rivka | (no subject)

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nursing

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A couple of times in the past, I've had a simple upper respiratory infection spiral into a massive case of reactive airway disease: shortness of breath, wheezing, dizziness, brain fog, and prolonged fits of coughing in a spasmodic, wheezy, and completely nonproductive manner. The first time I was amazingly ill and wound up in the ER, and then on multiple daily nebulizer treatments at home. I lay on the couch like a zombie for a couple of weeks. I occasionally needed an inhaler for months before my breathing finally returned to normal.

The second time, the acute illness wasn't as bad. But I still wound up on home nebulizer treatments, and carried - and needed - an inhaler for months afterward.

I've been having episodes of wheezing and shortness of breath recently. Not consistently, but sometimes. Michael caught me having a can't-breathe-coughing-helplessly episode and browbeat me into going to the doctor. Fortunately, they've opened up a new urgent care clinic right near my office, for members of the university community only.

I went there this morning. My inconsistent symptoms obligingly appeared for the nurse practitioner. (More accurately, I started having them on my way in to work, and that reminded me that I'd promised Michael I would be seen, so I went.) She gave me a breathing treatment in the office. The heavens parted and choirs of angels sang hosannas as I found myself able to take deep, satisfying breaths.

The breathing treatment had albuterol and something else in it. She looked up the something-else to see whether it was safe for breastfeeding. Class B; fine with me. She wrote me a prescription for an albuterol inhaler, which I dropped off at the university pharmacy.

This afternoon I went to pick up my prescription. There was a bright yellow sticker on the inhaler box: "Not recommended for use while breastfeeding." I asked to speak to a pharmacist, who hunted through the package insert and found that the "not recommended" label was due to animal studies, that human studies are lacking, and that the manufacturers suggest that one "consider whether to stop breastfeeding or stop use of the medication."

Refused the prescription. Called the nurse practitioner, who has yet to call me back. Came back to my office and did some googling for albuterol breastfeeding.

According to the National Library of Medicine's LactMed database: "Although no published data exist on the use of albuterol by mouth or inhaler during lactation, data from the related drug, terbutaline, indicate that very little is expected to be excreted into breastmilk.[1] The authors of several reviews and an expert panel agree that use of inhaled bronchodilators is acceptable during breastfeeding because of the low bioavailability and maternal serum levels after use."

So I don't know what the hell is going on with the Proventil package insert, or whether I should believe the folks who actually made the medicine or the database. I understand that for liability reasons they are on much safer ground if they tell pregnant and nursing women to never take anything, and online sources seem to be pretty much in agreement about the safety of albuterol. But. But.

The wheezing and coughing aren't really that bad. Crap. I don't know.

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I see three choices:

1. Trust the database.
2. Find an alternative medication that is acknowledge to be safe for lactating women (if such exists).
3. Wean and take this medication.

Of these, option 2 is clearly the preferred strategy. One is fraught with risk (how much or how little risk remains to be seen), and three with pain.

You seem to be contemplating an option 4: Just put up with the wheezing and coughing. I think that option 4 is a very bad idea - option 3, while difficult, shitty, and generally not recommended, would be preferable.

You seem to be contemplating an option 4: Just put up with the wheezing and coughing. I think that option 4 is a very bad idea - option 3, while difficult, shitty, and generally not recommended, would be preferable.

I swear I'm not underreporting. The wheezing and coughing legitimately aren't that bad. I mean, they're awful when they're happening, but I have long stretches of time when I am breathing fine and normally active.

Edited 2010-11-09 21:12 (UTC)

Yes, but best to consider your options NOW and decide what to do if it gets worse, and at what point in "getting worse" Plan B kicks in. If you get as sick as the first time, you will not be in any shape to be nursing anyway.

What my doctor told me when I was reluctant to overuse drugs was that "just little wheezing" was doing permanent damage to my airways and lungs.

I do not know is this case for you, but it is worth checking.

Can you look up what Colin would be put on if he were having similar symptoms? If the drug is approved to treat children, then I would feel presumably it won't harm him in small doses, and take the medicine happily.

SteelyKid was put on albuterol in a nebulizer for walking pneumonia at 21 months, which IIRC is very close to Colin's age now. FWIW.

Both my kids were on Xopenex and albuterol at various times for wheezing and RAD at under a year. I've also used it, and much prefer it to regular albuterol, as far as side effects.

