I read with interest the July/September 2007 issue dedicated to breast-feeding. The relationship between pain management, specifically epidural analgesia, and its potential impact on successfully breast-feeding in the early newborn period was not explored. I offer the following information to stimulate discussion and serve as a potential area of future nursing research for the promotion of successful breast-feeding.

The association between epidurals in labor for healthy full-term newborns delivered by vaginal delivery and early breast-feeding success was explored.1 Standardized records of mother-baby dyads representing 115 consecutive healthy, full-term, breast-feeding newborns delivered vaginally of mothers receiving epidural analgesia were analyzed and compared with 116 newborns not exposed to maternal epidural analgesia. The primary outcome was 2 successful breast-feeding encounters by 24 hours of age, as defined by a LATCH breast-feeding assessment score of 7 of 10. Two successful breast-feedings within 24 hours of age were achieved by 69.6% of the mother-baby dyads that had epidurals compared with 81% of the mother-baby dyads that had not had an epidural. This was reported as significant with a P value of .04. Moreover, mothers of newborns who had an epidural and who did not breast-feed within 1 hour were at high risk for having their newborn receive bottle supplementation (odd ratio = 6.27). It was concluded that labor epidural analgesia had a negative impact on breast-feeding during the first hour of life.

The American Academy of Breast-feeding Medicine (ABM) is a leading proponent of policies to enhance breast-feeding.2 In the Breast-feeding Medicine Clinical Protocol #15, the ABM recommends that 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 instrumentation and cesarean delivery, effect on the newborn, and possible breast-feeding effects. Unmedicated, spontaneous vaginal birth with immediate, uninterrupted skin-to-skin contact leads to the highest likelihood of baby-led breast-feeding initiation. Labor pain management strategies may affect these labor outcomes and secondarily affect breast-feeding initiation. Continuous labor support reduces the need for pharmacologic pain management in labor and leads to improved breast-feeding outcomes both in the immediate postpartum period and several weeks after birth. Infants lose more weight in the first postpartum days when labor medications are used. Some of this weight loss may be a result of mothers receiving an intravenous fluid load for epidural analgesia. Babies may be slightly heavier on the average and lose more weight in the first days postpartum when epidural analgesia is used. In addition, intravenous fluids may increase breast engorgement and interfere with subsequent milk production and/or transfer of milk.

Epidural analgesia for labor has been associated with a 15-fold increase in the incidence of intrapartum maternal fever.3 Ten percent of full-term newborns with a temperature greater than 37.8[degrees] may have bacterial sepsis. For the 90% of newborns that do not have sepsis, a portion of these newborns have fever secondary to maternal fever from the epidural. Some of infants are further examined in the neonatal intensive care unit, which may increase separation time between mother and infant and subsequently reduce the opportunity to breast-feed in the early newborn period.

If parents, and more importantly nurses, are not aware of the possible impact that epidurals may have on breast-feeding, it is impossible for the laboring mother to make an informed decision regarding her choice of pain management and the nurse to take proactive steps to encourage successful breast-feeding.

JoAnne Silbert-Flagg, RN, MS, CPNP, IBCLC

Doctor of Nursing Practice Student, Columbia University, New York, Instructor of Nursing, Johns Hopkins University School of Nursing, 525 North Wolfe Street/Room 472N, Baltimore, MD 21205, [email protected]

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