BREASTFEEDING MEDICINE

Volume 13, Number 2, 2018 Clinical Research

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2017.0193

Implementation and Organization

of a Perioperative Lactation Program:
A Descriptive Study

Elizabeth F. Rieth,1 Kara M. Barnett,1 and Jennifer A. Simon2

Abstract

Introduction: As breastfeeding rates rise, perioperative care of lactating women is an increasingly important issue.
There is a lack of reports describing the implementation of perioperative lactation programs. Beginning in 2014,
Memorial Sloan Kettering Cancer Center developed a perioperative lactation program to address the comprehensive
care of lactating patients. The aim of this study was to determine the incidence of lactation in our perioperative
population, as well as to describe preliminary data and experiences during the implementation of our program.
Materials and Methods: This retrospective descriptive study included lactating patients who underwent pro-
cedures requiring anesthesia care at our institution from August 2014 to February 2017. This period coincided
with implementation of the lactation program, which focused on patient identification, education, and support,
as well as staff education and collaboration. Patient volume and characteristics, procedure types, and in-
traoperative non-narcotic analgesic use were analyzed.
Results: Over the 30-month study period, we identified 80 lactating perioperative patients, with *2–3 patients
presenting monthly. The median (range) age of the child was 5 (0.6–24) months. Most of our lactating patients
were American Society of Anesthesiologists class I–II patients (81%), who underwent general anesthesia
(89%), and received at least one non-narcotic analgesic intraoperatively (89%).
Conclusion: Our study showed that we cared for lactating patients undergoing a wide range of procedures on a
regular basis. The results from this study are intended to inform the next phase of our research, which will focus
on determining how this work impacts outcomes such as postoperative lactation complications, breastfeeding
resumption, and overall patient satisfaction.

Keywords: perioperative lactation program, lactation pharmacology, anesthesia in lactation, breastfeeding

resumption after anesthesia, analgesic use in lactation, cancer

Introduction predispose a lactating woman to developing mastitis and which

may be present in the perioperative period include missed

A s breastfeeding rates rise in countries such as the

United States and Canada,1,2 the appropriate care of lac-
tating women in the perioperative setting is an increasingly
feedings, a change in the usual breastfeeding schedule, a de-
crease in the number of feedings, as well as maternal stress,
fatigue, and illness.3,4 Avoiding mastitis is particularly impor-
important issue. These women require specific care, especially tant in the perioperative setting, as its symptoms (including
during a stressful perioperative period in which mother and fever, rigors, myalgia, and lethargy) may closely resemble those
infant are separated. Without a plan for managing lactation of a postoperative surgical infection.3,5 Maternal level of milk
during the perioperative period, these patients are at risk for production is critical to the risk of engorgement and result-
lactation complications, such as breast engorgement, mastitis, ing negative outcomes, including decreased milk production.
decreasing milk supply, and undesired weaning. Mastitis occurs Also, postoperative pain can suppress lactation.6 In addition,
in the majority of cases in the first 6 weeks postpartum, but may maternal contact with the healthcare system is a known factor
occur at any time during lactation.3 Known factors which may for premature weaning and supplementation with formula.4

1
Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
2
Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York.

97
98 RIETH ET AL.

