Esketamine and Breastfeeding

Summary of use during lactation

Esketamine is the more potent S-isomer of the racemic drug, ketamine. Esketamine nasal spray used as an antidepressant has not been studied during breastfeeding. Minimal data indicate that single doses of intravenous esketamine or ketamine use during cesarean section delivery may not affect the breastfed infant or lactation. Until more data are available, repeated doses esketamine nasal spray should probably be avoided during breastfeeding. If esketamine is used, monitor the infant for sedation, poor feeding and poor weight gain.

Drug levels in milk and infant serum

Maternal Levels. Relevant published information was not found as of the revision date. Infant Levels. Relevant published information was not found as of the revision date.

Effects in breastfed infants

Four mothers who received epidural analgesia with lidocaine and bupivacaine for cesarean section also received general anesthesia with ketamine and midazolam (dosages not specified). Their infants were either breastfed or received their mother's breastmilk by bottle. No adverse effects were reported in the infants.[1]

Effects on lactation and breastmilk

A pregnant woman sustained 28% body surface area burns near term. She underwent an emergency cesarean section on her due date under ketamine anesthesia. Although the infant required vigorous resuscitation, the infant began breastfeeding immediately. The infant had transient jaundice that resolved in a few days.[2] A study compared women undergoing cesarean section who received either placebo or S-ketamine (esketamine) 0.5 mg/kg intramuscularly, followed by a continuous infusion of 2 mcg/kg/minute for 12 hours. This low dose was used to enhance analgesia and reduce residual pain rather than to provide anesthesia. All women received intraspinal bupivacaine 8 to10 mg and sufentanil 5 mcg for analgesia, as well as midazolam 0.02 mg/kg intravenously before the S-ketamine or placebo injection. Postoperatively, patients received patient-controlled intravenous morphine for 24 hours, followed by acetaminophen, oral ketorolac and a single dose of ondansetron 8 mg intravenously as needed. Of the 56 patients enrolled in the study (28 in each group), 13 in each group were contacted at 3 years postpartum. Patients who received placebo reported breastfeeding for an average of 10.5 months and those who received S-ketamine reported breastfeeding for an average of 8 months; however, the difference was not statistically significant.[3] A randomized, double-blind study compared the effects of intravenous propofol 0.25 mg/kg, ketamine 0.25 mg/kg, ketamine 25 mg plus propofol 25 mg, and saline placebo for pain control in mothers post-cesarean section. A single dose was given immediately after clamping of the umbilical cord. The time to the first breastfeeding was 58 minutes in those who received placebo, 31.9 minutes with ketamine and 25.8 minutes with propofol plus ketamine. The time was significantly shorter than the other groups with the combination.[4] A study of women with gestational diabetes undergoing elective cesarean section randomized them to postoperative patient-controlled analgesia with either intravenous esketamine 0.5 mg/kg, sufentanil 150 mcg and ondansetron 4 mg (n = 70) or sufentanil and ondansetron alone in the same doses (n = 70). There was no difference between the groups in the time to first lactation, with most beginning at 24 to 48 hours after delivery.[5]

References

1. Ortega D, Viviand X, Lorec AM, et al. Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery. Acta Anaesthesiol Scand 1999;43:394-7.10225071 PubMed
2. Mokube JA, Verla VS, Mbome VN, Bitang AT. Burns in pregnancy: A case report from Buea Regional Hospital, Cameroon. Pan Afr Med J 2009;3:21.21532730 PubMed
3. Suppa E, Valente A, Catarci S, et al. A study of low-dose S-ketamine infusion as "preventive" pain treatment for cesarean section with spinal anesthesia: Benefits and side effects. Minerva Anestesiol 2012;78:774-81.22374377 PubMed
4. Jaafarpour M, Vasigh A, Khajavikhan J, Khani A. Effect of ketofol on pain and complication after Caesarean delivery under spinal anaesthesia: A randomized double-blind clinical trial. J Clin Diagn Res 2017;11:UC04-UC07.28511482 PubMed
5. Han T, Chen Q, Huang J, et al. Low-dose esketamine with sufentanil for postcesarean analgesia in women with gestational diabetes mellitus: A prospective, randomized, double-blind study. Front Endocrinol (Lausanne) 2023;14:1202734.37635978 PubMed