Codeine and nursing moms -- rare but dangerous side-effect (death ment'd)

This is super-rare, but as they mention in the article codeine is
prescribed to so many women, even though such a death is very rare it
is important to get the message out that codeine can be dangerous to
nurslings.

Elle

Codeine can turn toxic in nursing mothers: Gene transformed drug into
morphine, which killed infant

The Globe and Mail.

Wed 10 May 2006

LISA PRIEST TORONTO Some mothers prescribed codeine after childbirth
carry multiple copies of a gene capable of transforming the common pain
reliever into morphine, producing a toxic breast milk that in one case
killed a newborn.

The case, to be presented today at a scientific meeting in Toronto,
will reveal what is described as the first documented fatality of its
kind -- a morphine overdose through the ingestion of breast milk, said
Gideon Koren, director of the Hospital for Sick Children's Motherisk
Program.

"An estimated 150,000 women a year receive codeine following
childbirth," said Dr. Koren, adding that it is commonly prescribed to
alleviate the pain of episiotomies and cesarean sections. "Even if the
gene is relatively rare, you're talking about a large number of kids at
risk."

In this case, the mother of a baby boy was prescribed the tablets, a
mixture of codeine and acetaminophen last spring, after an episiotomy,
a surgical procedure used to enlarge the vaginal opening before
childbirth.

For two weeks, the woman took the drug, not knowing she had multiple
copies of the gene, which rapidly metabolizes the drug, Dr. Koren said.
As the first-time mother nursed her newborn son, he became very sleepy.
He became more difficult to breastfeed and more lethargic by his
seventh day.

Concerned, she brought the baby to the doctor. Her physician told her:
"Let's wait," according to Dr. Koren, adding that most doctors are not
aware of the problem.

By the 12th day, the boy had grey skin and decreased milk intake. He
died at home on the 13th day.

About 1 per cent of Caucasians are estimated to have multiple copies of
the gene. That compares with 30 per cent of Ethiopians and 10 per cent
of Southern Europeans, who are estimated to have the gene in multiple
copies.

Strategies to prevent overdoses include not prescribing codeine to
nursing mothers, using the drug in lower amounts, and watching babies
for signs of morphine overdose and in suspected cases, giving its
antidote, naloxone. Testing mothers for the gene is considered a less
plausible approach, largely because of cost, Dr. Koren said.

"The fact that codeine is taken by so many women and some have this
gene duplication makes it a serious situation," said Dr. Koren, who is
also professor of pediatrics, pharmacology, pharmacy and medical
genetics at the University of Toronto.

He is to present his findings to the Canadian Therapeutic Congress, a
meeting of doctors, scientists and pharmacists who specialize in
pharmaceuticals.

Although the American Academy of Pediatrics lists codeine as compatible
with breastfeeding, Dr. Koren said there is a "lack of sufficient
published data to support this recommendation."

Whatever the case, the drug is popular and is used to alleviate all
forms of pain.

Canadian pharmacies dispensed more than 8.7 million prescriptions for
the codeine and acetaminophen combination pills from April of 2005 to
March of 2006, according to Sue Cavallucci of IMS Health, a private
health-information and consulting-services company that serves the
pharmaceutical and health-care industries. The drug is made by several
drug companies.

In this case, solving the mystery of how the baby died was no easy
feat; it required medical detective work worthy of a novel.

When the baby boy was sent to the coroner's office, they initially
thought he likely succumbed to sudden infant death syndrome, said Jim
Cairns, deputy chief coroner for Ontario.

Toxicology tests were performed on the baby, routine for all sudden and
unexplained deaths of children under 2. The tests revealed a morphine
level that "wasn't just at the lower end of fatal, it was sky high,"
Dr. Cairns said. "There was a huge level of morphine that none of us
could figure out."

Dr. Cairns contacted Dr. Koren who had a hunch the mother was what is
medically referred to as an "ultra rapid metabolizer" of 2D6, a liver
enzyme, that transforms codeine into morphine. This enzyme is in the
cytochrome P450 family, which processes 25 per cent of all drugs,
including those that can cause the most adverse reactions.

This mother exhibited telltale signs of having multiple copies of the
2D6 gene: she suffered constipation and severe drowsiness after taking
codeine, Dr. Koren said.

To deal with severe episiotomy pain, she was instructed to take two
tablets, each containing a mixture of 30 milligrams of codeine and 500
milligrams of acetaminophen, four times a day or every six hours. On
the second day, the dose was cut in half -- she was told to take one
tablet every six hours, Dr. Koren said.

Doctors were able to solve the mystery, in part, because she had stored
the breast milk she had pumped when her baby wasn't feeding well.

