Thursday, June 23, 2011

A Look at the Research: The Link Between Epidural Analgesia and Breastfeeding

Science & sensibility by Lamaze is bringing us a review of latest research on use of epidural analgesia with possible link to breastfeeding difficulties after the delivery. 

It’s probably fair to say that most women who decide to have an epidural during labor don’t consider its possible impact on breastfeeding. Perhaps this is because no thought is given generally to any possible links between drugs and breastfeeding success (or otherwise). Instead, both pregnant (or laboring) women and caregivers usually assume that breastfeeding is a separate issue. Evidence from early research certainly doesn’t seem to support that view and a little common sense would also lead us to challenge it further…

Considering drugs used in labor generally, Jordan, et al (2009) provide some evidence that drug use in labor and birth has an impact on breastfeeding rates at 48 hours postpartum. (Of course, when women have already given up on breastfeeding two days after giving birth, it’s unlikely that they will re-establish breastfeeding later, even though this might be possible.) However, although Jordan et al’s conclusions are fairly clear, we also need to take into account the fact that many anesthesiologists wouldn’t accept these researchers’ conclusions simply because their data is retrospective (i.e. it looks back at what happened in the past, and tries to establish causal links); anesthesiologists (like many other specialists) consider prospective randomized studies to be more reliable. In any study, cause-effect relationships are difficult to prove—and epidural usage and its impact on breastfeeding success is no different in this respect.
Nevertheless, there are also prospective studies which have reported fairly clear problems with narcotics used in labor (Beilin, et al, 2005; Camann, et al, 2007; Torvaldsen, et al, 2006). In the study by Beilin, et al researchers concluded: “Among women who breastfed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breastfeeding 6 weeks postpartum than women who were randomly assigned to receive less fentanyl or no fentanyl.” (Most women nowadays receive fentanyl as part of the epidural cocktail. Bupivicain, the drug it partly replaces in the epidural cocktail, causes paralysis in the lower part of the body so substituting part of this with fentanyl reduces this effect. However, some research suggests that problems with breastfeeding develop as a result of using fentanyl in the epidural cocktail. The study by Torvaldsen, et al concluded: “Women in this cohort who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breast-feeding in the first 24 weeks”. Despite making this statement, the researchers felt they were unable to say whether there was a causal link between epidural anesthesia and breastfeeding difficulties. This was despite the fact that “Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week” and the fact that women who had epidurals were more likely to stop breastfeeding than women who used non-pharmacologic methods of pain relief.
Having said all that, an article by Pandya (from a Department of Anaesthesia in India) in 2010 claims that any impact on breastfeeding is not statistically significant. A study conducted on a small number of women (87) in Toronto, Canada, by Wieczorek et al (2010) also concludes that breastfeeding is unaffected by epidural use. An editorial by Camann (see references below) provides a good overview of research done up to and including 2007 and an article by Loubertet al (2011) summarises research up to the present day.
A study by Lin et al (2011) somewhat less clearly but nevertheless significantly, indicates a possible link between the use of narcotic analgesia in the epidural mix and later actual or perceived breastfeeding problems. Another study by Reynolds at St Thomas’ Hospital in London (2009) concludes: “Successful breastfeeding is dependent on many factors, therefore randomized trials are required to elucidate the effect of labour analgesia.” Wilson et al’s randomized controlled trial did take place after this recommendation (2010) and the conclusion was, in fact, that epidurals had no impact on breastfeeding. Devroe et al (2009) came to a similar conclusion.
Read the rest of the article with references here .

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