Objectives: Breast feeding behavior of infants may be affected when Lactating mothers were exposed to anesthetic agents; it is very important for the anesthetic drugs to be of short half-life and has less metabolite that can be transmitted to the baby via breast milk. Aim of this study is to compare sevoflurane and propofol effects on infant’s breast feeding behavior.

 
Patients and methods: the study was Prospective, cross‐sectional, comparative study. This study was conducted on 20 lactating women underwent ≤ one hour surgical procedures. They were divided in two groups .Group 1 (n=10) received sevoflurane in the induction, and maintenance of anesthesia .Group 2 (n=10) received propofol in the induction, and maintenance of anesthesia. Parameters measured were infants feeding behavior score for both groups at 2, 4, 6,12hours postoperatively.
 

Results: Infants had rooting reflex 2 (80%) in sevoflurane group while (30%) in propofol group. nipple grasps score 3 (40%) in sevoflurane group while (10%) in propofol group. swallowing reflex score 2 (60%) in sevoflurane group while (20%) in propofol group. Total score was 10-12 and 8-10 in sevoflurane and propofol respectively P value <0.001. Duration of each meal in minutes was 2.4(0.5) in sevoflurane group and 2.00 (0.00).

 
Conclusion: The study concluded that both sevoflurane and propofol have accepted infant’s breastfeeding score, but sevoflurane had a significant higher score than propofol.

 
Keywords: Breast Feeding Behavior; Propofol; Sevoflurane. 

Breast milk is considered the ideal nutrition for infants. Early contact is essential for initiation of breast feeding; American Academy of Pediatrics recommends that, whenever possible, breast milk be the only milk that infants receive for the first year [1]. , in addition to the psychological relationships between mothers and babies, breast milk is essential for the immune system, a nutritionally complete food source with low cost. There are many factors that may affect initiation of breast feeding, mother factors as the multiparty, regularity of breast feeding, the use of supplemental bottle feeding, ethnic status of the mother, the socioeconomic status, and other maternal factors such as inverted nipples, lack of education, or incentive. Infants’ issues as the infant cannot latch onto the breast or suckle well, the presence of palatal structure abnormalities, or the presence of congenital neurological abnormalities [2]. Mothers exposed to anesthetic drugs during general anesthesia which may affect lactation, besides the operative pain that may also suppress lactation [3]. It is very important to choose anesthetic drugs which have short half-life and has less metabolite that can be transmitted to the baby via breast milk. Most of the studies compared the effects of the drugs specially the narcotics when used epidurally or intrathecally on early breast feeding [4]. There are little studies compared the effects of general anesthetics on breast feeding behavior of infants. Sevoflurane is an inhaled general anesthetic, which has low blood – gas coefficient, so it has rapid induction and recovery time [5]. Propofol is a 2,6‐diisopropylphenol with sedative‐hypnotic properties, so it has also rapid induction and recovery time [6].

 
The aim of this study is to compare the effects of sevoflurane and propofol when used as maintenance drugs during general anesthesia and the breast feeding behaviors of infants.

 
2. Patients and methods:
 

After patients written consents, a prospective comparative randomized study was conducted, 20 lactating mothers scheduled for elective surgical procedures under general anesthesia in kasr El AIni teaching hospital; they were divided in 2 groups each group 10 patients.
 

Inclusion criteria were, age 20‐40 years, all mothers are healthy multipara who gave birth to full term healthy newborns, and surgical procedures were ≤1 hour.

 
Exclusion criteria, any history of breast feeding problems for both mothers and infants, supplemented bottle lactation.

 
Routine monitoring was by using ECG, noninvasive blood pressure, pulse oximeter, capnography. No premedication was given.

 
In group 1 Induction was achieved by using sevoflurane by face mask with 6 liter 100% Oxygen, the concentration of sevoflurane was 0.5% and increased gradually to reach 4%. In group 2 inductions was achieved by using propofol 1‐2mg/kg IV, 100% oxygen via face mask. 1 µg/kg fentanyl was given to all studied patients.

 
Signs of complete induction of anesthesia were absence of eye lash reflex, absence of the response for verbal command, absence of movement, coughing, tearing, increased heart rate and blood pressure more than 15% from the base line.

 
Atracurium 0.4 mg/kg IV was given for intubation in all patients. Cuffed endotracheal tubes were used. Ventilation rate was 10 per minute, and the tidal volume was 6‐8 ml /kg, end tidal CO2 was maintained between 30‐35 mmHg.

 
Maintenance of anesthesia was achieved by using 2%sevoflurane with 3 liter/min 70% oxygen in air in group 1.
 

In group 2 anesthesia’s was maintained by using propofol IV infusion at a rate of 50‐150µ/kg/min, muscle relaxation was maintained by0.05 mg/kg atracurium in all patients.

 
At the end of surgical procedures Reversal of muscle relaxant was achieved by using 0.06 mg/kg neostigmine and 0.1 mg/kg atropine.

 
Postoperative analgesia was conducted with local infiltration of lidocaine 2% in the operative site, paracetamol IV infusion (Perflgan), narcotics were avoided.

 
Assessment of the infant (breast feeding Behavior score) [7] was done by a pediatric consultant. 

Parameters were assessed were (rooting reflex, nipple grasp, duration of the each meal, strength of suckling and swallowing and the total of 14) .The parameters were assessed at 2, 4, 6,8,10,12 hours postoperatively.

