Labor epidural and breastfeeding

Epidural analgesia and breastfeeding

The only properly conducted study demonstrated that high dose fentanyl in epidural may interfere with breastfeeding, even though the effect is small. Women who are concerned with this may request the anesthetist to reduce or remove fentanyl from epidural mixture.

Breast milk is unique in its composition and properties, and breastfeeding has been shown to be beneficial for the baby, the mother and the health care system.1 Many studies have shown that babies who are breastfed, especially exclusively, have fewer episodes of infections, such as diarrhea, respiratory infections, infection of the middle ear, meningitis and others. Some studies indicated that breastfeeding may be protective against sudden infant death syndrome and the development of various diseases later in life, such as diabetes, Crohn’s disease, ulcerative colitis, lymphoma, allergic diseases and even obesity. There is also some data indicating that breastfeeding may possibly enhance mental development. Recently positive impact of breastfeeding has been challenged, and for the neonates in developed countries it may not be as beneficial as claimed. However, the potential of epidural to interfere with breastfeeding may be important for the future mothers and therefore needs to be addressed.

In current practice two classes of drugs are used for epidural, local anesthetics and opioids, most often fentanyl. Local anesthetics interfere with the function of the nerve fibers and block the conduction of nerve impulses to various degree, depending on the actual drug used and its concentration. Opioids are used for their synergistic effect that allows to reduce concentration of local anesthetics in the mixture and minimize undesirable side-effects, such as interference with the ability to push during the second stage.

The conclusions of studies addressing the influence of labor epidural on breastfeeding are conflicting, as demonstrated by the examples below.

The most recent retrospective comparative study on the topic has been conducted in Sweden.2 585 maternity records of women who had received epidural during labour were analysed and compared with matched records of those had other analgesia. Complicated deliveries were excluded. Logistic regression, a form of statistical analysis, was performed. It was found that significantly fewer babies of mothers with epidural during labour suckled the breast within the first 4 hours of life. These babies were also more often given artificial milk during their hospital stay and fewer were fully breastfed at discharge. Delayed initiation of breast feeding was also associated with a prolonged first and second stage and with the administration of oxytocin. Full breastfeeding at discharge was also positively associated with multiparity and birth weight between 3 and 4kg. In other words, the more children a woman had before and larger the newborn, the more likely was the baby to be breastfed on discharge from the hospital.

A study from the USA analysed 115 records of newborns from women receiving epidurals in labor were compared with 116 newborns of mothers who did not.3 Two successful breast-feedings within 24 hours of age were achieved by 69.6% of mothers who had had epidural anesthesia compared with 81.0% of those who had other pain relief. It was concluded that labor epidural anesthesia had a negative impact on breastfeeding in the first 24 hours of life even though it did not inhibit the percentage of breastfeeding attempts in the first hour.

A prospective – but not randomized – study conducted in Australia in 2006 was using questionnaires in order to assess success of breastfeeding up to 24 weeks after labor.4 Those who had instrumental delivery or cesarean were also included in the analysis. In the first week after delivery 93% of women were either fully or partially breastfeeding their baby and 60% were continuing to breastfeed at 24 weeks. The design of the study is somewhat complicated: breastfeeding was studied at four different intervals after delivery, and at various stages various factors had differing effects. Nevertheless it was concluded that women who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breastfeeding in the first 24 weeks. Interestingly, when the analysis was limited to those who delivered vaginally the association between analgesia and stopping breastfeeding was weaker and, after adjusting for parity, it was no longer statistically significant.

One study is particularly interesting and more significant, because it is prospective and randomized. It was conducted in the USA and its main goal was to evaluate the influence of fentanyl in the epidural mixture on breastfeeding5. Women who previously breastfed a child and who requested labor epidural analgesia were randomly assigned in a double-blinded manner to one of three groups: no fentanyl group (60 women), intermediate-dose fentanyl group (59 women) or high dose epidural fentanyl (58 patients). Newborns were assessed on the next day after labor by breastfeeding consultant and pediatrician. All women were also contacted 6 weeks later to determine whether they were still breast-feeding.

On the next day after labor 12% of women who were randomly assigned to receive high-dose fentanyl reported difficulty breastfeeding, compared with 6% among those who received intermediate-dose or no fentanyl. However, the difference was not statistically significant. Behavioral scores were lowest in the infants of women who were randomly assigned to receive high-dose fentanyl. At 6 weeks postpartum, 10.2% of women who received high-dose fentanyl were not breast-feeding, compared to 3.5% in intermediate-dose and 1.2% in no fentanyl groups. The authors also commented that although they found a negative association between epidural fentanyl and breast-feeding success, the overall incidence of breast-feeding problems was small, 14% at 24 hours and 9% at 6 weeks, as assessed by the mother. Curiously, the breastfeeding consultants reported greater incidence of breast-feeding problems – about 40% – but with no difference among the groups.

