Levobupivacaine and Breastfeeding

Summary of use during lactation

Levobupivacaine is no longer marketed in the US. Levels in breastmilk are low, and it is poorly absorbed orally by the infant. Bupivacaine, the racemic mixture of dextro- and levobupivacaine, has not caused any adverse effects in breastfed infants. Local anesthetics during labor and delivery with other anesthetics and analgesics has been reported by some to interfere with breastfeeding. However, this assessment is controversial and complex because of the many different combinations of drugs, dosages and patient populations studied as well as the variety of techniques used. In contrast, epidural local anesthetics begun after clamping of the umbilical cord appears to enhance breastfeeding success because of improved pain control. Overall, it appears that with good breastfeeding support epidural levobupivacaine with or without fentanyl or one of its derivatives has little or no adverse effect on breastfeeding success.[1-6] Labor Labor pain medication may delay the onset of lactation. In one study, adding levobupivacaine wound infiltration to multimodal analgesia after cesarean section improved breastfeeding comfort.

Drug levels in milk and infant serum

Maternal Levels. Twenty women undergoing cesarean section deliveries with epidural anesthesia were randomized to receive either levobupivacaine 0.5% (n = 10) or bupivacaine 0.5% (n = 10) in a single-blinded study. The drugs were given as 0.5 mL (2.5 mg) boluses as needed up to 150 mg (mean 80 mg). Blood and milk samples were obtained before and 0.5, 1, 2, 6, 12 and 24 hours after administration of the drugs. Levobupivacaine was detected in breastmilk 30 minutes after administration, with the peak milk concentration of about 0.25 mg/L occurring at about 2 hours after administration. Levobupivacaine was almost at baseline level by 7 hours and absent from milk (<5 mcg/L) by 24 hours after the dose. The passage of racemic bupivacaine into breastmilk was virtually identical.[7] Infant Levels. Relevant published information was not found as of the revision date.

Effects in breastfed infants

Relevant published information on levobupivacaine was not found as of the revision date. However, bupivacaine administered to the mother by intrapleural or epidural routes had no effect on 13 breastfed infants.[8]

Effects on lactation and breastmilk

A nonrandomized convenience sample of women who did (n = 209) or did not (n = 157) receive epidural analgesia during labor was analyzed to determine whether epidurals affected the onset of lactation. Although not standardized, the typical procedure used sufentanil 10 to 15 mg together with either ropivacaine 0.1% or levobupivacaine 0.0625% epidurally, supplemented by epidural boluses of ropivacaine 0.1% or levobupivacaine 0.0625% about every 2 hours. No difference was found in the time of lactation onset between the two groups. Although women in both groups stated they wished to breastfeed prior to delivery, exclusive breastfeeding at 20 days postpartum was less frequent in the women who received an epidural (43%) than in women who did not (57%).[9] A randomized, unblinded study of women undergoing cesarean section found that women who received postoperative wound infiltration with levobupivacaine. A bolus of 50 mg was infused subfascially 5 cm lateral to the wound incision, followed by 6.25 mg/hour for 48 hours. Additional analgesia included acetaminophen, celecoxib, nefopam, morphine and droperidol. On day 2 postpartum, women who received the levobupivacaine infusion reported more comfort with breastfeeding. More women who received the levobupivacaine were breastfeeding on day 2, but the difference was not statistically significant.[10] A retrospective medical record study in China compared women who received patient-controlled epidural analgesia during labor (n = 527) to those who did not (n = 395). Epidural analgesia included 0.1% levobupivacaine and 5 mg of sufentanil in 10 mL of saline. All women completed a questionnaire regarding their breastfeeding experience at 6 months postpartum. There were no statistically significant differences between the groups in the proportion who initiated breastfeeding within 1 hour after birth or who exclusively or partially breastfed their infants at 1, 3, or 6 months postpartum.[11]

Alternative drugs to consider

Lidocaine, Ropivacaine

References

1. ReynoldsF. Labour analgesia and the baby: Good news is no news. Int J Obstet Anesth 2011 20 38 50 21146977 PubMed
2. LoubertC HinovaA FernandoR Update on modern neuraxial analgesia in labour: A review of the literature of the last 5 years. Anaesthesia 2011 66 191 212 21320088 PubMed
3. ShresthaB DevganA SharmaM Effects of maternal epidural analgesia on the neonate--a prospective cohort study. Ital J Pediatr 2014 40 99 25492043 PubMed
4. ZuppaAA AlighieriG RiccardiR Epidural analgesia, neonatal care and breastfeeding. Ital J Pediatr 2014 40 82 25432659 PubMed
5. FrenchCA CongX ChungKS. Labor epidural analgesia and breastfeeding: A systematic review. J Hum Lact 2016 32 507 20 27121239 PubMed
6. HeesenP HalpernSH BeilinY Labor neuraxial analgesia and breastfeeding: An updated systematic review. J Clin Anesth 2020 68 110105 33069970 PubMed
7. BolatE BestasA BayarMK Evaluation of levobupivacaine passage to breast milk following epidural anesthesia for cesarean delivery. Int J Obstet Anesth 2014 23 217 21 24953218 PubMed
8. OrtegaD ViviandX LorecAM Excretion of lidocaine and bupivacaine in breast milk following epidural anesthesia for cesarean delivery. Acta Anaesthesiol Scand 1999 43 394 7 10225071 PubMed
9. MauriPA ContiniNN GilibertiS Intrapartum epidural analgesia and onset of lactation: A prospective study in an Italian birth centre. Matern Child Health J 2015 19 511 8 24894732 PubMed
10. JollyC JathieresF KeitaH Cesarean analgesia using levobupivacaine continuous wound infiltration: A randomized trial. Eur J Obstet Gynecol Reprod Biol 2015 194 125 30 26366789 PubMed
11. XuQ WuZF YangNN Impact of epidural analgesia during labor on breastfeeding initiation and continuation: A retrospective study. J Matern Fetal Neonatal Med 2020 33 3816 9 30890010 PubMed