Friday, August 7, 2009

"Nothing by mouth": surgery guidelines for the breastfed baby

This post is a continuation of Hobo Mama's celebration of World Breastfeeding Week: August 1-7, 2009.


Mikko had to have a minor surgery when he was around a year old, to search for what appeared to be an undescended testicle. Because of his age, even minor surgery required major anesthesia, so he was going to be put under entirely.

Therefore, we were given the standard protocol for "nothing by mouth" for a certain number of hours before surgery, to avoid aspiration of stomach contents while Mikko was unconscious. We were told Mikko could have no solid food for 12 hours before surgery, no breastmilk for 8 hours, and then only clear liquids (water and pulpless juice like apple) up until 4 hours before. The surgery was scheduled for early morning, theoretically to assist us in keeping him unfed.

But we had a baby who was interested in one food only, particularly at night: breastmilk. What on earth were we going to do to get a preverbal, cosleeping infant through eight long hours with no nummies? In fact, the hospital kept telling us our son could hold onto any favorite comfort item, such as a favorite blankie or stuffed animal — we wondered if it would be possible to do a quick removal and send my breasts along with him into the operating room.

As Kellymom says in "Breastfeeding when baby has surgery":

"Many times, when baby is scheduled to undergo surgery, the mother is told 'no breastfeeding after midnight the night before surgery' or 'no breastfeeding less than 8 hours prior to surgery.' Many moms are understandably concerned about this, since withholding nursing from a baby or young child for this amount of time will frequently result in a miserable time for all concerned. Not only is baby hungry, but mom and baby's most useful comforting tool — nursing — is also gone."

"Understandably concerned," I started doing some research about whether our hospital was following the recommended NPO strategy for breastfed infants — and found that those guidelines have been heavily revised, in favor of allowing breastmilk closer to surgery.

If you look at the preoperative fasting guidelines from no less a body than the American Society of Anesthesiologists — surely a group knowledgeable about anesthesia if ever there was one — you can see that recent guidelines are much more liberal. Here is a summary chart of the NPO guidelines, and here is the longer PDF version from the society itself.

You can see that, for a healthy individual undergoing elective surgery (as was our little Mikko), the new guidelines are as follows: Babies can have a light meal of solid food up to 6 hours beforehand, formula or non-human milk also 6 hours before, breastmilk 4 hours before, and clear liquids up to 2 hours beforehand.

The hospital handouts I received, as well as the doctors and nurses I spoke to, were very clear that breastmilk was not considered a clear, easily digested liquid, and so it must not be ingested more than 8 hours before surgery.

This is not a big surprise, considering this article from the American Journal of Nursing, aptly titled "Preoperative fasting: old habits die hard." Basically, experts review and revise their guidelines and try to disseminate the new information, but it takes a long time for it to trickle to everyone who needs to know. You'll notice this if you have considered giving or have given birth in a hospital — you'll have read in book after book that, say, episiotomies and male circumcision should no longer be routine — but unless you're very fortunate, the hospital will still try to do them as a matter of course.

The reason that breastmilk should not be lumped into the same category as solid food, or even formula, is that it is very easily digested. Breastmilk is relatively low fat, which is why human babies eat so frequently. Some research suggests that babies could actually breastfeed even closer to surgery, but four hours is considered conservatively safe. Part of the confusion among hospital staff is in how to classify breastmilk — it's not a solid, and it's not even as food-like as cow's milk, and yet it does typically take longer to digest than clear water or apple juice. (Kellymom has a great article with references to research on the issue of preoperative fasting and different hospitals' guidelines.) Even the old recommendations regarding solids (12 hours or more vs. 6 hours now) have been revised because of improved anesthesia since the first guidelines became standard — and yet the outdated guidelines persist in so many hospitals.

I tried to get some advocacy from Mikko's pediatrician on the matter. I thought maybe if she'd read the new guidelines she would agree with me that the hospital's guidelines were unnecessarily restrictive — and even traumatic — to an infant facing surgery and separation from his parents. But she was no help at all, because her mother had just died from aspirating during surgery. I felt like such a heel for bringing it up. Especially because she'd told us about her mother's recent death before and I'd forgotten, so this was the second time I'd brought it up! Funnily enough, she also guilted us into the surgery in the first place because her husband had had the same condition — only, he had two undescended testicles — and his mother had put off the surgery until he was in elementary school, with the consequence that he was permanently infertile! We seriously couldn't win; any quibble we had our pediatrician could meet with a (true) horror story!

So there was no help there. I had tried bringing up my reservations with the NPO restrictions on breastmilk with the surgical staff and met with no success there, either. I resolved to write a letter after the surgery suggesting that the hospital abide by the ASA's new guidelines, especially with regards to breastmilk. It's particularly significant at this hospital, because it's a children's hospital, so there are a lot of nursing infants undergoing surgery there, unnecessarily being kept unfed for twice as long before surgery as is required for safety.

It's especially difficult because breastfeeding itself, not just the ingested breastmilk, is a comforting mechanism for babies in distress — such as a baby undergoing surgery. By the time we were checked in for the surgery, having been made to wait in a loud room with bright lights and strange faces for quite some time, Mikko was frantic and nursing would have done a lot to calm him. One solution that astute anesthesologists have suggested is allowing comfort nursing on a pre-pumped breast. The baby would still receive some milk, but not a full meal's worth. This, of course, was not allowed us at the hospital that forbade breastfeeding at all for 8 hours prior!

I won't tell you exactly what we chose to do in terms of preoperative fasting for our baby's surgery, because I don't want anyone blaming me for dispensing medical advice against the counsel of physicians. If, however, your nursing baby is undergoing surgery, please use the resources I've linked to to speak with the surgical staff or your pediatrician about acceptable preoperative breastfeeding guidelines. If your hospital, like mine, insists on following outdated restrictions, write a letter and send along the ASA's revised recommendations.