Most of the literature regarding perioperative lactation presurgical nurses, postanesthesia care unit nurses, infor-
consists of reviews regarding the safety of anesthetic and matics and technology staff, and pharmacists. An initial goal
analgesic medications. Chu et al., Cobb et al., and Dalal et al. of the program was to develop a proposed workflow to guide
found that current evidence suggests that once a mother is the care and support of lactating patients throughout the
awake and alert postoperatively, breastfeeding generally can perioperative period (Fig. 1). The workflow included elements
be resumed.7–9 such as a proposed order set (Appendix A1).
Few case reports or case series exist regarding periopera- To develop guidelines for perioperative lactation man-
tive lactation management. One study of the role of oxytocin agement, the lactation program examined the literature and
in anesthetic consumption found that breastfeeding before evidence around lactation guidelines. PubMed was searched
induction of anesthesia attenuates the stress response to using the subjects: ‘‘Perioperative Lactation,’’ ‘‘Postoperative
surgery.10 Stuttmann et al. detailed four case reports of xenon Lactation,’’ ‘‘Anesthesiology and Lactation,’’ ‘‘Case Series
anesthesia for lactating patients, concluding that xenon and Lactation,’’ with the word ‘‘breastfeeding’’ also sub-
anesthesia, combined with short-acting opioids, may be a stituted for ‘‘lactation.’’ Further search for appropriate mate-
technique that enables immediate resumption of breastfeeding rial was performed after additional review of the reference lists
after surgery.11 in the searched articles.
There is a lack of reports describing the practical im- In addition, well-known references within the lactation field
plementation of programs providing comprehensive perio- were examined to develop guidelines with respect to commonly
perative care for lactating women. The only such work we used anesthetics, analgesics, and perioperative medications
found was written in 2013 by Watson et al. The authors de- (Table 1). These references included Medications and Mothers’
scribed the development of a policy to support breastfeeding Milk, a comprehensive source for professionals seeking phar-
in an unquantified sample of women who were acutely ill in macological advice on breastfeeding.14 In addition, we con-
the intensive care unit. They included one descriptive sur- sulted the ‘‘InfantRisk Center,’’ which provides education
gical obstetric case study of lactation management for a pertaining to medication safety for breastfeeding mothers and
mother who was critically ill after undergoing cesarean sec- operates a hotline for questions regarding medication use in
tion. They concluded that care of breastfeeding women with lactating women.20 We also referred to the ‘‘Drugs and Lac-
acute illness requires specific strategies for early patient tation Database,’’ also known as ‘‘LactMed,’’ which is main-
identification and lactation support.12 tained by the U.S. National Library of Medicine.15
Beginning in August 2014, Memorial Sloan Kettering Several steps were taken to consistently identify lactating
Cancer Center (MSKCC) developed and implemented a patients before the date of the procedure. Patients are typi-
comprehensive program to support lactating women in the cally seen at our presurgical testing clinic, where a history
perioperative setting. The aim of this study was to determine and physical is performed by advanced practice providers.
the incidence of lactation in our perioperative population, as By modifying the history form to include a checkbox for
well as to describe preliminary data and experiences during ‘‘breastfeeding’’ under the ‘‘review of systems,’’ we ensured
the implementation of our program. The results from this that most women were screened for lactation and identified at
study are intended to inform the next phase of our research, a centralized location. In addition, staff in surgeons’ office
which will focus on determining how this work impacts practices, the presurgical testing clinic, and the gastrointes-
outcomes such as postoperative lactation complications, tinal endoscopy clinic were asked to alert the program when
breastfeeding resumption, and overall patient satisfaction. lactating patients were identified before their procedures. An
email distribution list was created to facilitate communica-
Materials and Methods tion with all lactation program members.
Patient education began when lactating patients were iden-
Study design and population
tified in our presurgical testing clinic. Advanced practice pro-
The MSKCC Institutional Review Board provided ethics viders provided education, including a pamphlet designed by
approval (October, 2014, #WA0491-14; renewal, March, the lactation program, entitled ‘‘Preparing for your surgery or
2016, #16-173) and waived the need for informed consent. procedure while you are breastfeeding or lactating’’ (Appendix
This retrospective descriptive study included lactating pa- A2). Patients were asked to bring their personal breast pumps
tients who underwent procedures requiring anesthesia care and all supplies needed for expression of milk on the day of
at MSKCC (New York, NY) from August 26, 2014 to Feb- their procedures. To decrease the risk of perioperative en-
ruary 28, 2017. The start date was chosen to coincide with the gorgement, patients were instructed to breastfeed or express
initial development and implementation of the program, and milk until the breasts were empty in the presurgical holding
the end date coincided with the latest time at which all data area, immediately before undergoing anesthesia. Additionally,
were complete when we conducted the study. they were instructed to resume breast milk expression imme-
The lactation program at MSKCC was founded by a diately in the postoperative period on achieving an awake state,
postanesthesia care unit nurse at our institution who practices as well as to pump every 3–4 hours, or at least as often as the
in the community as an International Board-Certified Lac- baby typically fed. Patients were instructed to breastfeed or
tation Consultant (IBCLC). Although her official profes- express milk for their children’s consumption only once they
sional role at the institution is within the realm of nursing were alert in the postoperative period, and to postpone breast-
rather than lactation consultancy, her expertise and experi- feeding if medication administration led to maternal sedation.
ence outside of the hospital as an IBCLC was an invaluable Selection criteria were lactating patients identified pre-
resource for the program. Other lactation program members operatively who wished to maintain lactation in the perio-
included two anesthesiologists, a gynecologic cancer sur- perative period. Some patients who were lactating at the time
geon, presurgical testing clinic advanced practice providers, of the presurgical testing clinic visit decided definitively to
PERIOPERATIVE LACTATION PROGRAM 99

