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National Guideline Clearinghouse (NGC). Guideline summary: Analgesia and anesthesia for the breastfeeding mother In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): cited 2006. Available: http://www.guideline.gov.

Bibliographic Source(s)

• Montgomery A Hale TW Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother. Breastfeed Med 2006 Winter;1(4):271-7. [50 references] PubMed

Guideline Status

This is the current release of the guideline.

Guideline Category

Counseling
Evaluation
Management
Prevention
Risk Assessment
Treatment

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Dentists
Nurses
Physician Assistants
Physicians

Guideline Objective(s)

To provide recommendations for safe and appropriate use of pharmacologic agents for anesthesia and pain relief in breastfeeding women during labor and in the postpartum period and for other surgery in lactating women

Target Population

• Women in childbirth labor with pain
• Women in the postpartum period with pain
• Breastfeeding mothers undergoing surgery

Interventions and Practices Considered

1. Informed consent discussion in prenatal period on pain management during labor
2. Analgesia and anesthesia for labor
   • Support by doula
   • Nonpharmacologic methods (hypnosis psychoprophylaxis (Lamaze) intradermal or subcutaneous water injections for back pain)
   • Intravenous opiates (fentanyl meperidine/pethidine) (Nalbuphine butorphanol and pentazocine in specific circumstances)
   • Epidural analgesia including minimization of dose conservative use of fluids and postpartum follow-up and breastfeeding support
3. Anesthesia for Cesarean section (regional general)
4. Postpartum anesthesia
   • Nonopioid analgesics (acetaminophen ketorolac diclofenac cox-2 inhibitors)
   • Intravenous medications (morphine fentanyl nalbuphine butorphanol pentazocine hydromorphone)
   • Patient-controlled analgesia (PCA)
   • Oral medications (hydrocodone codeine)
   • Epidural/spinal medications
     • Single-dose opioids
     • Continuous infusion
5. Anesthesia for surgery in breastfeeding mothers including choice of agent and unlikely need to pump and discard breast milk
6. Resumption of breastfeeding following anesthesia

Major Outcomes Considered

• Pain relief
• Adverse events in the breastfed infant associated with treatment
• Successful breastfeeding

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

An initial search of relevant published articles written in English in the past 20 years in the fields of medicine psychiatry psychology and basic biological science is undertaken for a particular topic. Once the articles are gathered the papers are evaluated for scientific accuracy and significance.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus (Committee)
Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

I Evidence obtained from at least one properly randomized controlled trial

II-1 Evidence obtained from well-designed controlled trials without randomization

II-2 Evidence obtained from well-designed cohort or case-control analytic studies preferably from more than one center or research group

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

III Opinions of respected authorities based on clinical experience descriptive studies and case reports; or reports of expert committees

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

An expert panel is identified and appointed to develop a draft protocol using evidence based methodology. An annotated bibliography (literature review) including salient gaps in the literature are submitted by the expert panel to the Protocol Committee.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Draft protocol is peer reviewed by individuals outside of lead author/expert panel including specific review for international applicability. Protocol Committee's sub-group of international experts recommends appropriate international reviewers. Chair (co-chairs) institutes and facilitates process. Reviews submitted to committee Chair (co-chairs).

Draft protocol is submitted to The Academy of Breastfeeding Medicine (ABM) Board for review and approval. Comments for revision will be accepted for three weeks following submission. Chair (co-chairs) and protocol author(s) amends protocol as needed.

Following all revisions protocol has final review by original author(s) to make final suggestions and ascertain whether to maintain lead authorship.

Final protocol is submitted to the Board of Directors of ABM for approval.

Major Recommendations

Analgesia and Anesthesia for Labor

Maternity care providers should initiate an informed consent discussion for pain management in labor during the prenatal period before the onset of labor. Risk discussion should include what is known about the effects of various modalities on the progress of labor risk of instrumented and Cesarean delivery effect on the newborn and possible breastfeeding effects.

Continuous support in labor ideally by a trained doula reduces the need for pharmacologic pain management in labor decreases instrumented delivery and Cesarean section and leads to improved breastfeeding outcomes both in the immediate postpartum period and several weeks after birth (Hodnett et al. 2003).