Also, as the comment below illustrates, Dr. Thomas Hale has a large database of medications and their safety in nursing mothers. You can read the boards and usually will find the med in there. He also has a (very expensive) book called Medications and Mother's Milk (http://www.amazon.com/Medications-Mothers-Milk-Lactational-Pharmacology/dp/098233799X/ref=sr_1_1?ie=UTF8&s=books&qid=1289428554&sr=8-1), which includes the lactation category, side effects, things to watch for in infants, etc. Great book, though it's $36! Worth every penny IMO. I've got the 2002 edition and have used it many, many, many times, both for myself and others.

Dr hales
http://neonatal.ama.ttuhsc.edu/cgi-bin/discus/discus.cgi?pg=topics&access=guest

http://neonatal.ttuhsc.edu/discus/messages/53/66231.html?1193368302

Rachael Rubinfeld posted on Thursday, October 25, 2007 - 01:10 am Edit Post Delete Post Print Post
I'd just like to clarify something. I'm nursing a 7 month old. My internist prescribed the inhaler b/c of some asthmatic reaction to brochitis. The tag on the inhaler says very specifically do not use if breastfeeding. And the book says the inhaled version is safe- but to watch infant for tremors and excitement. Am I ok if I use this?

Tom Hale Ph.D. posted on Thursday, October 25, 2007 - 10:11 pm Edit Post Delete Post Print Post
Rachael:

Albuterol is no problem at all for a breastfeeding mother or her infant.

Go ahead and breastfeed.

Tom Hale Ph.d.

Also, I have asthma, which is what you sound like you have. Breathing is much more important than anything else, and you can damage your lungs and potentially be in substantial life threatening danger if it is not well treated/responded to, so if you do have to choose, pick albuterol over nursing. And you probably want to be on a steroid as well, like Advair. Luckily, you do not have to choose. ; )

We have an at home nebulizer since Liam also has asthma - for the winter, I am glad to have it.

As I was reading your symptoms, I thought "oh jeez, now Rivka has asthma too." Please go to your regular doctor and have yourself checked out! Untreated asthma leads to horrible things like pneumonia. Treated asthma lets you walk around and do normal things without coughing and chest pain!

According to my primary care doctor, I don't have asthma. I've had three episodes of this in the last 10 years, and each time it's been a temporary problem related to an upper respiratory infection.

While it's happening, though, it does mimic asthma pretty closely.

Thank goodness! In that case, I wonder if Xopenex would be a better inhaler. I don't know what's in it except that it isn't albuterol.

Xopenex is levalbuterol. It has only left-handed molecules of albuterol, but not right-handed ones (plain albuterol has both).

Short course in stereochemistry: Some molecules are assymetrical, so they exist in right-handed and left-handed versions. Sometimes there's a difference in how those molecules fit into cellular receptors, so either the left- or right-handed version has a greater therapeutic effect [and/or fewer/milder side effects] than the other. Since you can patent the single-enantiomer form of a drug, doing so has become somewhat of a cottage industry. Things to look for in drug names: dextro- or levo- [refers to how the assymetrical molecule rotates polarized light] or es- or ar- [refers to standard naming of chiral centers in molecules as S- or R-]. Example: escitalopram (Lexapro) is the S-enantiomer of citalopram (Celexa). "Racemic" means that both forms (dextro- and levo- or S- and R-) are present in a mixture.

No, I'm not in teacher-mode, not in the slightest. <quietly kicks podium into corner>

Apologizing for teacher-mode in *this* crowd? ::blinks:: Which is to say, thank you and how cool!

Reactive Airway Syndrome is basically Asthma that happens because of a specific thing (like a resp infection) instead of because of general cussedness. Symptoms are basically the same...

Cough-variant asthma is what I'm diagnosed with, and sounds very close to what you experience.

Do you cough when you laugh or cry, or exercise, or inhale very cold air?

Yes, but only in the context of these few particular illness episodes that I've had. Otherwise not. It doesn't happen every time I get an upper respiratory illness, even - just these three times over 10 years. The precipitating cold doesn't even need to be that bad. I've had plenty worse.

But indeed, when I have it, I am pretty much exactly like a person with cough variant asthma.

As part of my asthma management plan, I use an albuterol inhaler "as needed"-the pulmonologist and I have checked with the LC I use, checked Hale's Medication's and Mother's Milk and called the Infant Risk Center. I've done enough research to feel like it's okay to take while nursing.

Miriam (who is younger than Colin) has been on inhaled albuterol via nebulizer before, in higher doses than she gets through breastmilk when I take it.

And none of my inhalers have come with the yellow "No breastfeeding" stickers.

Thank you. This does seem to be the consensus. I am pissed off because now I'll need to make another trip to the pharmacy to get the scrip filled.