FIG. 1. Workflow for care of the lactating patient in the perioperative period.

wean their children before the procedure despite patient ed- conjunction with their healthcare providers and children’s pe-
ucation. These patients typically stated that they were ready diatricians. In developing the lactation program, involvement of
to wean their children without regard to undergoing a pro- community pediatricians was considered particularly important
cedure, and that the separation provided an opportunity for for instances in which babies may be preterm, newborn, or have
weaning. medical issues, such as apnea, bradycardia, or hypotonia, or
Patients were asked to notify their children’s pediatricians when high doses, frequent doses, or prolonged use of maternal
of their upcoming procedures to develop a plan for resumption perioperative narcotics may be required. Involvement of pedi-
of breastfeeding and administration of expressed breast milk atricians allowed a clear designation of their role in determining
postoperatively. Because the lactation program had two a plan for observation or monitoring of children when breast-
dedicated anesthesiologist members, they were available to feeding was resumed.
consult and collaborate with patients, their children’s pe- Anesthesiologist lactation program members provided
diatricians, and their surgeons regarding the perioperative education to anesthesia staff, including fellow anesthesi-
course, including medications prescribed and administered. ologists and certified registered nurse anesthetists. This be-
This typically occurred through preoperative phone calls gan with one-on-one education regarding care of individual
with patients and/or their pediatricians, and email or in-person lactating patients who presented perioperatively, starting in
conversations with the surgical team. Community pedia- August 2014. Formal in-service education regarding care of
tricians were viewed in this role as any other perioperative the lactating patient was provided for the entire MSKCC an-
consultants with whom anesthesiologists may communicate esthesia department through lectures in July 2015 and August
perioperatively. Lactation program anesthesiologists were 2016. Education emphasized the use of intraoperative non-
available to provide education to community pediatricians as narcotic analgesics and avoidance of medications requiring
needed, for example, regarding the compatibility of anes- breastfeeding interruption when possible (Table 1). The in-
thetics with lactation (Table 1). traoperative anesthesia team was notified on or before the day
This team approach regarding medications used in the peri- of the procedure regarding the patient’s lactation status. An-
operative period was designed to support patients in making esthetic management was determined by the anesthesia team
informed decisions regarding resumption of breastfeeding in members, who were responsible for communicating with the
100 RIETH ET AL.

