Lactation Podcast

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org. And on our new app, which is available on Apple and Android devices. So now on to today's show, the other day I was doing a lap Coley with the amazing doctor, Dr. Austin Echoff, who's a resident of Duke. And during induction of the patient it was mentioned that the patient is breastfeeding her little one.

And in a very kind of knee jerk response, I blathered something out about pump and dump, but fortunately Austin was there to set me straight and she provided some much needed education. And with that, an episode was born. So we have some fantastic guests today. As I mentioned, Dr. Austin Echoff. She's a fourth year general surgery resident at Duke who is currently applying to surgical oncology.

We also have Dr. Annie Dotson, who is a family medicine and breastfeeding medicine physician here at Duke University. And Dr. Katrina Mitchell, who is a breast surgeon at Ridley Tree Cancer Center in Santa Barbara, California. She's also the creator of the Physician Guide to Breastfeeding, an evidence based resource for breastfeeding families, breast cancer patients, and a surgery resource for lactation.

So thank you all for being here today. So Austin, once you kick it off, we have a very simple case to begin this discussion. Absolutely. And this was her actual case for that day. So it was a 30 month old female who was lactating and she was undergoing a non elective lap coli for acute cholecystitis.

One of the first questions I think about when I see her in the ED is what imaging can I do? Can I use IV contrast with the CT scan? What about a hiatus scan? That's a great question. A very common question in the ER and surgical medical floors. So less than 1 percent of iodinated contrast that's used in a CT scan is

excreted in breast milk.

So there's absolutely no need to discard that breast milk or interrupt breastfeeding. The same also goes for an MRI with gadolinium contrast. A HIDA scan is a little trickier because a new U S nuclear regulatory agency recommended breastfeeding interruption for 24 hours. with any technetium 99 substance, but this is likely just an overcall to keep the regulations simple.

Most likely it's 12 hours for a HIDA scan. However the best case scenario would be that the person just got an ultrasound and you were able to make an operative decision based on that. Yeah, that's fantastic. I've actually always wondered these things. So the clarity is perfect. Now, we have this patient in the operating room at this point, and we have a number of different medications that we typically administer, including for induction and keep the patient asleep.

Out of these common meds, Katrina, what do we have to think about? And when it comes to pump and dump, are we obligated to do so?

That's also a great question and an easy answer. So you don't need to pump and dump after any anesthesia. I would say the one thing I'd probably try to stay away from would be a pair of vertebral block that would impact the thoracic region, just because it's, it'd be sort of strange to have a numb breast when breastfeeding.

But otherwise, once the mother is awake, she Has The drugs metabolized out of our system and is safe to breastfeed. Yeah, this is mind blowing to me. Let's talk opioids, for example. Are there differences between the opioids that we have to think about or referential use?

That is true. You do want to preferentially use morphine and hydromorphone or Dilaudid with IV medication because there's poor oral bioavailability and you preferentially want to use Norco, i. e. hydrocodone for oral pain control, but You don't need to pump and dump if you're using say something like oxycodone or Percocet.

However, those are the more preferred ones. I think the biggest thing to remember is not to use tramadol or coding because some moms can be ultra rapid metabolizers of them. And this can result in high blood levels in the baby. So is there a big enough difference between hydrocodone and oxycodone for our patients that are recovering, let's say from abdominal surgery and

you need some narcotic pain control is hydrocodone that much better that we should be switching over to it as opposed to oxycodone? Or is there not that much of a difference? It's not a huge difference to the point that I would say someone had to pump and dump because they had oxycodone. It's just has to do with the metabolism of the drugs and hydrocodone is just preferred.

But again, I think it all, I think Annie had brought this up too, that It's really every situation is a little bit unique with things like that. Is it a mom of a 25 weeker in the NICU or is it a mom of a 10 month old? But

again, I think the real message because the pendulum tends to sway way far on the side of pumping and dumping is to just remember that the vast majority of situations you don't have to.

I tell my patients, basically, if you want an easy answer. You can't breastfeed with chemotherapy, but pretty much everything else, with some rare, rare exceptions like thyroid radiation, but that kind of counts as, you know, cancer care in my mind. And Annie, what about medications like propofol, very frequently used in the OR?

Yeah, all of those are really safe. You know, once the mom, the patient is awake enough after surgery, it's totally fine to start either pumping or feeding directly on the breast, which sometimes we forget about post surgery in a PACU situation if an infant can be there. Also okay to direct breastfeed. You know, what Katrina was mentioning about the exceptions sometimes happen when we have

infants that are kind of at high risk.

First, some hypotonia hypotension or apnea, really young babies. So if that's the case, including your pediatric colleagues, your NICU colleagues into the conversation to see if there's a risk that isn't really for the breastfeeding in a normal situation, but in an exceptional situation would be reasonable.

