New AAP recommendations re: postpartum pain management

[pgg]

The Sept issue of Pediatrics has some new bold declarations that boil down to stating that morphine is the only opiate safe for use in breastfeeding mothers. No codeine, oxycodone, hydrocodone.

It also takes kind of a hardline stance vs ketorolac:

Injectable and oral forms of ketorolac are contraindicated in nursing women, according to product labeling, because of potential adverse effects related to closure of the ductus arteriosus in neonates.

The lack of FDA approval for ketorolac in breastfeeding women isn't new, but this AAP statement seems to be. Previously they endorsed its use (see table 6 ... The transfer of drugs and other chemicals into human milk. Pediatrics 1994;93:137-50).


We routinely prescribe oxycodone/acetaminophen, and do 24h of scheduled IV ketorolac in post-c-section patients. Getting rid of Percocet & Vicodin isn't that big a deal; I guess we could start using oral morphine. Or for labor epidurals, I may start dosing them with 3 mg of morphine after delivery, possibly leaving the catheter in and dosing again 24h later. For scheduled sections, maybe CSEs with the catheter pulled after a dose of morphine 24h later.


I am curious about others' thoughts on this though, particularly whether or not you'll continue using ketorolac.

---

Members don't see this ad.

 

[gasattack3]

The Sept issue of Pediatrics has some new bold declarations that boil down to stating that morphine is the only opiate safe for use in breastfeeding mothers. No codeine, oxycodone, hydrocodone.

It also takes kind of a hardline stance vs ketorolac:
The lack of FDA approval for ketorolac in breastfeeding women isn't new, but this AAP statement seems to be. Previously they endorsed its use (see table 6 ... The transfer of drugs and other chemicals into human milk. Pediatrics 1994;93:137-50).


We routinely prescribe oxycodone/acetaminophen, and do 24h of scheduled IV ketorolac in post-c-section patients. Getting rid of Percocet & Vicodin isn't that big a deal; I guess we could start using oral morphine. Or for labor epidurals, I may start dosing them with 3 mg of morphine after delivery, possibly leaving the catheter in and dosing again 24h later. For scheduled sections, maybe CSEs with the catheter pulled after a dose of morphine 24h later.


I am curious about others' thoughts on this though, particularly whether or not you'll continue using ketorolac.

The bold is what we do. We don't leave them in for another 24hrs though.

 

[Oggg]

Wow ketorolac is the bomb for postop pain after c section.

 

[norwood]

Interesting article on ketorolac and breastfeeding, which cites a European study from 1989 in which ten lactating mothers were given ketorolac 10mg qid, with the ketorolac level in their milk then being measured:

http://www.drugs.com/breastfeeding/ketorolac.html

Apparently a small but finite amount of ketorolac can come through in breast milk. The website's author argues that the European authors goofed up their math and concluded a much higher blood level of ketorolac in the babies than would actually be there. Not knowing how much ketorolac it takes to close the average PDA, I'd probably skip it for now - which is a change from how I've practiced so far.

For a scheduled section, I'd be more likely to add a bit of fentanyl or morphine to the Marcaine than I'd be to do a CSE. Oral (or, I guess, IV) morphine still works, and I'm assuming Tylenol is still on the OK list, so there's a backup plan if that doesn't provide adequate pain relief.

This assumes, of course, that Mom is breastfeeding.

 

[epidural man]

The Sept issue of Pediatrics has some new bold declarations that boil down to stating that morphine is the only opiate safe for use in breastfeeding mothers. No codeine, oxycodone, hydrocodone.

It also takes kind of a hardline stance vs ketorolac:
The lack of FDA approval for ketorolac in breastfeeding women isn't new, but this AAP statement seems to be. Previously they endorsed its use (see table 6 ... The transfer of drugs and other chemicals into human milk. Pediatrics 1994;93:137-50).


We routinely prescribe oxycodone/acetaminophen, and do 24h of scheduled IV ketorolac in post-c-section patients. Getting rid of Percocet & Vicodin isn't that big a deal; I guess we could start using oral morphine. Or for labor epidurals, I may start dosing them with 3 mg of morphine after delivery, possibly leaving the catheter in and dosing again 24h later. For scheduled sections, maybe CSEs with the catheter pulled after a dose of morphine 24h later.


I am curious about others' thoughts on this though, particularly whether or not you'll continue using ketorolac.

TAP with exparel should get rid of the need for any opioids. 😉

 

[pgg]

So we had a meeting of anesthesiology, OB, pediatrics, and the pharmacy this morning to discuss this.

The consensus was to quit using oxycodone and hydrocodone, in accordance with these new AAP recommendations. For now, at least until the dust settles, we're just going to switch our usual two 5/325 Percocet q4h PRN to 650 of acetaminphen plus 15 mg MSIR q4h PRN.

Everyone was in favor of continuing to use ketorolac, for a few reasons.

1) Unlike oxycodone & hydrocodone, the article made no recommendations, just noted the existing longstanding label warning. Nothing new here.
2) We typically only use it for the first 24h, during which time breast milk production is minimal.
3) The risk is theoretical in the first place, and only a concern for the neonate born with an undiagnosed ductus-dependent congenital heart defect. (Otherwise, closure of the DA in a normal, air-breathing neonate is a non-issue.) In the first place, the odds of missing a PDA-dependent heart defect in a newborn are low. And since deliberate treatment of PDAs with indomethacin requires direct IV dosing, the risk of accidental closure of a needed PDA by trace amounts of ketorolac would seem to be a huge stretch.