Table 1. Commonly Used Anesthetics, Analgesics, and Perioperative Medications

Breastfeeding interruption
Agent recommended?a Additional information
Sedative–hypnotics
Propofol13,14,15 No Low milk levels
Dexmedetomidine14,16,17 Yes-10 hours Terminal elimination half-life 2 hours
Etomidate15 No Low milk levels
Ketamine14 No Short serum half-life
Benzodiazepines
Midazolam13,14,15 No Short half-life
Narcotic analgesics (intravenous) Consult pediatrician if high doses, frequent dosing,
or prolonged maternal use are required
Fentanyl13,14,15 No Low oral bioavailability, short half-life
Hydromorphone14,15 No Potent narcotic; compatible with breastfeeding, but may
consider alternative such as morphine or fentanyl
Morphine14,15 No Low oral bioavailability
Remifentanil14,15 No Low oral bioavailability, short half-life
Narcotic analgesics (oral)
Codeine14,15 Yes; consult pediatrician; Active metabolite; avoid maternal use,
child may require choose alternative agent
monitoring when
breastfeeding is resumed
Hydrocodone14,18 No Limit dose to 30 mg/day
Oxycodone14 No Limit dose to 30 mg/day
Non-narcotic analgesics
Acetaminophen14,15 No
Ketorolac14,15,19 No Consult pediatrician if infant has a
ductal-dependent cardiac lesion
Inhalational agents Short serum half-lives
Desflurane15 No
Isoflurane15 No
Nitrous oxide14,15 No
Sevoflurane14,15 No
Local anesthetics (all routes)14,15 Low oral bioavailability
Bupivacaine No
Lidocaine No
Mepivacaine No
Ropivacaine No
Muscle relaxants
Cisatracurium15 No Low oral bioavailability
Rocuronium15 No Low oral bioavailability
Succinylcholine15 No Low oral bioavailability, short half-life
Vecuronium No
Reversal agents
Glycopyrrolate14,15 No Low oral bioavailability, short half-life
Neostigmine15 No Short half-life
Sugammadex20 Yes-4 hours New medication
Antiemetics
Aprepitant14 No Transfer into milk likely minimal
Dexamethasone14 No
Ondansetron14 No
Scopolamine (transdermal)14 No Low oral bioavailability
Cardiovascular agents
Ephedrine14 No
Esmolol14,15 No Short half-life
Labetalol14,15 No Low milk levels
Metoprolol14,15 No Low milk levels
Phenylephrine14,15 No Low oral bioavailability
Antibiotics
Cefazolin14,15 No Low oral bioavailability
Cefotetan14,15 No Low oral bioavailability
Clindamycin14,15 No Consult pediatrician if infant develops
effects on gastrointestinal flora
Piperacillin and tazobactam14,15 No Low milk levels
Vancomycin14,15 No Low oral bioavailability
a
Time after administration of agent; recommendations apply to acute, short-term maternal use of standard doses in the perioperative
period; for agents that do not require breastfeeding interruption, breastfeeding may be resumed once the mother has achieved an awake,
stable, alert state for a healthy, full-term non-neonate; consult pediatrician if baby is preterm, a neonate, or has medical conditions.
PERIOPERATIVE LACTATION PROGRAM 101

surgical team any requirements for postoperative breastfeed- The characteristics of our lactating patient population are
ing interruption, such as use of dexmedetomidine or su- shown in Table 2. The youngest child was 2.5 weeks old and
gammadex (Table 1). was the only neonate in the study. The median (range) age of
Perioperative analgesia guidance for surgeons emphasized the child was 5 (0.6–24) months.
the postoperative use of non-narcotic analgesics when fea- Several patients had multiday postoperative hospitaliza-
sible, as well as the avoidance of codeine.21,22 Hydrocodone tions, including two (0.03%) patients, each of whom stayed
and oxycodone are oral narcotics that are prescribed fre- for 9 days. Twenty-nine (36%) patients were discharged
quently by surgeons at our institution for postoperative an- on the day of the procedure and did not require overnight
algesia. Because some studies have reported adverse infant hospitalization.
effects, such as sedation and respiratory depression, at higher Most of our lactating patients were ASA class I–II patients
doses of hydrocodone and oxycodone, we requested that (81%), who underwent general anesthesia (89%), and received
surgeons limit prescriptions of hydrocodone and oxycodone at least one non-narcotic analgesic intraoperatively (89%).
to 30 mg a day.14,18 The procedures performed in our lactating patient popu-
Nursing staff were instructed to facilitate breastfeeding or lation are listed in Table 3. The most commonly performed
expression of milk in the presurgical holding area, immedi- procedures were thyroidectomy and/or neck dissection (40%),
ately before transfer of lactating patients to the operating followed by ambulatory gynecologic surgery (12%), and
room. This occurred either by ensuring that patients were minor soft tissue tumor resection (9%).
comfortable expressing milk (for example, with access to an
electrical outlet and privacy) or by allowing breastfeeding Discussion
children as visitors in the presurgical holding area. In-
traoperative nursing staff were instructed to choose chlor- Our results showed that, although our lactating patient
hexidine over iodine surgical skin preparation when possible, population was a small percentage of our total perioperative
as ingestion of iodine by a breastfeeding child may interfere population, we regularly cared for lactating patients during
with thyroid function.14 Nursing staff in postoperative areas the study period.
assisted patients with milk expression once awake, for ex- The only published article we found regarding the practical
ample by assisting patients in achieving a comfortable sitting implementation of a lactation program described a policy that
position. supported lactating critically ill women, including those in
Because we practice at a cancer center that lacks in-house the perioperative period. The policy was implemented in the
obstetric and lactation consultant services, it was necessary to setting of a tertiary hospital’s perinatal program and was
institute new measures for material support of our lactating supported by a lactation consultant service, in contrast to our
patient population. Our institution acquired hospital-grade program, which had no such support. The authors contacted
breast pumps and supply kits for use if personal breast pumps
and supplies were forgotten, malfunctioning, or did not pass
inspection with biomedical engineering. A human milk stor- Table 2. Lactating Patient Characteristics,
age policy was developed, and designated human milk storage August 2014 to February 2017 (n = 80)
refrigerators with central temperature monitoring were placed
in perioperative sites, with nursing staff coordinating milk n (%) or median
storage. Patients with extended stays were encouraged to send Characteristic (range)
milk home for use or storage when appropriate and feasible.
Maternal age at surgery, years 35 (21, 46)
ASA
Data collection and analysis
I 6 (7)
Patient age, American Society of Anesthesiologists (ASA) II 59 (74)
physical status, anesthesia type, hospital length of stay, in- IIII 15 (19)
traoperative non-narcotic analgesic use, and procedure type IV 0 (0)
were collected from the medical records. The child’s age was Child age at surgery, months 5 (0.6, 24)
provided by the patient. Patient characteristics are presented Anesthesia type
as number (percentage) or median (range). Descriptive sta- General 71 (89)
tistics were calculated using Microsoft Excel 2007 (Micro- MAC 8 (10)
Regional 1 (1)
soft Corporation, Redmond, WA).
Hospital length of stay, days
Results
0 29 (36)
1 27 (33)
Over the 30-month study period, we identified 80 lactat- 2–4 19 (24)
ing perioperative patients, with *2–3 patients presenting 5–7 3 (4)
monthly. This represented 0.07% of the *109,000 total an- >7 2 (3)
esthetics performed at MSKCC during this period, including Intraoperative non-narcotic analgesic use
those performed at our main surgical, gastrointestinal endos- Acetaminophen only 47 (59)
copy, and multiple ambulatory locations. The majority of these Ketorolac only 2 (2)
cases was performed on our main surgical operating room Both acetaminophen and ketorolac 22 (28)
Neither acetaminophen nor ketorolac 9 (11)
platform, where 52 (65%) of the lactating patients represented
0.15% of the *34,000 cases performed on the main platform ASA, American Society of Anesthesiologists physical status;
during this period. MAC, monitored anesthesia care.
102 RIETH ET AL.

