ANESTHESIA AND THE BREASTFEEDING PATIENT

PRESENTED BY:DR. REBECCA SULLIVAN, CRNA

PANA SPRING SYMPOSIUM HERSHEY, PA MAY 5, 2019

OBJECTIVES• THE LEARNER WILL BE ABLE TO DISCUSS THE RISK AND BENEFIT

DECISIONS RELATING TO ANESTHETIC MEDICATION ADMINISTRATION TO A BREASTFEEDING PATIENT

• THE LEARNER WILL UNDERSTAND THE MECHANISMS INVOLVED IN THE TRANSFER OF MATERNAL MEDICATIONS INTO BREASTMILK

• THE LEARNER WILL UNDERSTAND THE CURRENT RECOMMENDATIONS FOR ANESTHESIA IN A BREASTFEEDING PATIENT

BREASTFEEDING INFORMATION

• Ingestion of drugs passed to infants through human milk has been topic of many published reports.

• Goal of presentation is to discuss mechanism of drug concentrations secreted in human milk

HISTORY

• THE STATEMENTS/LISTS ARE INTENDED TO DESCRIBE POSSIBLE EFFECTS ON THE INFANT AND OR LACTATION, IF KNOWN

• IF A DRUG/CHEMICAL IS DOES NOT APPEAR ON TABLE , IT ONLY INDICATES THAT THERE WERE NO REPORTS IN THE LITERATURE.

1983http://toxnet.nlm.nih.gov

Lactmed database

PREGNANCY RISK CATEGORIES

LACTATION RISK CATEGORIES

L1: SAFEST• CONTROLLED STUDIES FAIL TO DEMONSTRATE A

RISK TO INFANTS• THE PRODUCT IS NOT ORALLY BIOAVAILABLE TO THE

INFANT

LACTATION RISK CATEGORIES

L2: SAFER• LIMITED NUMBER OF STUDY SUBJECTS• THE EVIDENCE OF DEMONSTRATED RISK

FOLLOWING USE OF MEDICATION IS REMOTE

LACTATION RISK CATEGORIES

L3: MODERATELY SAFE• NO CONTROLLED STUDIES

• MEDICATION SHOULD BE GIVEN ONLY IF THE BENEFIT JUSTIFIED

• NEW MEDICATIONS ARE AUTOMATICALLY CATEGORIZED AS MODERATE SAFETY

LACTATION RISK CATEGORIES

L4: POSSIBLY HAZARDOUS• POSITIVE EVIDENCE OF RISK TO A BREASTFED

INFANT OR TO BREAST MILK PRODUCTION • THE BENEFITS OF USE FOR MOTHER MAY BE

ACCEPTABLE DESPITE THE RISK TO INFANT.

LACTATION RISK CATEGORIES

L5: CONTRAINDICATED• STUDIES HAVE DEMONSTRATED SIGNIFICANT AND

DOCUMENTED RISK• THE MEDICATION IS CONTRAINDICATED IN WOMEN

WHO ARE BREASTFEEDING AN INFANT.

BREASTFEEDING BENEFITS

• SIMPLICITY, PORTABILITY

• NUTRITIONAL ADVANTAGES OVER FORMULA

• REDUCTION IN INFANT MORTALITY

• ENHANCED ANTIBODY RESPONSE TO VACCINATIONS

• HIGHER IQ (ENHANCES COGNITIVE DEVELOPMENT)

• DECREASE IN RISK OF IMMUNOLOGICALLY MEDIATED DISORDERS

BREASTFEEDING FACTS

• STATISTICS• IN THE US MORE THAN 10 MILLION WOMEN ARE EITHER

PREGNANT OR BREASTFEEDING AT ANY GIVEN TIME.• 70% INITIALLY CHOOSE TO BREASTFEED

BREASTFEEDING FACTS

• BENEFITS TO MOTHER• ENHANCED MOTHER-CHILD INTERACTION

• KANGAROO CARE “SKIN TO SKIN”• SUCKLING PROMOTES POSTNATAL UTERINE INVOLUTION• ENHANCED WEIGHT LOSS, REDUCED BLOOD LOSS

POSTPARTUM

BREASTFEEDING FACTS

• USUAL REASONS FOR STOPPING• INABILITY OF INFANT TO LATCH ON

EFFECTIVELY• LACK OF MILK PRODUCTION• RETURN TO WORKFORCE

RECOMMENDATIONS FOR MED ADMINISTRATION

• OVER 90% OF MOTHERS RECEIVE ONE OR MORE DRUGS IN FIRST WEEK OF POSTPARTUM

• MANY WOMEN ARE ADVISED TO DISCONTINUE NURSING BECAUSE OF CONCERNS OF ADVERSE IMPACT TO INFANT

RISK BENEFIT ANALYSIS

• CONSIDER MULTIPLE FACTORS • NEED FOR DRUG BY MOTHER• POTENTIAL ADVERSE EFFECTS ON INFANT• POTENTIAL EFFECTS ON MILK PRODUCTION• AMOUNT OF DRUG EXCRETED IN HUMAN MILK• ORAL ABSORPTION BY BREASTFEEDING INFANT• TIMING OF FEEDING

