Is Esketamine safe while breastfeeding?

Summary of use during breastfeeding

Esketamine is the more potent S-isomer of the racemic drug, ketamine. Single doses or infusions of intravenous esketamine during or after cesarean section delivery may not affect the breastfed infant and may improve the onset and frequency of lactation in the early postpartum period. Esketamine nasal spray used as an antidepressant has not been studied during breastfeeding. Until more data are available, repeated doses esketamine nasal spray should probably be avoided during breastfeeding.

Effects on the breastfed infant

Four mothers who received epidural analgesia with lidocaine and bupivacaine for cesarean section also received general anesthesia with ketamine and midazolam (dosages not specified). Their infants were either breastfed or received their mother’s breastmilk by bottle. No adverse effects were reported in the infants.[1]

Effects on milk supply

A pregnant woman sustained 28% body surface area burns near term. She underwent an emergency cesarean section on her due date under ketamine anesthesia. Although the infant required vigorous resuscitation, the infant began breastfeeding immediately. The infant had transient jaundice that resolved in a few days.[2]

A study compared women undergoing cesarean section who received either placebo or S-ketamine (esketamine) 0.5 mg/kg intramuscularly, followed by a continuous infusion of 2 mcg/kg/minute for 12 hours. This low dose was used to enhance analgesia and reduce residual pain rather than to provide anesthesia. All women received intraspinal bupivacaine 8 to10 mg and sufentanil 5 mcg for analgesia, as well as midazolam 0.02 mg/kg intravenously before the S-ketamine or placebo injection. Postoperatively, patients received patient-controlled intravenous morphine for 24 hours, followed by acetaminophen, oral ketorolac and a single dose of ondansetron 8 mg intravenously as needed. Of the 56 patients enrolled in the study (28 in each group), 13 in each group were contacted at 3 years postpartum. Patients who received placebo reported breastfeeding for an average of 10.5 months and those who received S-ketamine reported breastfeeding for an average of 8 months; however, the difference was not statistically significant.[3]

A randomized, double-blind study compared the effects of intravenous propofol 0.25 mg/kg, ketamine 0.25 mg/kg, ketamine 25 mg plus propofol 25 mg, and saline placebo for pain control in mothers post-cesarean section. A single dose was given immediately after clamping of the umbilical cord. The time to the first breastfeeding was 58 minutes in those who received placebo, 31.9 minutes with ketamine and 25.8 minutes with propofol plus ketamine. The time was significantly shorter than the other groups with the combination.[4]

A study of women with gestational diabetes undergoing elective cesarean section randomized them to postoperative patient-controlled analgesia with either intravenous esketamine 0.5 mg/kg, sufentanil 150 mcg and ondansetron 4 mg (n = 70) or sufentanil and ondansetron alone in the same doses (n = 70). There was no difference between the groups in the time to first lactation, with most beginning at 24 to 48 hours after delivery.[5]

A prospective study compared two groups of women undergoing cesarean section. The study group (n = 68) received esketamine 0.2 mg/kg intravenously over 40 minutes, while the control group (n = 68) received normal saline. Both groups received PCIA with butorphanol, flurbiprofen and dexamethasone and other routine postoperative care. The study group had earlier first breastfeeding and more breastfeeding sessions within 48 hours after surgery. The mothers who received esketamine had lower scores on the Edinburgh Postnatal Depression Scale than the control mothers on days 2 and 7 postpartum.[6]

Levels in milk

Maternal Levels. Relevant published information was not found as of the revision date.

Infant Levels. Relevant published information was not found as of the revision date.