Neuraxial opioids and the newborn Petter Kainu 7

Neuraxial opioids and the newborn Petter Kainu 7. 10. 11 SOAT, Tartto

u Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. u Wang F. Shen X. Guo X. Peng Y. Gu X. Labor Analgesia Examining Group. u Anesthesiology 2009. 111(4): 871 -80

Labour analgesia and the baby: good news is no news Felicity Reynolds, IJOA 2011

Backround u newborn is very sensitive to opioids u newborn metabolizes opioids slowly u no balancing pain

Assessing newborn u Apgar-scores – are developed originally to assess druginfluence – unsensitive u Neonatal – reflects acid-base status the function of placenta poorly drug influences

Assessing newborn u NACS (Neurologic and Adaptive Capacity Scoring System) + and other scoring systems – muscular tone, reactivity , reaction to different stimuli beginning of spontaneous breathing u p. CO 2 u pulseoximetry u drug concentrations from blood samples u

Kinetics of epidural opioid u epidurally administered opioids enter rapidly circulation u lipophilic opioids rapidly cross the placenta u ion trapping (acidotic fetus)

Kinetics of epidural opioid u if ≥ 150 -200 µg of fentanyl is used, the baby has measurable amouts of fentanyl in circulation – Epidural fentanyl in labour. Carrie LE. O'Sullivan GM. Seegobin R. Anaesthesia 1981. 36(10): 965 -9 u if epidural-infusions are used, fentanyl does not seem to accumulate – Maternal and neonatal fentanyl and bupivacaine concentrations after epidural infusion during labor. Bader AM. Fragneto R. Terui K. Arthur GR. Loferski B. Datta S. Anesthesia & Analgesia 1995. 81(4): 829 -32

Epidural opioid & respiratory depression u case reports u Epidural Opioid Analgesia and Neonatal Respiratory Depression. Kumar M, Paes B. Journal of Perinatology 2003. 23(5): 425 -7

Epidural opioid & NACS u with epid-/iv-opioid. vs no analgesic in some studies babies have had lower NACS – Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying. Ransjo-Arvidson AB. Matthiesen AS. Lilja G. Nissen E. Widstrom AM. Uvnas-Moberg K. Birth 2001. 28(1): 5 -12 – observational study (n=28) – unmedicated infants were more active (video recorded analyzed by experts)

Epidural opioid & NACS Effect of labor epidural analgesia with and without fentanyl on infant breastfeeding: a prospective, randomized, double-blind study. Beilin Y. Bodian CA. Weiser J. Hossain S. Arnold I. Feierman DE. Martin G. Holzman I. Anesthesiology 2005: 103(6): 1211 -7 u when ≥ 150 μg fentanyl was used, NACS were slightly lower (p=0, 03) u

Breast feeding & epidural analgesia u the initiation of breast feeding is crucial for breast feeding to be succesfull u if infant is less active or ”tired” the interaction may become disturbed u opioid may supress activity of the infant

Breast feeding & epidural analgesia u Breast-feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices. Volmanen P. Valanne J. Alahuhta S. International Journal of Obstetric Anesthesia 2004. 13(1): 25 -9

Volmanen et al. u only part of the epidurals had fentanyl u bupivacaine?

u The impact of intrapartum analgesia on infant feeding. Jordan S. Emery S. Bradshaw C. Watkins A. Friswell W. International Journal of Obstetrics & Gynaecology 2005. 112(7): 927 -34 u retrospective review, 18165 pts

u Intrapartum epidural analgesia and breastfeeding: a prospective cohort study Torvaldsen S. Roberts CL. Simpson JM. Thompson JF. Ellwood DA. International Breastfeeding Journal 2006, 1: 24 u n=1280

u Epidural analgesia and breastfeeding: a randomised controlled trial of epidural techniques with and without fentanyl and a non-epidural comparison group. Wilson M. J. A. Mac. Arthur C. Cooper G. M. Bick D. Moore P. A. S. Shennan A. Anaesthesia 2010. 65(2): 145 -153

u u u u n=1064 Study groups: Low dose infusion-group (LDI group): bolus (30 µg fent +15 mg bupiv in 15 ml), followed by infusion (10 ml/h) CSE-group: Spinal (Bup 5 mg + Fent 25 µg) follwed by epidural infusion as in LDI-group Control group: Epidural bolus (15 mg bup without fentanyl), infusion without fentanyl Two comparison groups without epidural analgesia (pethidin/no pethidin- not randomized) Rescue medication: – Control group: Epidural fentanyl 50µg Results: – Epidural fentanyl did not affect breast feeding – Pethidine had negative influence on breast feeding

Conclusions u u epidural labour analgesia/opioid can influence infant serious influences are unlikely breast feeding seems to be adversely affected most studies are non-randomized cohort studies – except u Beilin et al 2005 u Wang et al 2009 u Wilson et al 2010

Conclusions u Editorial in Anesthesiology in regard to Beilin study: – ”We should continue to use medications that are known to be effective and are satisfactory to patients, and provide the best obstetric outcome possible. ” u Obstetric Anesthesia Diggest: – ”As lower consentrations of local anesthetic are assosiated with many benefical effects for mother and baby, fentanyl should not be discarded based on weak links. ”

u Reynolds F: Labour analgesia and the baby: good news is no news. International Journal of Obstetric Anesthesia 2011. 20(1): 38 -50 – ”The effect on breast feeding has yet to be established, though it is certainly no worse than that of systemic opioid analgesia. ”

However, u should we restrict larger doses of epidural opioids? – not > 150 µg of fentanyl?

u More studies are warranted!