Table 3. Procedure Types for Lactating Patients, of perioperative lactation. This included concerns regarding
August 2014 to February 2017 (n = 80) the logistics of breast milk expression and resumption of
breastfeeding perioperatively, as well as the compatibility
Procedure type n (%) of medications, particularly anesthetics and analgesics, with
Thyroidectomy and/or neck dissection 32 (40) lactation. Patients often expressed relief in having a plan
Ambulatory gynecological surgery 10 (12) for lactation management that involved their entire health-
Various procedures requiring ‡3 day 10 (12) care teams, including children’s pediatricians. Future work
postoperative hospitalization (colorectal, may involve surveying patients to evaluate the extent to
gynecological, neurosurgical, ophthalmic, which lactation program interventions decrease perio-
orthopedic, vascular) perative stress and anxiety, and allow patients to resume
Minor soft tissue tumor resection 7 (9) breastfeeding and meet overall breastfeeding goals. Given
Gastrointestinal endoscopy 4 (5) that a study found that breastfeeding before anesthesia in-
Melanoma resection 4 (5) duction attenuates the stress of surgery,10 further research
Various procedures requiring £1 day 4 (5)
postoperative hospitalization (genitourinary, might explore methods that support breastfeeding throughout
gynecological, ophthalmic, otolaryngologic) a patient’s hospital stay.
Ambulatory plastic surgery 3 (4) Dalal et al. suggested consultation with a lactation spe-
Cystoscopy 3 (4) cialist and pediatrician for patients undergoing major sur-
Sarcoma resection 3 (4) gery. They also suggested monitoring for breastfed infants
of mothers who require medications that may be respira-
tory depressants.9 Our lactation program sought to explore
the practical implementation of such suggestions. It also
women after their discharge and asked questions regarding attempted to address several challenges in our patient popu-
their breastfeeding experience at the hospital. They reported lation in balancing the perioperative use of medications,
outcomes that were limited to subjective patient responses, particularly opioids, with resumption of breastfeeding post-
such as ‘‘Breastfeeding was important to me; I wanted to keep operatively. These challenges include the varied periopera-
my options open because I didn’t know what the outcome tive narcotic requirements of our lactating patient population,
would be.’’12 with some patients requiring multiple days of postopera-
Our work uniquely details the practical implementation of tive narcotics through patient-controlled analgesia, and other
a perioperative lactation program at an institution that lacks patients not requiring any perioperative narcotics. In ad-
the support of in-house lactation consultant and obstetric dition, we practice at a specialty hospital that is not affiliated
services, which is often the case at specialty institutions that with a community or in-house general pediatric practice.
provide anesthesia care, such as ambulatory surgery centers. Also, collaboration with children’s pediatricians may be
In addition, our work may be generalizable to a large subset challenging due to their varied levels of knowledge regarding
of lactating patients undergoing a variety of procedures and perioperative lactation management.
anesthetics. Despite our cancer focus, our study population One review for anesthesia providers regarding postopera-
included patients undergoing general and regional anesthesia, tive breastfeeding recommends that mothers should closely
as well as monitored anesthesia care. These patients underwent monitor their infants for signs and symptoms of behavioral
many types of minor to major procedures, including colorectal, changes while consuming medications.8 The responsibility to
gynecological, gastrointestinal endoscopy, genitourinary, minimize medication effects must also be borne by health-
head and neck, neurosurgical, ophthalmic, orthopedic, otolar- care providers. To address the aforementioned challenges,
yngologic, plastic surgery, soft tissue, and vascular procedures. our program emphasized patient education and collaboration
The major limitation of our work is a lack of data regarding among the patient’s entire healthcare team, incorporating the
outcomes in our lactating patient population, as the im- combined knowledge and expertise of anesthesiologists, pe-
plementation phase of our lactation program yielded only diatricians, and surgeons. Additional areas for future research
demographic data. We anticipate that data from this study, as include maternal narcotic requirements and their impact on
well as our experience with this phase of the program, will breastfeeding children.
inform the next stage of our research. Specific areas for future
research may include evaluating lactation complications, Conclusion
such as perioperative breast pain, engorgement, mastitis,
Our study showed that we cared for lactating patients un-
decreased milk supply, and undesired formula supplemen-
dergoing a wide range of procedures on a regular basis during
tation or weaning. Lactation program members caring for
the implementation of our comprehensive perioperative lac-
patients in the postoperative period observed postoperative
tation program. The results from this study are intended to
sedation and pain to be possible factors that may interfere
inform the next phase of our research, which will focus on
with postoperative milk expression and breastfeeding. Time
determining how this work impacts outcomes such as post-
to resumption of milk expression or breastfeeding postoper-
operative lactation complications, breastfeeding resumption,
atively, postoperative milk expression and breastfeeding in-
and overall patient satisfaction.
tervals and limitations, and rates of lactation complications
are areas for further exploration.
Acknowledgments
Overall patient satisfaction is another area for future
study. Lactation program members who interacted with The authors wish to thank Dr. Gregory Fischer, Dr.
patients preoperatively noted that patients often had the Rebecca Twersky, and Madeleine Hicks for their support
highest level of preoperative anxiety regarding management and assistance.
PERIOPERATIVE LACTATION PROGRAM 103

