Effect of Labor Epidural Anesthesia on Breast-Feeding of Healthy Full-Term Newborns Delivered Vaginally

Dennis J. Baumgarder, MD, Patricia Muehl, RN, MSN, Mary Fischer, MS, Bridget Pribbenow

Disclosures

J Am Board Fam Med. 2003;16(1) 

In This Article

Abstract and Introduction

Background: Epidural anesthesia is commonly administered to laboring women. Some studies have suggested that epidural anesthesia might inhibit breast-feeding. This study explores the association between labor epidural anesthesia and early breast-feeding success.
Methods: Standardized records of mother-baby dyads representing 115 consecutive healthy, full-term, breast-feeding newborns delivered vaginally of mothers receiving epidural anesthesia were analyzed and compared with 116 newborns not exposed to maternal epidural anesthesia. Primary outcome was two successful breast-feeding encounters by 24 hours of age, as defined by a LATCH breast-feeding assessment score of 7 or more of 10 and a latch score of 2/2. Means were compared with the Kruskal-Wallis test. Categorical data were compared using the Mantel-Haenszel chi-square test. Stratified analysis of potentially confounding variables was performed using Mantel-Haenszel weighted odd ratios (OR) and chi-square for evaluation of interaction.
Results: Both epidural and nonepidural anesthesia groups were similar except maternal nulliparity was more common in the epidural anesthesia group. Two successful breast-feedings within 24 hours of age were achieved by 69.6% of mother-baby units that had had epidural anesthesia compared with 81.0% of mother-baby units that had not (odds ratio [OR] 0.53, P = .04). These relations remained after stratification (weighted odds ratios in parenthesis) based on maternal age (0.52), parity (0.58), narcotics use in labor (0.49), and first breast-feeding within 1 hour (0.49). Babies of mothers who had had epidural anesthesia were significantly more likely to receive a bottle supplement while hospitalized (OR 2.63; P < .001) despite mothers exposed to epidural anesthesia showing a trend toward being more likely to attempt breast-feeding in the 1 hour (OR 1.66; P = .06). Mothers who had epidural anesthesia and who did not breast-feed within 1 hour were at high risk for having their babies receive bottle supplementation (OR 6.27).
Conclusions: Labor epidural anesthesia had a negative impact on breast-feeding in the first 24 hours of life even though it did not inhibit the percentage of breast-feeding attempts in the first hour. Further studies are needed to elucidate the exact nature of this association.

Breast milk is considered the optimum source of nutrition for infants, and Healthy People 2010 expresses a goal of increasing the proportion of breast-feeding mothers from 64% (1998) to 75% by 2010.[1] The numerous infant benefits of breast-feeding include reducing allergic manifestations, sudden infant death syndrome, and infections, such as gastroenteritis, otitis media, respiratory tract infections, and others.[1,2] A variety of hospital routines appear to promote breast-feeding success, including education, extensive rooming-in, and withholding formula gift packs or coupons.[2,3] The importance of early placement of the infant to breast is less clear,[2] perhaps because study hospitals have high rates of early suckling.[3] Similarly, use of supplemental formula in the nursery is believed to inhibit breast-feeding success.[2] A strong negative association with early formula supplementation and breast-feeding at 1 and 4 months was found by bivariate analysis in one study of 394 women, with borderline significance (P < .6) found with multivariate analysis.[3] The breast-feeding rate of mothers at 20 weeks' postpartum is significantly less if supplementation by formula occurs by the second postpartum week.[4]

Epidural anesthesia is commonly administered to laboring women planning to breast-feed. There is a perception among some medical personnel that epidural anesthesia might inhibit breast-feeding, perhaps because of reports of adverse effects of narcotic and epidural analgesia on certain infant neurobehavioral parameters.[2,5,6] The current medical literature, however is insufficient to accept or reject this hypothesis.

Walker[5] reviewed 13 articles that reported the effects of epidural analgesia on infant neurobehavioral outcomes as measured by scored structured neurobehavioral examinations. Only five studies included a control group, and only two of those five included infant assessments after 24 hours of age. The latter two studies[7,8] found depressed motor abilities of babies whose mothers received epidural anesthesia. A dose effect was found for some of the measured parameters.[8] The remainder of the studies in Walker's review showed conflicting results of neurobehavioral tests in newborns exposed to epidural anesthesia; none of the reviewed studies examined breast-feeding as a specific outcome.[5]

The 1974 study of Scanlon et al[9] compared neurobehavioral testing in the first 8 hours of life of 28 babies exposed to epidural anesthesia and 13 babies not exposed to epidural anesthesia. The epidural anesthesia group had lower scores on muscle strength and tone and rooting, but not sucking. A 1989 Finnish study examined the effects of maternal lumbar epidural anesthesia on neonatal neuro behavioral response at ages 3 hours, 1 day, 2 days, and 4 to 5 days in healthy neonates born vaginally at term to 15 mothers who had epidural anesthesia during labor and compared the outcomes with those of babies born to 19 mothers who did not have anesthesia. Babies who were born to mothers receiving epidural anesthesia scored significantly better on alertness at ages 3 hours, 2 days, and 4 to 5 days and better on sucking at 3 hours.[6]

The effects of epidural anesthesia on neurologic parameters can vary from agent to agent,[10] and can be due to direct effects of the medication on the infant or indirect effects on the neonate, delivery process, or infant-mother interaction.[8] The effects can also be subtle but unmasked when studied in combination with other factors, such as labor length, parity, and ponderal index.[11]

There are few studies specifically examining the effects on breast-feeding of epidural anesthesia used during labor. Video recordings were made of 28 newborns put to breast immediately after birth. Spontaneous breast-seeking and breast-feeding behaviors were reduced in the 18 babies exposed to a variety of analgesia types compared with 10 babies not exposed to analgesia. Only three patients who had had epidural anesthesia were included in this study.[12] Lie and Juul[13] studied two groups of 28 mothers who underwent cesarean section and partially self-selected to receive either general or epidural anesthesia. Patients with epidural anesthesia had higher breast-feeding frequency and longer breast-feeding periods than those who had general anesthesia and were similar to a control group of 28 patients who were delivered vaginally. Labor epidural anesthesia was not studied.

Rosen and Lawrence[14] found no effects of epidural anesthesia on weight loss or subjective reports of feeding behaviors before hospital discharge in 181 breast- and bottle-feeding newborns. Similarly, the study of 171 women by Halpern et al[15] showed no early or late (6 to 8 weeks' postpartum) adverse effects on breast-feeding by the use of epidural anesthesia during labor. Women having cesarean sections were included and not segregated in either study.[14,15] Albani et al[16] found no adverse effects of intrapartum epidural anesthesia on breast-feeding rate among 1,914 women who were delivered vaginally.

A recent well-designed study by Riordan et al[17] compared 37 women with no labor analgesia, 52 with intravenous analgesia, 27 with only epidural anesthesia, and 13 with both epidural and intravenous analgesia. Using a breast-feeding assessment tool that measures infant readiness, rooting, fixing, and suckling to measure early success, breast-feeding scores were similar and significantly lower for women who had intravenous and epidural-only analgesia compared with women who had no analgesia.

The purpose of our study was to examine specifically the effects of epidural anesthesia during labor on breast-feeding success and bottle supplementation, for the initial hospitalized newborn period, of healthy neonates born vaginally at term in a community hospital.

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