I can say this, even though I haven't written my letter more than a year later... But I will. Honest.

I haven't spoken in this post about how wrenching it felt to choose surgery for a young one, or how it was to sit through it — and this a minor, elective one, at that! Fortunately, in the end, we were well taken care of by the hospital besides the preoperative guidelines. A receptionist was delighted to lead me to their new, private pumping room while Mikko was away from us and I felt about to burst. And, then, immediately after Mikko came to, the staff brought him into a private room where I was able to nurse him in his drowsy state. Sam turned off the lights, and we three sat there for over an hour, with nobody disturbing us, but just letting Mikko breastfeed and wake up at his own pace, comfortably cradled in his mama's arms.

If you can get your hospital to agree to nothing else regarding breastfeeding and surgery, I hope you can get them to agree to that!

La Leche League International also had a good idea to schedule an infant's surgery in the late morning instead of right after waking up:

"Some mothers find it helpful to schedule the surgery so that they can take advantage of a 3-4 hour length of time when their baby or toddler is fairly content without nursing. For example, if the NPO period is 3 hours, then baby could nurse through the night until 7 a.m., get up early, and then play with mom or dad until the scheduled surgery time of 10 a.m. It may be easier to skip breakfast and to distract a child from nursing in the morning than it would be to keep the child from nursing through the night."

This would be particularly helpful for cosleeping infants, since the milk bar is so conveniently close and mama so groggily unaware in the early morning hours. (I know whereof I speak.) So you might suggest to the surgical schedulers a timing that works for your little one instead of taking the typical route of the earliest surgery possible for young children.

Another tip, if you are having an early morning surgery, is to try what we did, which worked better than we had feared. We kept a cup of apple juice and one of water on the nightstand. When Mikko woke up during the night, Sam took care of him and gave him juice or water to drink. Since Mikko usually gets up in the late morning, waking him up for an early surgery meant he was still so groggy that he wasn't himself enough to demand breastfeeding. Sam got him ready to go, the better to keep him away from temptation, and then we quickly bundled him into the car. Sam and I had gotten ready before waking him so that the time from waking Mikko to leaving was a matter of minutes. It was waiting in the waiting room and then the interior waiting room that was the hard part, but fortunately there were new sights to distract him for a lot of the time. I was able to hug and cuddle him and try to distract him with playing. Only for the last twenty minutes or so did we have a total meltdown, before the nurse helped us force a sedative into him. He had had enough of waiting and being hungry and thirsty by that point.

Now, I want to be clear, in case you think I'm advocating recklessness, that it's better safe than sorry when it comes to surgical complications. That's why I recommend you speak with the surgical staff and your pediatrician if you're concerned about the preoperative guidelines rather than just decide on your own. That way you can ask if they're familiar with the new anesthesia recommendations for breastmilk and other foods and find out why they're counseling you the way they are. It might be that your particular child has a medical condition that requires a longer lead time to digest food or breastmilk, or that there's something particular about the specific anesthesia that will be used. And, of course, if your baby is taking in formula or solid foods, note that the lead time is longer for those than for breastmilk.

In case you were curious, Mikko's surgery was uneventful. It turns out there was no undescended testicle, just one that had died sometime during the birth or right around then. He's not at increased risk for cancer, but he will be wearing a cup for all sports to protect the remaining side. I have mixed feelings about whether we did the right thing even to go ahead with the surgery, but there was a chance that there was a second testicle that could have been saved. For all the agony I went through with this surgery, Mikko had the recovery typical of young children: fast, with no ill effects. The only thing that ticked him off was our trying to force pain medicine down him! It seriously was harder than pilling our cat, and that's saying something. (Why do they make children's liquid medicine bright, staining red??) In any case, he was very grateful to be nursing again without restriction!


Here again are links regarding preoperative fasting as it relates to breastmilk:

     • Summary chart of the American Society of Anesthesiologists' NPO guidelines: 6 hours for infant formula and other light solids, and 4 hours for breastmilk

     • The ASA's full text of "Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists" from 2002 [PDF]

     • "Breastfeeding when baby has surgery ... How long before & after general anesthesia is it safe for baby to nurse?": Kellymom's fantastic article with research references and different hospitals' guidelines

     • "My baby is having surgery under general anesthesia. How long before the surgery can I breastfeed him?": La Leche League's explanation of the guidelines with a reference to what would be a helpful book to recommend to any medical staff who care for breastfeeding women or their children: Breastfeeding: A Guide for the Medical Profession, by Drs. Ruth Lawrence and Robert Lawrence, which has this wonderful quote:

"The infant who is hospitalized is already traumatized by the separation, the strange surroundings and people, and the underlying discomfort of the disease process itself. If the infant is to be fed orally, feeding should be at the breast as often as possible... The infant should not be subjected to the added trauma of being weaned from the breast when the infant needs the security and intimacy of nursing most...."

Best wishes to you as you advocate for your nursing child during what can be a very stressful situation, and quick healing to your little one.

Postoperative photo titled "Connected"
courtesy timsamoff on flickr (cc)


The Poor Husband said...

For a hilarious breast-feeding in public story, please check out
It gives a great account of some of our experiences while my wife was breastfeeding our children.

Hope you enjoy.

platespinner said...

Wow! Thank you for some great posts and what a brilliant resource to refer back to.

I don't know if you do these things but I've passed on a meme to you at mine if you feel like doing it. (Feel free to ignore!)

Thanks again for all your great posts :-)


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