Use of which of the following medications would MOST likely necessitate a delay in resumption of breastfeeding after surgery?
- □ (A) Fentanyl
- □ (B) Hydromorphone
- □ (C) Codeine
Lactating patients have traditionally been advised to avoid breastfeeding for a period after surgery and anesthesia, and to discard breast milk in a process known as “pump and dump.” Recently, recommendations have changed, and many medications used in the perioperative period are considered low risk for immediate resumption of breastfeeding (Figure). Many opioid analgesics are considered safe based on relative infant dose (RID), a term denoting neonatal drug exposure. RID (expressed as a percentage) is the amount of the medication delivered in breast milk divided by the normal dose of the medication. For example, the amount of fentanyl taken in breast milk would be about 1% of a safe intravenous dose. It is important to note that preterm infants are at increased risk of sedation from opioids; these recommendations refer to full-term infants.
Fentanyl has an RID of 1 and hydromorphone has an RID of 3. A delay in breastfeeding would not be recommended with either of these drugs. The U.S. Food and Drug Administration has issued a warning against the use of codeine in lactating women. Patients with a CYP2D6 mutation may be ultrametabolizers, leading to very high concentrations of morphine in breast milk.
Anesthesiology Continuing Education (ACE) is a self-study CME program that covers established medical knowledge in the field of anesthesiology. ACE can help fulfill the CME requirements of MOCA®. To learn more and to subscribe, visit asahq.org/ace.