Breastfeeding in the perioperative period

Abstract

Sir, Perioperative advice regarding breastfeeding to a lactating patient posted for surgery is a dilemma for the anesthesiologists in the absence of clear cut guidelines.[1] There is a concern that drugs given to mother may be excreted in the breast milk resulting in adverse effects on the newborn. Most drug inserts carry an instruction that these should be used with caution in lactating mothers adding to the anxiety of mothers and healthcare providers. However, depriving the neonate of the beneficial effects of mother's milk is a major decision which requires careful consideration. Perioperatively, there are certain myths and beliefs that deprive the baby of his/her mother's milk. These are: Breastfeeding needs to cease for 24 hours to 7 days after a surgical procedure. Breast milk can be replaced with formula feedings without adverse effect on the neonate. Breastfeeding can be resumed without difficulty once it has been temporarily stopped. Animal milk can be a good substitute for mother's milk. Various studies and meta-analysis have proved that mother's milk is the best an infant can get and nothing can be substituted for it.[2] The advantages of mother's milk led American academy of pediatricians recommend that mother's milk be the only and exclusive milk that a baby should receive during first 6 months and then supplemented breastfeeding for another 6 months.[3] In developing countries such as India, breast milk is the cheapest milk available to a neonate and because it is freshly available to the baby and needs no sterilization, it attains greater importance. When mother is in hospital, care of baby is likely to suffer and if she can feed the baby, it not only prevents many complications in the baby but also is immensely beneficial to the mother and the baby. We have the following points to make in this regard: Proper planning of surgery timing and anaesthetic technique can minimize interruption in breastfeeding for the infant. The fact that infants have limited capacity for metabolism of drugs used for anaesthesia should be taken into account while planning any anaesthetic technique for mothers who are breastfeeding their children. Such an anaesthetic technique should also take into account the age and maturity of baby, the stage of lactation (early or late), and the drugs should be so planned that they interrupt feeding only for the shortest period of time. Whenever feasible, regional anaesthesia should be preferred over general anaesthesia because feeding can be resumed almost immediately postoperatively in most cases.[145] Premature infants or those prone to apnea, hypotension, or weakness probably should be protected by a few more hours of interruption from breastfeeding before resuming (12-24 h) nursing following GA.[6] Limited information is available regarding anaesthetic agents and their compatibility with breastfeeding, although most of the agents used for anaesthesia practice (propofol, thiopental sodium, midazolam, etomidate, vecuronium, rocuronium, succinylcholine, halothane, isoflurane, sevoflurane, atropine, commonly used NSAIDs, and short-acting opioids) are considered safe, whereas ketamine and diazepam are best avoided.[178910] There have been some reports regarding safety of xenon also.[11] In our opinion, some measures that can help in limiting the time the baby is without mother's milk are breastfeeding the baby as close to time of surgery as possible, preferably just before shifting to operation room, storing the breast milk by freezing it, breastfeeding the baby as early as possible-once the mother is fully awake and there is no residual effect of any medications and preferring day care surgery. Unfortunately, there are no guidelines to direct anesthesiologists on how to manage such patients in the best possible way. Formulation of protocols for lactating mothers scheduled for surgery will not only reduce anxiety of mother but also of the caregivers. Adequately trained and motivated nursing staff can provide invaluable help in the overall management of these patients. It would be prudent if the Association of Obstetric Anaesthesiologists, India, takes a lead in this field to guide obstetricians, anesthesiologists, and surgeons in promoting minimal or no interruption in breastfeeding to infants by mothers scheduled for emergent or incidental surgery.