Is there a specific age cutoff you think of? I think that can be, that's so challenging because many of those babies are on a combination of different feeding things at that point.

So they're often not on solely maternal breast milk from their parent. They might also be getting some fortification and so there's no real cutoff. I would just include the NICU if you have somebody that has a really young baby. I was just gonna say, I think it just underscores where we all are with surgery as well in turning to non narcotic pain control.

And if you have a huge abdominal

surgery and that's a situation to use a block you know, epidural and to minimize narcotics there. And there's a great paper from Academy of Breastfeeding Medicine that kind of talks about intraoperative medications you can come look at.

There's tons of resources to reference and know which ones are safe and. Really, most of them are

At Duke, I know we have pumps that we can bring both in pre op and post op. Are there best practices such as ordering pumps bedside or things like that that we can help our patients?

Yeah, I think best practices having access to a pump really important. That can also include patients bringing their own personal pumps if they opt to do that, but certainly having access to a hospital grade pump both preceding the surgery and afterwards directly in the PACU is really important.

I think having a policy in this case is critical because there's many things that go into having that pump at the bedside, including having access to pump parts, having a protocol in place

to teach the patient how to use a pump. Not all patients have used them when they come in for surgery, having some kind of assistance related to lactation if they need it.

So that if a patient isn't able to do the pumping themselves, somebody can assist them or to keep them on a timing that matches their feeding schedule if they aren't able to match that themselves. So all of those really are critical to lay in a policy. And it's not just about having the pump, but having the resources available to really support the use of that pump.

I would add that having a mom breastfeed a baby, if she's able, is really the most ideal situation because it's going to stabilize her vital signs postoperatively. It's going to reduce her need for pain medication and I think it can be relaxing for moms to be able to breastfeed their baby before they go back to the OR.

And I have been very, very lucky to work with a lot of anesthesiologists who

have really set the tone for our entire OR.

It's just, it's not a surprise that there's a mom breastfeeding a baby before case.

How did y'all get anesthesia on board to be partners in this I've been lucky that I've had a lot of younger female anesthesiologist who have been interested in it. Promoting this education themselves, both at the hospital and the surgery centers. And again, I think I, I'm probably just lucky that there's a certain amount of culture of open-mindedness on this topic that I am aware doesn't exist everywhere.

And I think it's just gonna be a work in progress for a lot of places, particularly bigger institutions where there's a lot more red tape to jump through. And you have experience with that in terms of big institutions and building something. If someone's interested in trying to get something together with their parry up partners to engage with this material and ensure that patients benefit from it.

Do you have any recommendations for

them? Yeah. I mean, I think bringing people together at the same table is really important. You can kind of frame it around a committee or a work group is great. That kind of sets it with a purpose. I think there are a lot of people that do care about this topic.

Parents in particular, surgeons are also parents and maybe aren't vocalizing that as a priority, but once you really bring it to the table, it starts to become important because it's something many people have gone through themselves. All right. So Katrina we did surgery. We did our lap Coley. It went well.

How do you commonly administer medications that we give after surgery affect lactation? This could be again, opioids and says Tylenol anti medics and even antibiotics. Mm hmm. So the opiates are per what we had mentioned above and says Tylenol, antibiotics, all safe.

Antibiotics

are all safe with the exception of you want to be careful with some very young babies and Bactrim that definitely is not the majority of patients, and there's usually alternatives to that medication as well. So even the things that people think of as big guns, you know, Vanco, well, it's probably, it's probably not even a big gun in general surgery anymore.

It's been too long since I've done general surgery, but you know, the Zosens, Vancos, they're all fine. Are there meds we want to avoid because they decrease supply? The only thing that's really going to impact production considerably is going to be something like Sudafed, but really even antihistamines that traditionally have been thought of like Benadryl or loratadine, they're fine.

And scopolamine patches are also fine. I would say scopolamine is probably not the most ideal as an anti emetic and a lactating patient just because of the

other side effects of dry mouth and just the anti cholinergic effects. But I'd start with probably Zofran and also just minimize narcotic usage to try to get ahead of the nausea.

And I think having a resource for what you should look at in terms of when you have a medication, you're not sure about. E lactansia is a really great resource. It has information in English, Spanish, and it also includes case reports, which is really nice because some of the medicines that we might be administering might not have a lot of published data might.

be based on one case report. So having that compiled can be great. There's some other ones like infant risk that has a call line lacked med. Those are great too. Those are us based. But just have a resource where you can look up your medicines. Andy, is there a lot of literature for this because sometimes when I look it up essentially every med has these very vague answers about safety for use with lactation or

in pregnancy, yeah, I mean, some of it's based on pharmacology principles based on the size of the molecule for the drug. Because it is challenging to do real research in, you know, pregnant and lactating patients. But there can be some case reports that are published which is why the eLactancia one is really nice.