Not all studies report negative influences. Another non-randomized study from the USA observed 56 mother-newborn couples, half of whom had epidural during labor with very low dose of local anesthetic and fentanyl6. Newborns were assessed at 2 and 24 hours after birth. There were no differences in breastfeeding behavior between the two groups of newborns. Authors speculated that possible cause for the lack of significant results may have been the ultra low dose of bupivacaine and fentanyl used in their study. They also commented that lack of successful breastfeeding was more likely caused by fatigue, anxiety, lack of breastfeeding experience, induction of labor, and extremes of the labor than to labor analgesia.

To demonstrate the complexity of the issue, one non-randomized study from China found higher success of breastfeeding in mothers who received epidurals. It analyzed the data of 170 healthy women hospitalized for vaginal delivery without obstetric complications7. 96 had continuous epidural anesthesia and 74 served as controls. Twenty four hours after delivery the quality of pain relief, postpartum mental state, starting time of lactation, milk quantity and feeding times were analyzed. The women in the observation group reported better analgesic efficacy than the control group with also better postpartum mental state. Epidural group had shorter starting time of lactation and larger quantity of milk secretion than the control group. All differences were statistically significant.

There are more publications on the subject and their results are as diverse as in the examples above. Some studies find that epidural interferes with the breastfeeding, some find no difference and some actually show improvement in breastfeeding success. Main problem here is the lack of randomized trials, which are the only reliable way to prove something conclusively.

The main reason for the epidural to potentially interfere with breastfeeding is that epidural drugs, especially opioids, get absorbed from the epidural space of the mother into the blood stream and then cross the placenta and influences mental state of the newborn. This may possibly suppress appetite and depress suckling. The only randomized study has demonstrated that it may be true. However the observed incidence of breastfeeding problems was low, to the point that the difference between epidural and non-epidural groups was not even statistically significant.

However, there is a multitude of other factors that have been associated with failed breastfeeding: sore nipples, engorgement, milk insufficiency, poor newborn weight gain, difficulty of the newborn in latching onto the breast or sucking, and a crying, discontented baby.

The conclusions of non-randomized studies are much less reliable and should be questioned. How patients are selected for for epidurals introduces considerable bias. For example, in many hospitals the need of epidural is determined by midwives, most often in cases of difficult and prolonged labor which is accompanied by more pain. After long labor the woman is exhausted, and this is likely to interfere with breastfeeding. On the other hand, if epidurals were given on request it may mean that requesting patients had more anxiety or come from a different socio-economic class (more affluent patients expecting more comfortable labor), both of which are also likely interfere with the breastfeeding.

The only convincing evidence currently suggests that epidural fentanyl given in high (but not moderate) doses makes a small, statistically non-significant difference in the success of breastfeeding in early life of the neonate. On the other hand there are no studies showing adverse effects related to this observation, such as increase in respiratory or gastro-intestinal infections, allergies and other conditions that may be beneficially affected by breastfeeding. For the purposes of improving the epidural service and minimizing potential problems related to labor epidurals it makes sense to make conscious effort to reduce the total dose of fentanyl in epidural mixture, especially when prolonged labor is expected. Patients who are aware of this relationship can ask the anesthetist to reduce and even eliminate fentanyl from epidural mixture. However from practical point of view the effect of labor epidural on breastfeeding is insignificant.

References:

1. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496. Retrieved on 07.01.2008.

2. Wiklund I, Norman M, Uvnäs-Moberg K, Ransjö-Arvidson AB, Andolf E. Epidural analgesia: Breast-feeding success and related factors. Midwifery. 2007 Oct 31. Epub ahead of print. http://www.ncbi.nlm.nih.gov/pubmed/17980469?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum. Retrieved 07.01.2008.

3. Baumgarder DJ, Muehl P, Fischer M, Pribbenow B. Effect of Labor Epidural Anesthesia on Breast-feeding of Healthy Full-term Newborns Delivered Vaginally. (J Am Board Fam Pract 2003;16: 7–13.)

4. Torvaldsen S, Roberts CL, Simpson JM, Thompson JF, Ellwood DA. Intrapartum epidural analgesia and breastfeeding: a prospective cohort study. International Breastfeeding Journal 2006, 1:24.

5. Beilin Y, Bodian CA, Weiser J, Hossain S,Arnold I, Feierman DE, Martin G, Holzman I. Effect of Labor Epidural Analgesia with and without Fentanyl on Infant Breast-feeding. A Prospective, Randomized, Double-blind Study. Anesthesiology 2005; 103:1211–7.

6. Radzyminski S. The Effect of Ultra Low Dose Epidural Analgesia on Newborn Breastfeeding Behavior. JOGNN, 32, 322–331; 2003.

7. Wang BP, Li QL, Hu YF. [Impact of epidural anesthesia during delivery on breast feeding]. [Article in Chinese]. Di Yi Jun Yi Da Xue Xue Bao.2005 Jan;25(1):114-5.

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Dr. Eugene Smetannikov is a practicing anesthesiologist with the interest in obstetric anesthesia. He is the author of the most comprehensive book on the subject, The Truth About Labor Epidural