WHAT INFLUENCES TRANSFER TO MILK?

• MOLECULAR WEIGHT

• CONCENTRATION IN MATERNAL PLASMA

• PKA

• PROTEIN BINDING

• LIPOPHILICITY

HOW DO DRUGS ENTER MILK?

• DRIVEN BY EQUILIBRIUM FORCES (CONCENTRATION GRADIENT)

• BREAST MILK CAN BE THOUGHT OF AS A SPECIAL COMPARTMENT CLOSELY LINKED TO PLASMA

• PASS FROM MATERNAL PLASMA THROUGH CAPILLARY WALLS INTO THE ALVEOLAR CELL LINING

PASSAGE OF MEDS

• COLOSTRAL PERIOD• FIRST 72 HOURS LARGE GAPS BETWEEN ALVEOLAR CELLS

EXIST.• MILK PROTEIN AT HIGHEST.

• THESE GAPS PERMITS ENHANCED PASSAGE OF MOLECULES INTO BREAST MILK

https://www.medsmilk.com

MILK PASSAGE

• PROLACTIN INFLUENCE ON ALVEOLAR CELLS

• ONCE THESE SPACES CLOSE THIS IS REFERRED TO AS MATURE MILK.

https://obgynkey.com/the-excretion-of-drugs-and-chemicals-in-human-milk/

RELATIVE INFANT DOSE

• DOSE OF DRUG INGESTED BY INFANT COMPARED TO MOTHERS DOSE (MG/KG)

• IF RELATIVE INFANT DOSE (RID) IS LESS THAN 10% MEDICATION IS QUITE SAFE TO USE

• THE RID OF THE VAST MAJORITY OF DRUGS IS <1%

• RETROGRADE DIFFUSION OF THE DRUG FROM BREAST MILK TO PLASMA REMOVES MEDICATION FROM THE MILK EVEN IF MOTHERS HAS NOT EMPTIED HER BREAST.

FYI volume of milk ingested by infant is generally 150ml/kg/day.

ANESTHETICS IN BREAST MILK

• MIDAZOLAM- SHORT HALF LIFE COMPARED TO OTHER BENZOS. SINGLE DOSE SAFE

• STUDIES SHOW 24 HRS 0.009% REMAINED IN HUMAN MILK

• FENTANYL- EXTREMELY LOW AFTER 2 HOURS • 24HR 0.039%

• ETOMIDATE- BRIEF PLASMA DISTRIBUTION PHASE

• KETAMINE- UNREPORTED

• PROPOFOL- BRIEF PLASMA DISTRIBUTION PHASE• 24 LEVEL IN BREAST MILK 0.025%

• ANESTHETIC GASES- LITTLE TO NOTHING REPORTED. BRIEF PLASMA DISTRIBUTION PHASES, ASSUMED SAFE.

ANESTHETICS IN BREAST MILK

• NEUROMUSCULAR BLOCKING AGENTS-POOR LIPID SOLUBILITY & LOW ORAL AVAILABILITY

• MORPHINE- LOW ORAL BIOAVAILABILITY AND LIMITED PASSAGE INTO MILK

• NEURAXIAL SINGLE DOSE MORPHINE• NEGLIGIBLE MATERNAL PLASMA LEVELS… MILK CLEAR

• DILAUDID- USE WITH CAUTION.