Nonpharmacologic methods for pain management in labor such as hypnosis psychoprophylaxis (e.g. Lamaze) intradermal or subcutaneous water injections for back pain and so on appear to be safe have no known adverse neonatal effects and may reduce the need for pharmacologic pain management. More study of breastfeeding outcomes is needed for these modalities.

Intravenous Opiates

1. Shorter-acting opiates such as fentanyl are preferred. Remifentanil is potent and has rapid onset and offset but can be associated with a high incidence of maternal apnea requiring increased monitoring. Its transfer in utero to the fetus is minimal.
2. Meperidine/pethidine generally should not be used except in small doses less than 1 hour before anticipated delivery because of greater incidence and duration of neonatal depression cyanosis and bradycardia.
3. Nalbuphine butorphanol and pentazocine may be used for patients with certain opioid allergies or at increased risk of difficult airway management or respiratory depression. However these medications may interfere with fetal heart rate monitoring interpretation. Observe the mother and infant for psychotomimetic reactions (3%).
4. Multiple doses of intravenous analgesic and their timing of administration may lead to greater neonatal effects. For example fentanyl administration within 1 hour of delivery or meperidine administration between 1 and 4 hours before delivery is associated with more profound neonatal effects.
5. When a mother has received intravenous narcotics for labor mother and baby should be given more skin-to-skin time to encourage early breastfeeding (Nissen et al. 1995).

Epidural Analgesia

1. If epidural anesthesia is chosen methods that minimize the dose of medication and minimize motor block should be used. Longer durations of epidural analgesia should be avoided if possible (Rosen & Lawrence 1994) and administration should be delayed until necessary to minimize effect on labor outcomes that may secondarily affect breastfeeding. Combined spinal-epidural analgesia and patient-controlled epidural analgesia may be preferable.
2. Infants lose more weight in the first postpartum days when labor medications are used (Dewey et al. 2003). Some of this weight loss may be a result of mothers receiving an intravenous (IV) fluid load for epidural analgesia. One report notes babies are slightly heavier on average and lose more weight in the first days postpartum when epidural analgesia is used (Merry & Montgomery 2000). In addition the use of large volumes of intrapartum IV fluids has been associated with a decrease in plasma oncotic pressure (Cotterman 2004) which may then increase breast engorgement and interfere with subsequent milk production and/or transfer. Conservative use of fluids may mitigate this effect. Definitive studies of these interrelationships are needed in order to better assess first-week weight loss in individual newborns.
3. When epidural analgesia has been used for labor particular care to provide mothers with good breastfeeding support and close follow-up after postpartum hospitalization should be taken.

Anesthesia for Cesarean Section

Regional anesthesia (epidural or intrathecal/spinal) is preferred over general anesthesia. (Krishnan Gunaskearan & Bhaskaranan 1995; Kangas-Saarel et al. 1989)

Separation of the mother and baby should be minimized and breastfeeding initiated as soon as feasible. In fact the baby may go to the breast in the operating room during abdominal closure with assistance to support the infant on the mother's chest. If breastfeeding is initiated in the recovery room there is the added advantage that the incision is often still under the influence of the anesthetic.

A mother may breastfeed postoperatively as soon as she is alert enough to hold the baby.

Postpartum Anesthesia

Nonopioid Analgesics

Nonopioid analgesics generally should be the first choice for pain management in breastfeeding postpartum women as they do not impact maternal or infant alertness.

1. Acetaminophen and ibuprofen are safe and effective for analgesia in postpartum mothers.
2. Parenteral ketorolac may be used in mothers not subject to hemorrhage and with no history of gastritis aspirin allergy or renal insufficiency.
3. Diclofenac suppositories are available in some countries and commonly used for postpartum analgesia. Milk levels are extremely low.
4. Cox-2 inhibitors such as celecoxib may have some theoretic advantages if maternal bleeding is a concern. This must be balanced with higher cost and possible cardiovascular risks which should be minimal with short-term use in healthy young women.

