Opioid Use During Labor, Delivery and Pediatric Procedures

Young mother with IV with her newborn baby in hospital bed

Fentanyl During Labor and Delivery and to Breastfeeding Mothers

There may be times when breastfeeding mothers are given fentanyl intravenously, such as during labor and delivery or other procedures after the baby is born. A summary of recommendations regarding fentanyl and breastfeeding follows (LactMed, 2023).

Use	Guidance
In labor and delivery, epidurally or intravenously	Considered safe. Amounts of fentanyl are usually small and are not expected to cause adverse effects in the infant.
Postnatally in mothers, during recovery from birth.	Avoid. Following delivery of infants, especially preterm infants, nonnarcotic analgesic is recommended when possible. It is best to “limit maternal intake of fentanyl to a few days at a low dosage with close infant monitoring (Ibid.).”
For short procedures, such as endoscopy, to control pain in breastfeeding mothers	Considered safe. It is not necessary to wait to resume breastfeeding or discard milk. “Limited information indicates that transdermal fentanyl in a dosage of 100 mcg/hour results in undetectable fentanyl concentrations in breastmilk (Ibid.).”

Recommendations for Fentanyl Use in Pediatric Procedures

Providers should approach the use of pharmaceutical fentanyl for managing severe pain with caution. In a 2021 report published in JAMA Surgery, an expert panel reminded providers to follow the stepwise philosophy of pain relief endorsed by the World Health Organization (Kelley-Quon et al., 2021). Non-opioid options should always be explored as a first-line treatment following surgery in children.

The expert panel findings that received a grade of A (high quality) or B (moderate quality) include:

A significant proportion of adolescents with access to opioids misuse them.
Of adolescents who misuse prescription opioids, a significant number will develop dependence/opioid use disorder.
Adolescent opioid misuse is associated with heroin misuse.
Prescriptions from a health-care professional are the most common source of opioids for adolescents who misuse them.
A significant proportion of adolescents who are prescribed opioids divert them.
Opioid-free postoperative analgesia is feasible for many pediatric operations.
When discharge analgesics are deemed necessary, we recommend nonopioid options as first-line treatment.
We recommend consistent pain management messaging from all members of the perioperative care team.
If opioids are prescribed, we recommend perioperative education should include instruction on possible adverse drug events, seriousness of drug events, and what to do if those occur.

Among the report’s recommendations that apply to general clinical care:

“We recommend that pain management education be tailored to the caregiver’s and child’s needs to promote shared understanding and expectations. To ensure that pain management education is accessible to all patients and their caregivers, education should be delivered both written and verbally. Caregivers prefer education to be in plain, nonmedical language, regardless of health literacy level, and delivered in the language most familiar to the family. Lastly, additional characteristics of the child (eg, developmental abilities), caregiver, and the procedure … should be accounted for when designing educational programs.”

Consult the Resources for a link to the report. See Tables 4 and 5 for detailed evidence and recommendations.

Why it Matters

The good news is that accidental overdoses are preventable when medical professionals, families and the community work together to educate, protect and treat adolescents and children.

Here’s what providers can do to reduce risk of accidental overdose in their community:

Monitor children and youth for signs of mental health disorders, abuse or other risk factors.
Address risk-related underlying problems promptly.
Partner with mental health and substance use specialists and refer when needed.
Educate families and children about the presence of copycat drugs containing fentanyl that are manufactured to look like prescription pills.
Plan ahead and be prepared to help in the case of substance use whether it’s by administering emergency buprenorphine or by supporting families through long-term harm reduction methods.

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