Yeah, I would add to that that if you have a lactating patient, you want to use a lactation specific resource like eLactansia. I tend to use LactMed, which is a NIH online resource. And as Annie had mentioned, they will not have a, Discrete yes or no or grading or number that can be scary or hard to interpret, but they actually discussed the drug provide any case reports that exist.

And even if there is nothing that is in existence. They will talk about the pharmacokinetics of the

medication, for example, monoclonal antibodies tend to be very large molecules and would not cross the blood milk barrier. And so they can extrapolate and say there's no information in this, but based on other drugs with the same properties, we can conclude this is likely safe.

Yeah, we're going to put links to those resources that you mentioned in the show notes so people can access those and I think now It'd also be a good time katrina. You have a website too with a lot of fantastic information on it, right? Yeah. So I put this together during COVID because I was just so frustrated with how isolated everyone was and how much misinformation was circulating on social media and online.

And I called it the physician guide to breastfeeding. And I really wanted to include everything I do with my breastfeeding medicine practice and the surgical aspects of my breastfeeding medicine practice

as well as surgery, breast cancer resources. So one part of it and it's part of a larger project called trash, the pump and dumb.

org. But I have a poster there that I made for the ER and the pharmacy, that has a highlight of all of the anesthesia and You know, common medications

And so in my post Austin enlightenment period, when I started thinking about this more and getting back to some of these resources that y'all had mentioned in preparation for this podcast. I also had a patient that we did an abdominal surgery on who was lactating. It was a great discussions between the anesthesia team and our surgery team. And in the end, the patient ultimately just said, well, I don't really want to worry about any of these things or the what ifs.

I'm not taking any narcotics. And I am not breastfeeding for 24 hours after my operation. What do you say to these patients? It's 24 hours of not breastfeeding such a terrible thing to?

She was very happy with her

decision and everyone's doing just great. So is that something you want to push? I know we have both have a lot of thoughts. Yeah, I think everything with breastfeeding is really assessing patient goals. You want to make sure that they have the knowledge that you're providing them with in terms of medication safety and the ability to breastfeed, but also there are parents who do, I think, worry a lot and really Many parents want to keep their infants safe.

So at the end of the day, it's really assessing their goals and their priorities and then talking about what's the plan then if we do have a 24 hour period where there's not breastfeeding, what might that look like? And so I think we're here to support patients and make sure that they're able to then get back on track if the goal is to then feed again.

And I, I just add that as a surgeon, counseling about lactation is the same as the way I would consent a patient for any surgical

procedure that I think it's important to lay out what Annie said at the, At the outset that I always say, I am, I'm happy to do what makes you comfortable. However, I recommend XYZ for XYZ reason.

I think also something to be aware of is that peripartum patients are very, very sensitive to, this is well documented in the perinatal mental health literature, actually, that They're very sensitive to emotions in the room around them.

And they have this kind of heightened awareness. So if there's any sense that someone maybe didn't feel safe, that you were sort of saying the words, but you didn't really believe 100 percent what you were saying, that could Cause a kernel of doubt in the patient's mind and say, no, hang on, wait, I don't want to breastfeed for 24 hours.

So I think it is important to also advocate for continued

uninterrupted breastfeeding because we know it's safe and 24 hours of interruption of breastfeeding in an otherwise exclusively breastfed baby is a problem, unfortunately. I absolutely agree with that. I think with breastfeeding as a whole, we do inflict, unfortunately, a lot of medical trauma with our uncertainty.

And so there are many things that are uncertain with breastfeeding, but at least going in with the knowledge and being supportive can really go a long way with patients when they feel like you might not know. Or you might feel that there could be an unsafe situation. They're going to try to do what's safest for their family.

And so we want to make sure that we're giving accurate knowledge that we're giving them options with appropriate risk assessment and then allowing them to digest that information.

If the scenario changes, and biliary colic, we're staying in clinic and the

plan is for elective cholecystectomy. Are there things that we can set this patient up for success? I guess I would say if something is elective, we would try to defer that until lactation is complete. And in that situation, I guess if someone didn't have an acute cholecystitis and there's something you can do to keep the person healthy without an acute cholecystitis episode, then Great.

I try to defer that like I would anything else elective, but I think otherwise it's some of the same principles as what we've discussed with this acute situation. It's really nothing is particularly different other than you can potentially plan ahead for a larger surgery and know, for example, if you were having a surgery where someone would be intubated in the ICU post op and that was planned for that you would have a store of breast milk ahead of time.