Both pain and opioid analgesia can have a negative impact on breastfeeding outcomes; thus mothers should be encouraged to control their pain with the lowest medication dose that is fully effective. Opioid analgesia postpartum may affect babies' alertness and suckling vigor. However when maternal pain is adequately treated breastfeeding outcomes improve (Hirose et al. 1996). Especially after Cesarean birth or severe perineal trauma requiring repair mothers should be encouraged to adequately control their pain.

Intravenous Medications

1. Meperidine should be avoided because of reported neonatal sedation when given to breastfeeding mothers postpartum (Wittles Scott & Sinatra 1990) in addition to the concerns of cyanosis bradycardia and risk of apnea which have been noted with intrapartum administration (Hamza et al. 1992; Hodgkinson et al. 1978).
2. The administration of moderate to low doses of IV or intramuscular (IM) morphine is preferred as its passage to milk and oral bioavailability in the infant are least with this agent (Wittles Scott & Sinatra 1990; Feilberg et al. 1989).
3. When patient-controlled IV analgesia (PCA) is chosen after Cesarean section morphine or fentanyl is preferred to meperidine.(Wittles et al. 1997)
4. Although there are no data on the transfer of nalbuphine butorphanol and pentazocine into milk there have been numerous anecdotal reports of a psychotomimetic effect when these agents are used in labor. They may be suitable in individuals with certain opioid allergies or other conditions described in the preceding section on labor.
5. Hydromorphone (approximately 7 to 11 times as potent as morphine) is sometimes used for extreme pain in a PCA IM IV or orally. Following a 2-mg intranasal dose levels in milk were quite low with a relative infant dose of about 0.67% (Edwards et al. 2003). This correlates with about 2.2 micrograms/day via milk. This dose is probably too low to affect a breastfeeding infant but this is a strong opioid and some caution is recommended.

Oral Medications

1. Hydrocodone and codeine have been used worldwide in millions of breastfeeding mothers. This suggests they are suitable choices even though there are no data reporting their transfer into milk. Higher doses (10 mg hydrocodone) and frequent use may lead to some sedation in the infant.

Epidural/Spinal Medications

1. Single-dose opioid medications (e.g. neuraxial morphine) should have minimal effects on breastfeeding because of negligible maternal plasma levels achieved. Extremely low doses of morphine are effective.
2. Continuous post-Cesarean epidural infusion may be an effective form of pain relief that minimizes opioid exposure. A randomized study that compared spinal anesthesia for elective Cesarean with or without the use of postoperative extradural continuous bupivacaine found that the continuous group had lower pain scores and a higher volume of milk fed to their infants (Hirose et al. 1996).

Anesthesia for Surgery in Breastfeeding Mothers

The implications of drugs used in anesthesia in postpartum mothers depends on numerous factors including the age of the infant stability of the infant stage of lactation (early or late stage) and ability of the infant to handle the clearance of small quantities of anesthetic medications (Hale 1999).

The ability of the infant to clear small amounts of these medications is of primary concern before returning to breastfeeding. Infants subject to apnea hypotension or weakness probably should be protected by a few more hours of interruption from breastfeeding before resuming (12 to 24 h) nursing.

Mothers with normal term or older infants generally can resume breastfeeding as soon as they are awake stable and alert. Resumption of normal mentation is a hallmark that these medications have left the plasma compartment (and thus the milk compartment) and entered adipose and muscle tissue where they are slowly released. A single pumping and discarding of the mother's milk following surgery will significantly eliminate any drug retained in milk fat although this is seldom necessary and not generally recommended. For women who undergo postpartum tubal ligation breastfeeding interruption is not indicated as the volume of colostrum is small (Rathmell Viscomi & Ashburn 1997). In addition the levels of medication in the maternal plasma and milk are low once mothers resume normal mentation. Regional anesthesia is recommended for this procedure in preference to general anesthetic for maternal safety.

Mothers who have undergone dental extractions or other procedures requiring the use of single doses of medication for sedation and analgesia can breastfeed as soon as they are awake and stable. Although shorter-acting agents such as fentanyl and midazolam may be preferred single doses of meperidine or diazepam are unlikely to affect the breastfeeding infant (Hale 1999).

Mothers who have undergone plastic surgery such as liposuction in which large doses of local anesthetics (lidocaine) have been used probably should pump and discard their milk for 12 hours before resuming breastfeeding.