 
Rooting reflex    
 
Did not root                                          0
Showed some rooting behavior              1
Showed obvious rooting behavior           2
 
Areolar grasp
                               
Non, the mouth only touched the nipple        0
Part of the nipple                                        1
The whole nipple not areola                          2
The nipple and some the areola                    3
 
Suckling
                               
No suckling                                                  0
Licking and tasting but not suckling                1
Single suckling                                              2
Repeated short suckling (Less than 10)           3
Repeated more than 2 long burst                    4
 
Swallowing
               
Was not noticed                                         0
Occasional swallowing was noticed             1
Repeated swallowing was noticed                2
 
Duration of the meal
               
Did not latch at all             0
Latched for 5 minutes        1
Latched 6-10 minutes        2
Latched 11-15 minutes      3
Total score                       14 (7)
 

Statistical analysis: data were represented as mean (SD) analysis was done by using SPSS version 15, T‐test and Chi‐square test.
*p≤0.05 is considered significant.

Breast feeding is very important for both mothers and infants, according to American academy recommend breast milk lactation in the first year of life [1]. Mothers may be exposed to general anesthesia during the period of lactation .There is no sufficient data about the effect of anesthetic drugs on human lactation.

 
Many studies conducted on the effects of anesthesia on breast lactation, they gave a great concern about the effects of narcotics in epidural and general anesthesia during cesarean section. They demonstrated the gain of the early eye and skin contact between mothers and infants on initiation of lactation [8]. Some studies determined the level of narcotics in colostrum after high dose of epidural fentanyl [9]. Other studies demonstrated the relation between type of anesthesia and the continuation of breast feeding lactation after surgical procedures [10]. American academy recommended the short acting and easily eliminated drug with the minimum dose should be used [1]. 

The mothers should weigh the benefit of continuation of lactation against the effect of anesthetics on infants. However the WHO listed anesthetic drugs that can be safely used during lactation [12]. There is no sufficient data about some anesthetics as sevoflurane and propofol, and which is better to be used .The present study compared sevoflurane and propofol on breast feeding behavior. The study found that breast feeding score was significantly higher in sevoflurane than propofol group. The explanation may be that sevoflurane, a potent inhalational anesthetic with a blood‐gas partition coefficient of 0.60, provides a relatively rapid inhalation induction and recovery from anesthesia, the low coefficient facilitate its elimination via the lungs. Binding of sevoflurane to blood protein is not yet investigated. It is metabolized by cytochrom P 450 to Hexfluroisopropranol, fluoride and CO2.

Hexfluroisopropranol conjugated in the liver and eliminated by the kidney [5]. On the other hand, Propofol is a highly protein‐bound drug and is metabolized by conjugation in the liver. Its rate of clearance exceeds hepatic blood flow, suggesting an extra hepatic site of elimination as well. Propofol is rapidly distributed into peripheral tissues so; it has short duration of action. The half-life of elimination of propofol is 2 ‐ 24 hours [6].

 
Limitation of the study that it was only for 12 hours while it needs to be more, at least 24 hours, but because of the ethical point of view the study time is shorter.

 
The study concluded that both sevoflurane and propofol are short acting drugs and both have good breasted feeding score, but sevoflurane has a significant higher score than propofol. There is no sufficient data about the level of sevoflurane or its metabolites (Hexfluroisopropranol, fluoride) in the breast milk. More studies are recommended to compare the level of sevoflurane and propofol and their metabolites in breast milk.

1. American Academy of Pediatrics, Committee on Drugs (2001) the transfer of drugs and other chemicals into human milk. Pediatrics 108:776-78

2. Beilin Y, Bodian CA, Weiser J, Hossain S, Ittamar A, et al. (2005) Effect of labor epidural analgesia with and without fentanyl on infant breast‐feeding: A prospective, randomized, double blind study. Anesthesiology, 103:1211-1217.

3. Briggs GG, Freeman RK, Yaffe SJ (2005) Drugs in pregnancy and lactation (7th edition). Philadelphia, Lippincott, Williams & Wilkins. 

4. Dennis CL (2002) Breastfeeding initiation and duration: A 1990–2000 literature review. Journal of Obstetric, Gynecologic, & Neonatal Nursing 31:247. 

5. Ysuda N, lockhart S, Egar EL (1991) Comparison between isoflurane and sevoflurane in human. Anesthesia analgesia 72‐316. 

6. Nitsun M, Szokol JW, Saleh HJ, Murphy GS, Vender JS, et al. (2006) Pharmacokinetics of midazolam, propofol, and fentanyl transfer to human breast milk. Clin Pharmacol Ther 79:549-57.

7. Kerstin Hedberg Nyqvist, RN MS (1996) Development of the Preterm Infant Breast feeding Behavior Scale (PIBBS): A Study of Nurse‐Mother Agreement. 12:207‐219.

8. McElhatton PR (1994) The effects of benzodiazepine use during Pregnancy and lactation. Reproductive Toxicology 8:461-475.

9. Spigset O, Hagg S (2000) Analgesics and breastfeeding: safety considerations. Pediatric Drugs 2-3.

10. Jensen D, Wallace S, Kelsay P (1994) LATCH: a breast feeding charting system and documentation tool. J Obstet Gynecol Neonatal Nurs 23:27–32. 

11. Tsen LC (2005) what’s new and novel in obstetric anesthesia? Contributions from the 2003 scientific literature. International Journal of Obstetric Anesthesia 14:126-146.

12. World Health Organization (2002) Breast feeding and maternal medication: Recommendations for drugs in the eleventh WHO Model list of essential drugs.