This research was funded in part through the NIH/NCI 13. Nitsun M, Szokol JW, Saleh HJ, et al. Pharmacokinetics of
Cancer Center Support Grant P30 CA008748. midazolam, propofol, and fentanyl transfer to human breast
milk. Clin Pharmacol Ther 2006;79:549–557.
14. Hale TW, Rowe HE. Medications and Mothers’ Milk 2017.
Disclosure Statement New York: Springer Publishing Company, 2017.
15. U.S. National Library of Medicine, Drugs and lactation
No competing financial interests exist. database (LactMed). Available at https://toxnet.nlm.nih.
gov/newtoxnet/lactmed.htm (accessed October 27, 2017).
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report card. 2016. Available at www.cdc.gov/breastfeeding/ 4404 (accessed October 27, 2017).
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2. Statistics Canada. Breastfeeding Trends in Canada. 2015. of dexmedetomidine in human breast milk using liquid
Available at www.statcan.gc.ca/pub/82-624-x/2013001/ chromatography-tandem mass spectrometry: Application
article/11879-eng.htm (accessed October 27, 2017). to a study of drug safety in breastfeeding after cesarean
3. Amir LH. ABM clinical protocol #4: Mastitis, revised section. J Chromatogr B Analyt Technol Biomed Life Sci
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surgical areas. Medsurg Nurs 2007;16:101–104. hydrocodone and hydromorphone levels in mothers using
5. Amir LH, Lumley J. Women’s experience of lactational hydrocodone for postpartum pain. Obstet Gynecol 2011;
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E-mail: riethe@mskcc.org