Specific Agents Used for Anesthesia and Analgesia

Anesthetics

Drugs used for induction such as propofol midazolam etomidate or thiopental enter the milk compartment only minimally as they have extraordinarily brief plasma distribution phases (only minutes) and hence their transport to milk is low to nil (Andersen et al. 1987; Matheson Lunde & Bredesen 1990; Dailland et al. 1989; Schmitt et al. 1987).

Little or nothing has been reported about the use of anesthetic gases in breastfeeding mothers. However they too have brief plasma distribution phases and milk levels are likely nil.

The use of ketamine in breastfeeding mothers is unreported. Because of its high rate of psychotomimetic effect including hallucinations and dissociative anesthesia (catalepsy nystagmus) ketamine is probably not an ideal anesthetic agent for breastfeeding mothers.

Analgesics

Opioid Analgesics

1. Morphine is still considered an ideal analgesic for breastfeeding mothers because of its limited transport to milk and poor oral bioavailability in infants (Wittles Scott & Sinatra 1990; Wittles et al. 1997).
2. The transfer of meperidine into breast milk is documented although it is somewhat low (1.7% to 3.5% of maternal dose). However the administration of meperidine and its metabolite (normeperidine) is consistently associated with neonatal sedation which is dose related. Transfer into milk and neonatal sedation have been documented for up to 36 hours after the dose (Wittles Scott & Sinatra 1990). Meperidine should be avoided during labor and in postpartum analgesia (except perhaps within 1 hour before delivery). Infants of mothers who have been exposed to repeated doses of meperidine should be closely monitored for sedation cyanosis bradycardia and possibly seizures.
3. Although there are no published data on remifentanil this esterase-metabolized opioid has a brief half-life even in infants (<10 minutes) and has been documented to produce no fetal sedation even in utero. Although its duration of action is limited it could be used safely and indeed may be ideal in breastfeeding mothers for short painful procedures.
4. Fentanyl levels in breast milk have been studied and are extremely low to below the limit of detection (Leuschen Wolf & Rayburn 1990; Madej & Strunin 1987).
5. Sufentanil transfer into milk has not been published but it should be similar to fentanyl.
6. Nalbuphine butorphanol and pentazocine levels in breast milk have not been published. At this time they would only be indicated in the specific situations mentioned previously. If these agents are used observe the mother and infant for psychotomimetic reactions (3%).
7. Hydrocodone and codeine have been used in millions of breastfeeding mothers. Occasional cases of neonatal sedation have been documented but these are rare and generally dose related. Doses in breastfeeding mothers should be kept at the minimum necessary to control pain. Routine consistent dosing throughout the day may lead to sedative effects in the breastfed infant.

Non-Steroidal Anti-inflammatory Analgesics

1. Ibuprofen is considered an ideal moderately effective analgesic. Its transfer to milk is low to nil (Townsend et al. 1984; Weibert et al. 1982).
2. Ketorolac is considered an ideal and potent analgesic in breastfeeding mothers. The transfer of ketorolac into milk is extremely low (Wischnik et al. 1989). However its use in patients with hemorrhage is risky as it inhibits platelet function. Other contraindications are noted in the preceding section on postpartum anesthesia.
3. Celecoxib transfer into milk is extraordinarily low (<0.3% of the maternal dose) (Hale McDonald & Boger 2004). Its short-term use is safe.
4. Naproxen transfer into milk is low but gastrointestinal disturbances have been reported in some infants after prolonged therapy. Short-term use (1 week) probably is safe (Fidalgo et al. 1989; Jamali & Stevens 1983).