And that's

when it's helpful to have a breastfeeding medicine physician involved in the care of the patient or a lactation consultant to help plan for the breast milk feeding of the baby. I do think, yeah, there's an opportunity to really create more of a structure, a plan in place. You can spend some time during your pre op visit talking about what that might look like including what's going to happen in the PACU During the procedure all of those situations, making sure that the support is in place.

If there's going to be a potential hospitalization afterwards, how can we support potentially having infant with parent would be really nice if that's supported in the hospital. So I think there's just the ability to have some more structure before that patient goes. to surgery. There's also the ability, this is really underutilized for surgery to talk with either the pediatric provider or if there is a lactation consultant

breastfeeding medicine provider involved in the care because they probably will have a lot of thoughts on what that plan could look like to best support the parents.

Katrina, I heard you say that you want to avoid elective surgery until after lactation is complete. If we're with a patient who needs surgery in a like slightly urgent manner but not emergently, is there a certain like couple months that we want to avoid? Like are the first few months of lactation most important or kind of?

There's no golden time rule. I don't think there's a particular time rule. I think that sure, if you don't have to do an operation on a mom early postpartum, that's ideal in general, just for her own recovery from birth, the physical, the hormonal impact of that change and separation from the baby. But it's the same as as I'm.

Always

telling my colleagues in cancer care that ultimately in the end, you need to do what you need to do medically or surgically and you shouldn't defer something that's otherwise indicated simply because of lactation, you want to support lactation and have a plan for lactation, but you don't, for example, want to tell a mom she can't get an MRI for a breast cancer diagnosis until she completely has stopped breastfeeding and it's six weeks later.

So, yeah. And I think also with what Annie had mentioned in terms of the plan, the Academy of Breastfeeding Medicine has a great resource that involves a lot, all the comprehensive aspects of care of the hospitalized lactating diet, breastfeeding diet. So mom and baby and plans for say, pumping mom's breasts in an ICU when she's intubated and.

Obviously, we talked about getting the breast milk to the baby that was prior

to the intubation and sedation. Yeah, I second that. That's actually a really nice resource. I was able to review that too. And so useful, especially in that elective setting, like you talked about getting them teed up. That's a great one for folks like myself who know much about this and so it's a, it is a good resource.

One question that came up in preparation to in discussions actually about this were questions about changes in breast milk supply with either a critical illness. For instance, I round in the ICU and this is where it came up. Also, with any surgery as well. Is there a change in supply Katrina with. With major illnesses or surgeries like this, a shock to the system.

I mean, I think anything it's, like anything, bowel wall perfusion can be impacted by, it's like any other organ in the body, that it can be impacted by serious illness, but I think the other thing that makes it even more complicated is

that It often may be impacted by the amount of time the mom hasn't breastfed, hasn't been with the baby.

So that supply and demand aspect of milk removal, so it can be very multifactorial. Yeah, even when we talk about with severe illness, really drastic anemia and supply. We really think, you know, your hemoglobin has to be pretty low to really affect your milk supply, even though that's part of when we're screening in general for patients that have low milk supply.

So the body can really, I think, compensate in these situations. And just like Katrina said, most of the supply that drop we're seeing may be a result of some things that are changing in terms of The scheduling of feeds, missed feeding maybe using a pump when it's previously been feeding on the chest.

Those are all big changes that are happening

sort of at the same time.

Petrina, when I was looking at your website, I came across the word oncolactation. Can you explain what that means? That s a new one for me. Thanks for bringing this up. We re close to an ab site near us. I, I. That d be awesome. That d be my dream actually. But ab site probably isn t quite there yet. But this is a term that I created to describe the intersection of cancer care and lactation And we have oncofertility well defined, which is involves counseling and supporting cancer patients in their fertility journey, and really lactation should be just as much a part of this conversation about reproductive health as making a baby in the first place.

So regardless of, obviously this comes up a lot with breast cancer surgery, but really all types of surgery. And Yeah,

and. And, you know, in cancer care, and there's some resources on your website as well, I can say, we'll put that in the show notes. So let's finish this off with some quick hits or some take home points.

Annie, do you want to share some pearls of wisdom as we exit? Sure. I think Pearl. Also wisdom breastfeeding patients, we all interact with them. So it's really important to know about their care in terms of surgery. And then know your hospital policies, or if your hospital doesn't have a policy related to caring for lactating parents, then get somebody to get one happening, get a team together, because this is really important.

And Katrina, thanks. And I think the sort of big picture take home point for me would be that pumping and dumping is rarely indicated. And it's going to be much more the exception than the rule. If you do have a uncommon situation where you'd have to pump and dump. That's fantastic. I

learned a ton preparing for this and talking with you today.

I hope all everyone listening does as well. I'm sure they will. Austin, do you want to take it home? I'm so excited. Dominate the day.