. Accessed at: https://www.ncbi.nlm.nih.gov/books/NBK501922/?report=classic#IX-D.
¥ FDA Announcement 468, 2012. Accessed at: https://www.medicaid.nv.gov/Downloads/provider/web_announcement_468_20120425.pdf.
^ Society for Obstetric Anesthesia and Perinatology -Statement on Sugammadex during pregnancy and lactation. Accessed at: https://www.soap.org/assets/docs/ SOAP_Statement_Sugammadex_During_Pregnancy_Lactation_APPROVED.pdf