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• Andersen LW Qvist T Hertz J Mogensen F. Concentrations of thiopentone in mature breast milk and colostrum following an induction dose. Acta Anaesthesiol Scand 1987 Jan;31(1):30-2. PubMed



• Cotterman KJ. Reverse pressure softening: a simple tool to prepare areola for easier latching during engorgement. J Hum Lact 2004 May;20(2):227-37. PubMed



• Dailland P Cockshott ID Lirzin JD Jacquinot P Jorrot JC Devery J Harmey JL Conseiller C. Intravenous propofol during cesarean section: placental transfer concentrations in breast milk and neonatal effects. A preliminary study. Anesthesiology 1989 Dec;71(6):827-34. PubMed



• Dewey KG Nommsen-Rivers LA Heinig MJ Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior delayed onset of lactation and excess neonatal weight loss. Pediatrics 2003 Sep;112(3 Pt 1):607-19. PubMed



• Edwards JE Rudy AC Wermeling DP Desai N McNamara PJ. Hydromorphone transfer into breast milk after intranasal administration. Pharmacotherapy 2003 Feb;23(2):153-8. PubMed



• Feilberg VL Rosenborg D Broen Christensen C Mogensen JV. Excretion of morphine in human breast milk. Acta Anaesthesiol Scand 1989 Jul;33(5):426-8. PubMed



• Fidalgo I Correa R Gomez Carrasco JA Martinez Quiroga F. [Acute anemia rectorrhagia and hematuria caused by ingestion of naproxen. An Esp Pediatr 1989 Apr;30(4):317-9. PubMed



• Hale TW McDonald R Boger J. Transfer of celecoxib into human milk. J Hum Lact 2004 Nov;20(4):397-403. PubMed



• Hale TW. Anesthetic medications in breastfeeding mothers. J Hum Lact 1999 Sep;15(3):185-94. [52 references] PubMed



• Hamza J Benlabed M Orhant E Escourrou P Curzi-Dascalova L Gaultier C. Neonatal pattern of breathing during active and quiet sleep after maternal administration of meperidine. Pediatr Res 1992 Oct;32(4):412-6. PubMed



• Hirose M Hara Y Hosokawa T Tanaka Y. The effect of postoperative analgesia with continuous epidural bupivacaine after cesarean section on the amount of breast feeding and infant weight gain. Anesth Analg 1996 Jun;82(6):1166-9. PubMed



• Hodgkinson R Bhatt M Grewal G Marx GF. Neonatal neurobehavior in the first 48 hours of life: effect of the administration of meperidine with and without naloxone in the mother. Pediatrics 1978 Sep;62(3):294-8. PubMed



• Hodnett ED Gates S Hofmeyr GJ Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2003;(3):CD003766. [42 references] PubMed



• Jamali F Stevens DR. Naproxen excretion in milk and its uptake by the infant. Drug Intell Clin Pharm 1983 Dec;17(12):910-1. PubMed



• Kangas-Saarela T Koivisto M Jouppila R Jouppila P Hollmen A. Comparison of the effects of general and epidural anaesthesia for caesarean section on the neurobehavioural responses of newborn infants. Acta Anaesthesiol Scand 1989 May;33(4):313-9. PubMed



• Krishnan L Gunasekaran N Bhaskaranand N. Anesthesia for caesarean section and immediate neonatal outcome. Indian J Pediatr 1995 Mar-Apr;62(2):219-23. PubMed



• Leuschen MP Wolf LJ Rayburn WF. Fentanyl excretion in breast milk. Clin Pharm 1990 May;9(5):336-7. PubMed



• Madej TH Strunin L. Comparison of epidural fentanyl with sufentanil. Analgesia and side effects after a single bolus dose during elective caesarean section. Anaesthesia 1987 Nov;42(11):1156-61. PubMed



• Matheson I Lunde PK Bredesen JE. Midazolam and nitrazepam in the maternity ward: milk concentrations and clinical effects. Br J Clin Pharmacol 1990 Dec;30(6):787-93. PubMed



• Merry H Montgomery A. Do babies whose mothers have labor epidurals lose more weight in the newborn period?. Acad Breastfeeding Med News Views 2000;6:3.



• Nissen E Lilja G Matthiesen AS Ransjo-Arvidsson AB Uvnas-Moberg K Widstrom AM. Effects of maternal pethidine on infants' developing breast feeding behaviour. Acta Paediatr 1995 Feb;84(2):140-5. PubMed



• Rathmell JP Viscomi CM Ashburn MA. Management of nonobstetric pain during pregnancy and lactation. Anesth Analg 1997 Nov;85(5):1074-87. [97 references] PubMed



• Rosen AR Lawrence RA. The effect of epidural anesthesia on infant feeding. JURMC 1994;6:3-7.