(Appendix follows/)
104 RIETH ET AL.

Appendix
Appendix A1

Appendix A2

PATIENT and CAREGIVER EDUCATION your surgery or procedure. By talking with your healthcare
team ahead of time, they can support you throughout your
Preparing for your surgery or procedure while you are care.
breastfeeding or lactating
If you have questions about any of the medications you
This information will help you prepare for your surgery will receive, there are resources that can help:
or procedure at Memorial Sloan Kettering Cancer Center
(MSKCC) while you are breastfeeding or lactating. B Infant Risk Center
www.infantrisk.com
Before Your Surgery or Procedure 806-352-2519
Talk with your surgeon and anesthesiologist about the type You can find information on the use of medications during
of medication that you will receive before, during, and after pregnancy and breastfeeding.
PERIOPERATIVE LACTATION PROGRAM 105

B TOXNET Drugs and Lactation Database (LactMed) team. You may also need help from your family or friends
www.toxnet.nlm.nih.gov/newtoxnet/lactmed.htm while you recover from your surgery or procedure.
You can find information about medication and other While you are separated from your baby, plan to pump every
chemicals that can be passed on to your infant from 3–4 hours, or at least as often as your baby feeds. Pumping
breast milk. frequently will help maintain your supply of breast milk until
B International Lactation Consultant Association you are able to breastfeed again.
www.ilca.org If you have questions about any of the medications you
888-452-2478 will receive after your surgery or procedure, talk with your
You can find a lactation consultant near you by searching healthcare provider about finding a different medication. You
under the ‘‘Directories’’ section. can also check the websites or call the number listed under the
‘‘Before Your Surgery or Procedure’’ section.
If possible, pump and store a supply of breast milk before If you expect to stay in the hospital for more than 24 hours,
your surgery or procedure. Storing your breast milk ahead of make arrangements with a family member or friend to bring
time will allow your baby to continue to be fed your breast your pumped breast milk home each day.
milk while you are separated. You can find information about Your breast milk can be stored in an insulated cooler bag
how to safely store your breast milk by visiting the Centers with ice packs for 24 hours. Keep the ice packs in contact
for Disease Control and Prevention website listed under with the milk containers at all times, and open the cooler bag
‘‘Additional Resources’’ below. as little as possible.
The Day of Your Surgery or Procedure Additional Resources
Plan to breastfeed or pump right before your surgery Additional websites you may find helpful
or procedure. This will help maintain your milk supply and Centers for Disease Control and Prevention
prevent pain and engorgement. Proper Handling and Storage of Human Milk
www.cdc.gov/breastfeeding/recommendations/
What to bring to the hospital handling_breast milk.htm
, Your own breast pump with power source Provides information about how to safely prepare and store
, All the supplies you need for milk expression breast milk.
, Milk storage containers Breastfeeding USA
, A cooler bag with ice packs (to store pumped breast www.breastfeedingusa.org
milk) Provides information and support for breastfeeding.
Talk with your healthcare team Resources for pumping supplies near MSKCC
On the day of your surgery or procedure, tell your Falk Medical Supplies
healthcare team that you are breastfeeding or lactating and 1167 First Avenue between East 63rd and East 64th Streets
wish to continue. New York, NY 10065
After Your Surgery or Procedure 212-744-8080
Anesthesia (medication to make you sleep) does not stay in Yummy Mummy
your body for very long. If you have questions about the 1201 Lexington Avenue between East 81st
anesthesia you received, talk with your anesthesiologist. You and East 82nd Streets
should plan to start pumping again as soon as you are awake New York, NY 10028
and able. If you need help, ask a member of your healthcare 212-879-8669