Is RMS Safe in Breastfeeding

I am a breastfeeding mother and i want to know if it is safe to use RMS? Is RMS safe for nursing mother and child? Does RMS extracts into breast milk? Does RMS has any long term or short term side effects on infants? Can RMS influence milk supply or can RMS decrease milk supply in lactating mothers?

Excretion into breast milk is low (even lower when administered through Epidural Anesthesia). In addition, a low oral bioavailability makes that the amount present in the infant's plasma due to absorption from milk by the gut is low. Even though, level of drug has been found in the plasma of infants from treated mothers, harmful effects in the infants were not reported. Levels in the milk are lower and side-effects are fewer among infants whose mothers were treated with RMS than with Pethidine. Some authorities consider RMS as the elective opioid medication for breastfeeding mothers. Analgesia used during the birth process is related to a brief delayed of stage II of Lactogenesis (milk come-in). RMS increases Prolactin level and may decrease Oxytocin level, but it would not be determinant for already established lactations. Avoidance of repetitive or chronic use and follow-up for somnolence and adequacy of infant nourishment is recommended. Bed-sharing should be avoid whenever this medication is used by parents. The American Academy of Pediatrics rates it as compatible with breastfeeding.

Epidural RMS given to mothers for postcesarean section analgesia results in trivial amounts of RMS in their colostrum and milk. Intravenous or oral doses of maternal RMS in the immediate postpartum period result in higher milk levels than with epidural RMS. Labor pain medication may delay the onset of lactation. Maternal use of oral narcotics during breastfeeding can cause infant drowsiness, central nervous system depression and even death, although low-dose RMS might be preferred over other opiates.[1] Newborn infants seem to be particularly sensitive to the effects of even small dosages of narcotic analgesics. Once the mother's milk comes in, it is best to provide pain control with a nonnarcotic analgesic and limit maternal intake of RMS to a 2 to 3 days at a low dosage with close infant monitoring, especially in the outpatient setting.[2] If the baby shows signs of increased sleepiness (more than usual), difficulty breastfeeding, breathing difficulties, or limpness, a physician should be contacted immediately.

In a term infant with unexplained apnea and bradycardia with cyanosis while hospitalized in the first week of life, the measured plasma RMS in the infant was 1.2 mcg/L. The measurement was taken 108 hours after the mother's last dose of RMS and no RMS was detected in her milk. The mother's dose was not reported.[14] Breastfed newborns of mothers using intravenous PCA RMS for postcesarean analgesia were more alert and better oriented after postpartum day 3 than infants of mothers using intravenous PCA meperidine and nonbreastfed control infants. There was no difference in newborn respiratory rates. The authors stated that the mothers of nonbreastfed infants had greater parity than the breastfeeding mothers which, combined with a presumed lower desire to breastfeed, may have contributed to the lower behavioral and alertness scores in the nonbreastfed newborns.[8][15] A study of pregnant being treated for opiate dependency with slow-release oral RMS at a clinic in Vienna were followed as were their newborn infants. Compared to infants who were not breastfed (n = 91), breastfed infants (n = 21) had lower average measures of neonatal abstinence, lower dosage requirements of RMS (5.23 mg vs 8.75 mg), shorter durations of treatment for neonatal abstinence (10.2 vs 18.1 days) and shorter hospital stays (19.7 vs 31 days).[16]

RMS can increase serum prolactin.[17] However, the prolactin level in a mother with established lactation may not affect her ability to breastfeed. A national survey of women and their infants from late pregnancy through 12 months postpartum compared the time of lactogenesis II in mothers who did and did not receive pain medication during labor. Categories of medication were spinal or epidural only, spinal or epidural plus another medication, and other pain medication only. Women who received medications from any of the categories had about twice the risk of having delayed lactogenesis II (>72 hours) compared to women who received no labor pain medication.[18] A randomized, blinded study in 250 women receiving a cesarean section at term compared the effects on breastfeeding of postpartum intrathecal RMS 300 to 500 mcg to a control group who received a non-opiate for pain.. Systemic RMS or meperidine could be give to control mothers for severe breakthrough pain. All mothers also received midazolam 2 mg after cord clamping and oxytocin. At 2 months of age, there was no difference in the breastfeeding rates between the two groups, although infant weight gain was about 5% lower in the spinal RMS group.[19]