• Schmitt JP Schwoerer D Diemunsch P Gauthier-Lafaye J. [Passage of propofol in the colostrum. Preliminary data. Ann Fr Anesth Reanim 1987;6(4):267-8. PubMed



• Townsend RJ Benedetti TJ Erickson SH Cengiz C Gillespie WR Gschwend J Albert KS. Excretion of ibuprofen into breast milk. Am J Obstet Gynecol 1984 May 15;149(2):184-6. PubMed



• Weibert RT Townsend RJ Kaiser DG Naylor AJ. Lack of ibuprofen secretion into human milk. Clin Pharm 1982 Sep-Oct;1(5):457-8. PubMed



• Wischnik A Manth SM Lloyd J Bullingham R Thompson JS. The excretion of ketorolac tromethamine into breast milk after multiple oral dosing. Eur J Clin Pharmacol 1989;36(5):521-4. PubMed



• Wittels B Glosten B Faure EA Moawad AH Ismail M Hibbard J Senal JA Cox SM Blackman SC Karl L Thisted RA. Postcesarean analgesia with both epidural morphine and intravenous patient-controlled analgesia: neurobehavioral outcomes among nursing neonates. Anesth Analg 1997 Sep;85(3):600-6. PubMed



• Wittels B Scott DT Sinatra RS. Exogenous opioids in human breast milk and acute neonatal neurobehavior: a preliminary study. Anesthesiology 1990 Nov;73(5):864-9. PubMed

Type of Evidence supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

The recommendations were based primarily on a comprehensive review of the existing literature. In cases where the literature does not appear conclusive recommendations were based on the consensus opinion of the group of experts.

Potential Benefits

• Appropriate use of analgesics and anesthetics in breastfeeding mothers
• Improved quality of care in breastfeeding mothers
• Decreased pain
• Decreased treatment-related side effects and adverse events in the breastfed infant

Potential Harms

• Pain that exceeds a woman's ability to cope or pain magnified by fear and anxiety may produce suffering in labor. Suffering in labor may lead to dysfunctional labors poorer psychologic outcomes and increased risk of postpartum depression all of which may have a negative effect on breastfeeding.
• Depressed or delayed suckling which can be caused by medications given to mothers can lead to delayed or suppressed lactogenesis and risk of excess infant weight loss.
• Treatment-related adverse events

Qualifying Statements

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Foreign Language Translations

For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Getting Better
Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness
Safety

Bibliographic Source(s)

• Montgomery A Hale TW Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #15: analgesia and anesthesia for the breastfeeding mother. Breastfeed Med 2006 Winter;1(4):271-7. [50 references] PubMed

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Academy of Breastfeeding Medicine

A grant from the Maternal and Child Health Bureau US Department of Health and Human Services

Guideline Committee

Academy of Breastfeeding Medicine Protocol Committee

Composition of Group that Authored the Guideline

Contributors: Anne Montgomery MD Department of Family Medicine University of Washington Seattle WA; Thomas W. Hale PhD Texas Tech University School of Medicine Amarillo TX (Lead authors)

Committee Members: Caroline J. Chantry MD Co-Chairperson; Cynthia R. Howard MD MPH Co-Chairperson; Ruth A. Lawrence MD; Nancy G. Powers MD

Financial Disclosures/Conflicts of Interest

None to report

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Academy of Breastfeeding Medicine Web site.

Print copies: Available from the Academy of Breastfeeding Medicine 140 Huguenot Street 3rd floor New Rochelle New York 10801.

Availability of Companion Documents

The following is available:

• Procedure for protocol development and approval. Academy of Breastfeeding Medicine. 2007 Mar. 2 p.

Print copies: Available from the Academy of Breastfeeding Medicine 140 Huguenot Street 3rd floor New Rochelle New York 10801.

A Korean translation of the original guideline document is available from the Academy of Breastfeeding Medicine Web site.

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on November 14 2007. The information was verified by the guideline developer on October 31 2008.

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Single copies may be downloaded for personal use. Copyright permission to be requested for use of multiple copies by e-mailing requests to abm@bfmed.org. An official request form will be sent electronically to person requesting multiple copy use.

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