• LOCAL ANESTHETICS -CONCENTRATION LOW IN MILK AND NOT EASILY ABSORBED MY INFANT

**EXCEPTION IS LARGE VOLUME TUMESCENT SOLUTION

• TORADOL/ACETAMINOPHEN- SAFE

OTHER MEDICATIONS OF CONCERN

• CODEINE- ACTIVE METABOLITE-• CONCERN REGARDING APNEA, BRADY AND SEDATION IN INFANTS WITH INACTIVE ENZYME

CYP2D6

• OXYCODONE-• CNS DEPRESSION IN 20% OF EXPOSED INFANTS

• HYDROCODONE-• LESS THAN 4% WT ADJUSTED DOSE- FREQ USED W BREASTFEEDING MOTHERS

• DEMEROL-• ACTIVE METABOLITE HALF LIFE PROLONGED. MAY CAUSE NEONATAL SEDATION, BRADYCARDIA

& APNEA

• STREET DRUGS- SEE UPCOMING SLIDE• ANTIANXIETY/ANTI DEPRESSANTS

• SPECIFIC TO MECHANISM AND METABOLISM .SEE RISK CHART

• HERBAL MEDICATIONS-• KAVA (LIVER DAMAGE), YOHIMBE (FATALITIES), ST JOHNS WART (COLIC, LETHARGY),

FENUGREEK (COAG/GLUCOSE ISSUES), CHAMOMILE,BLACK COHOSH, ECHINACEA, GINSENG, GINGKO, VALERIAN NOT RECOMMENDED IN BREASTFEEDING WOMEN

OTHER MEDICATIONS OF CONCERN

• CARDIAC DRUGS/ANTIHYPERTENSIVES-• AMIODARONE- WIDE VARIATIONS OF CONCENTRATIONS FOUND IN BREAST

MILK. CAN RESULT IN BRADY OR HYPOTHYROIDISM . RECOMMEND STOP BREASTFEEDING

• BETA ANTAGONISTS- ATENOLOL, SOTALOL, IMMATURE RENAL FUNCTION INNEONATES CAN RESULT IN BRADY OR HYPOTENSION

• IODINE• HYPOTHYROIDISM CAN RESULT IN BREASTFEEDING INFANT

• ANTICOAGULANTS-

• HEPARIN SAFE- LARGE MOLECULAR WEIGHT DOES NOT CROSS INTO MILK• WARFARIN SAFE (HIGH PROTEIN BINDING)

• HYPOGLYCEMICS-• INSULIN AND ORAL HYPOGLYCEMICS DO NOT CROSS INTO BREASTMILK IN

SIGNIFICANT AMOUNTS • IS HYDROLYZED IN INFANT GUT IF INGESTED

STREET DRUGS INFLUENCE ON INFANT

• Impaired neurological developmentAlcohol

• Minimal excretion, can withdrawalMethadone

• Irritability, tremors, GI issues (n/v/d)Cocaine

• Motor development delaysMarijuana

ANESTHESIA WITH NURSING INFANT

• IMPLICATIONS OF DRUGS USED IN ANESTHESIA IN POSTPARTUM MOTHERS DEPEND ON NUMEROUS FACTORS INCLUDING…

• AGE OF THE INFANT• STABILITY OF THE INFANT• LENGTH OF LACTATION• THE ABILITY OF INFANT TO CLEAR ANESTHETICS

PREMATURE INFANT CONSIDERATIONS

• EARLY MILK PRODUCED FOR PREMATURE INFANT IS DIFFERENT IN COMPOSITION FROM MILK OF TERM INFANT

• DATA OF DRUG CONCENTRATIONS REFERS TO MATURE MILK

• REDUCED CLEARANCE OR IMMATURITY OF METABOLIC PATHWAYS

RECOMMENDATIONS

• CHOOSE DRUGS WITH:• SHORT HALF LIVES• HIGH PROTEIN BINDING• LOW ORAL BIOAVAILABILITY• HIGH MOLECULAR WEIGHT• AVOID PCA (CONTINUOUS INFUSIONS)

• SPACE OUT DOSES, FEED IMMEDIATELY PRIOR• AVOID DRUGS WITH ACTIVE METABOLITES

SUMMARY

• RESUMPTION OF NORMAL MENTATION IS A HALLMARK THAT MEDICATIONS REDISTRIBUTED FROM PLASMA COMPARTMENT

• “CLEAR MIND, CLEAR MILK” REPLACES ”PUMP AND DUMP”

SUMMARY OF RECOMMENDATIONS

• THE LOWEST, SAFEST MATERNAL DOSE OF DRUG SHOULD BE ADMINISTERED TO NURSING MOTHER.

• AVOID MEDICATIONS THAT MAY DISRUPT THE PATIENTS ABILITY TO PRODUCE BREASTMILK

• THE POSSIBLE RISKS TO THE INFANT SHOULD BE WEIGHED AGAINST THE BENEFITS OF CONTINUING BREAST FEEDING.

CLEAR MIND, CLEAR MILK!

The age and condition of the

infant are deemed the most important criteria

A mother may breast feed

postoperatively as soon as she

is alert

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