WTF is up with Proventil/UMMC pharmacy, I wonder?

WTF is up with Proventil/UMMC pharmacy, I wonder?

It's called CYA.

FWIW, I was on inhalers (salbutamol & another one) for several months while nursing... and my little guy was put on salbutamol nebulizers for several days at 6 months old for RSV.

I suspect the drug company is being very cautious. I don't know if you will find what you need, but I have had very good luck with the MotherRisk clinic at the Hospital for Sick Children in Toronto.

http://www.motherisk.org/women/breastfeeding.jsp

I was going to suggest Motherisk too!

Godammit I wish they would take into account the difference between breastfeeding a newborn and a hearty toddler when making that sort of warning decision. I hope you find something you can decide on soon, and relatively painlessly. Wishing you deep breaths.

Have you considered getting the prescription so it's there in case you REALLY need it sometime? I mean, okay, you might not be comfortably able to breastfeed Colin until it's out of your system, but you can't do that if you suffocate either... seems like it's well worth having to hand on a just-in-case basis unless I'm overlooking something.

If it helps, we've been giving Charlie Albuterol since he was about 6 months old. So it may be excreted into breastmilk but it's also considered safe for babies who are having respiratory distress. His most recent prescription (he's age 2.25 and 35 pounds) appears to be for the same dose that I take.

Huh. It sounds like you're the type of person my internist was thinking of when she prescribed an albuterol inhaler for my bronchitis. I didn't have any wheezing, and my pulsox was 97% on room air, so I thought it was a little odd, but I tried it, mostly because I was feeling pretty desperate after a month of sickness and coughing. Didn't help, but I don't grudge the $25 copay.

I wonder if it's a suitable item for donation.

I'm glad you don't have Asthma, but untreated Reactive Airway Disease can cause damage to your lungs and lead to problems down the line. This is why they are so quick to treat children now for asthma and RAD, even though they can't officially diagnose until the child is old enough to take the breathing test. My pediatrician said if it looks like asthma, they treat it as such; if it gets better on the medication they assume they were right.

As others have pointed out, you should be just fine taking the Albuterol.

One note - if you find yourself hyper or unable to sleep, or notice anything in Colin (unlikely, but still) then ask to be switched to Xopenex. It's a more refined (and more expensive) version of the medicine, and it is less likely to cause hyperactivity. Another rare side-effect is tremors. I freaked out when my little boy started shaking like he had Parkinson's. Turns out it is entirely from the medication and when he's not on it they quickly go away.

Take it. The Proventil labeling folks are being legalistically paranoid, and stopped at "Pregnant/breastfeeding, eek!"

Among other things, the current guidelines for asthma management (from the National Heart, Lung, and Blood Institute at the NIH) recommend inhaled albuterol for asthma exacerbations, including in children age 0-4.

Systemic absorption of albuterol is very low, and what little makes it into your bloodstream, and from there to your breastmilk, is safe. (No, you wouldn't want to administer it unless he needed it, but if he did, the *entire* dose you're taking would be safe for him, let alone the fraction of the fraction he'll get via your breastmilk.)

Well, the packaging insert is there for one reason.

If you know of a possible danger with your product, and you ignore it, you are liable for punitive damages. If you've taken action that a prudent person (or possibly, a prudent expert?) would have taken, you're liable for actual damages, not punitive damages.

So - it's there as a liability shield. That it's there says nothing about the actual risk; the warning is there in the event of an adverse jury finding of fact.

If the top drug company chemist/biologist/whatever would use it while breastfeeding her children (or recommend it to the mother of his children), the warning would still stay. There's no benefit to removing it from the drug company's perspective.

I think I would feel safe in using it while breastfeeding (um, you know, modulo being woman, having had children, etc.) unless I was in a bad emotional headspace (and thus, liable to have excessively anxious "what ifs?").

Recent research has shown that untreated symptoms that continue over time, like the coughing you are experiencing, create areas of your lungs that are chronically filled with gunk. NOT a good thing. My doctor looked me in the eye and said: take this medicine if you cough more than 2 or three times in a couple of hours. I said: Yes Sir, very respectfully, and since then have not had to take antibiotics for lung infections.

Bottom line. You aren't doing either of your children, your partner or your job any favors by refusing treatment. Low oxygen levels in your brain are a bad thing.

There's a guide called Hale's something (I forget the full title) which is considered the authoritative guide to which medications are safe while breastfeeding, and which ones aren't. VERY few aren't. LactMed is also recommended. I'd say go with what the database says. Honestly, the drug companies are very conservative, but you don't have to listen to them.

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