Another interesting issue that came up is that the same AAP article recommends that breastfeeding women not take Zoloft or Prozac. Paxil and Wellbutrin are already out, so this creates a problem ... nothing's left. Is untreated depression a lesser risk than exposing a baby to a tiny amount of an SSRI that's been in use for decades, and actually had studies done in pregnancy? I'm glad this isn't my problem.


I'll be interested to see what kind of editorial comments rebuttals appear in the journal when this reaches print. And stand by for a swarm of TV ads ... "Did your kid not get into Harvard? Did you take Zoloft while breastfeeding? Did you take pain medicines after childbirth? You may be entitled to compensation."

 

[pgg]

TAP with exparel should get rid of the need for any opioids. 😉

I had given that some thought, but there's no way that's going to become a default solution given a varied gaggle of anesthesia providers, physician and CRNA. It's also no good for the ones who deliver the ancient cavewoman way. 🙂

 

[epidural man]

It's also no good for the ones who deliver the ancient cavewoman way. 🙂

Haha.

Oral...it tastes like milk.

 

[jwk]

So we had a meeting of anesthesiology, OB, pediatrics, and the pharmacy this morning to discuss this.

The consensus was to quit using oxycodone and hydrocodone, in accordance with these new AAP recommendations. For now, at least until the dust settles, we're just going to switch our usual two 5/325 Percocet q4h PRN to 650 of acetaminphen plus 15 mg MSIR q4h PRN.

Everyone was in favor of continuing to use ketorolac, for a few reasons.

1) Unlike oxycodone & hydrocodone, the article made no recommendations, just noted the existing longstanding label warning. Nothing new here.
2) We typically only use it for the first 24h, during which time breast milk production is minimal.
3) The risk is theoretical in the first place, and only a concern for the neonate born with an undiagnosed ductus-dependent congenital heart defect. (Otherwise, closure of the DA in a normal, air-breathing neonate is a non-issue.) In the first place, the odds of missing a PDA-dependent heart defect in a newborn are low. And since deliberate treatment of PDAs with indomethacin requires direct IV dosing, the risk of accidental closure of a needed PDA by trace amounts of ketorolac would seem to be a huge stretch.


Another interesting issue that came up is that the same AAP article recommends that breastfeeding women not take Zoloft or Prozac. Paxil and Wellbutrin are already out, so this creates a problem ... nothing's left. Is untreated depression a lesser risk than exposing a baby to a tiny amount of an SSRI that's been in use for decades, and actually had studies done in pregnancy? I'm glad this isn't my problem.


I'll be interested to see what kind of editorial comments rebuttals appear in the journal when this reaches print. And stand by for a swarm of TV ads ... "Did your kid not get into Harvard? Did you take Zoloft while breastfeeding? Did you take pain medicines after childbirth? You may be entitled to compensation."

Ah, nice to see common sense win out.

 

[urge]

I am curious about others' thoughts on this though, particularly whether or not you'll continue using ketorolac.

Thanks for the post.

The article said nasal ketorolac was fine. Doesn't make much sense to me but that's what it says.

Also, dilaudid is ok apparently.

Just give them some tylenol and tell them it is "good for the baby".

 

[VA Hopeful Dr]

So we had a meeting of anesthesiology, OB, pediatrics, and the pharmacy this morning to discuss this.

The consensus was to quit using oxycodone and hydrocodone, in accordance with these new AAP recommendations. For now, at least until the dust settles, we're just going to switch our usual two 5/325 Percocet q4h PRN to 650 of acetaminphen plus 15 mg MSIR q4h PRN.

Everyone was in favor of continuing to use ketorolac, for a few reasons.

1) Unlike oxycodone & hydrocodone, the article made no recommendations, just noted the existing longstanding label warning. Nothing new here.
2) We typically only use it for the first 24h, during which time breast milk production is minimal.
3) The risk is theoretical in the first place, and only a concern for the neonate born with an undiagnosed ductus-dependent congenital heart defect. (Otherwise, closure of the DA in a normal, air-breathing neonate is a non-issue.) In the first place, the odds of missing a PDA-dependent heart defect in a newborn are low. And since deliberate treatment of PDAs with indomethacin requires direct IV dosing, the risk of accidental closure of a needed PDA by trace amounts of ketorolac would seem to be a huge stretch.


Another interesting issue that came up is that the same AAP article recommends that breastfeeding women not take Zoloft or Prozac. Paxil and Wellbutrin are already out, so this creates a problem ... nothing's left. Is untreated depression a lesser risk than exposing a baby to a tiny amount of an SSRI that's been in use for decades, and actually had studies done in pregnancy? I'm glad this isn't my problem.


I'll be interested to see what kind of editorial comments rebuttals appear in the journal when this reaches print. And stand by for a swarm of TV ads ... "Did your kid not get into Harvard? Did you take Zoloft while breastfeeding? Did you take pain medicines after childbirth? You may be entitled to compensation."

I've noticed 2 trends in AAP recommendations.

1. They focus on the kid with little/no thought given to anyone else (in this case, the mother). That's completely understandable, but its worth keeping in mind.

2. Their recommendations are usually consensus statements. These aren't without value, but they're also usually light on evidence.

I have a hard time changing my practice patterns immediately after AAP statements.

Disclaimer: I'm an FP so I see this from the pain meds on disharge angle. Inpatient morphine, even injectable, is one thing - sending them home with it makes me a touch nervous.