When Dr. Koren tested it, high levels of morphine were revealed. The
levels were about ten-fold what the infant would have been given for
pain after an operation.

Though the Ontario mother did not want to be identified, she wanted
others to know about the problem. She has since given birth to another
child, Dr. Koren said.

"She's very eager for other women to know," he said.

"If moms know the dose should be limited, it's important. And anything
that looks unusual, mothers should seek medical advice."

That is scary, particularly as I was on codeine regularly, though not
immediately after the birth, as I had no interventions, even though I had my
SPD pain and what not, I gritted my teeth for a while and didn't take any
pain meds regularly until Ada was 6 weeks old, I guess we'd know by now if I
had the duplication. I suppose one of the morals of the story is if the mum
is taking drugs, you observe the infant closely.

Anne

wrote:
This is super-rare, but as they mention in the article codeine is
prescribed to so many women, even though such a death is very rare it
is important to get the message out that codeine can be dangerous to
nurslings.

Elle

Codeine can turn toxic in nursing mothers: Gene transformed drug into
morphine, which killed infant

The Globe and Mail.

Wed 10 May 2006

LISA PRIEST TORONTO Some mothers prescribed codeine after childbirth
carry multiple copies of a gene capable of transforming the common pain
reliever into morphine, producing a toxic breast milk that in one case
killed a newborn.

The case, to be presented today at a scientific meeting in Toronto,
will reveal what is described as the first documented fatality of its
kind -- a morphine overdose through the ingestion of breast milk, said
Gideon Koren, director of the Hospital for Sick Children's Motherisk
Program.

"An estimated 150,000 women a year receive codeine following
childbirth," said Dr. Koren, adding that it is commonly prescribed to
alleviate the pain of episiotomies and cesarean sections. "Even if the
gene is relatively rare, you're talking about a large number of kids at
risk."

In this case, the mother of a baby boy was prescribed the tablets, a
mixture of codeine and acetaminophen last spring, after an episiotomy,
a surgical procedure used to enlarge the vaginal opening before
childbirth.

For two weeks, the woman took the drug, not knowing she had multiple
copies of the gene, which rapidly metabolizes the drug, Dr. Koren said.
As the first-time mother nursed her newborn son, he became very sleepy.
He became more difficult to breastfeed and more lethargic by his
seventh day.

Concerned, she brought the baby to the doctor. Her physician told her:
"Let's wait," according to Dr. Koren, adding that most doctors are not
aware of the problem.

By the 12th day, the boy had grey skin and decreased milk intake. He
died at home on the 13th day.

About 1 per cent of Caucasians are estimated to have multiple copies of
the gene. That compares with 30 per cent of Ethiopians and 10 per cent
of Southern Europeans, who are estimated to have the gene in multiple
copies.

Strategies to prevent overdoses include not prescribing codeine to
nursing mothers, using the drug in lower amounts, and watching babies
for signs of morphine overdose and in suspected cases, giving its
antidote, naloxone. Testing mothers for the gene is considered a less
plausible approach, largely because of cost, Dr. Koren said.

"The fact that codeine is taken by so many women and some have this
gene duplication makes it a serious situation," said Dr. Koren, who is
also professor of pediatrics, pharmacology, pharmacy and medical
genetics at the University of Toronto.

He is to present his findings to the Canadian Therapeutic Congress, a
meeting of doctors, scientists and pharmacists who specialize in
pharmaceuticals.

Although the American Academy of Pediatrics lists codeine as compatible
with breastfeeding, Dr. Koren said there is a "lack of sufficient
published data to support this recommendation."

Whatever the case, the drug is popular and is used to alleviate all
forms of pain.

Canadian pharmacies dispensed more than 8.7 million prescriptions for
the codeine and acetaminophen combination pills from April of 2005 to
March of 2006, according to Sue Cavallucci of IMS Health, a private
health-information and consulting-services company that serves the
pharmaceutical and health-care industries. The drug is made by several
drug companies.

In this case, solving the mystery of how the baby died was no easy
feat; it required medical detective work worthy of a novel.

When the baby boy was sent to the coroner's office, they initially
thought he likely succumbed to sudden infant death syndrome, said Jim
Cairns, deputy chief coroner for Ontario.

Toxicology tests were performed on the baby, routine for all sudden and
unexplained deaths of children under 2. The tests revealed a morphine
level that "wasn't just at the lower end of fatal, it was sky high,"
Dr. Cairns said. "There was a huge level of morphine that none of us
could figure out."

Dr. Cairns contacted Dr. Koren who had a hunch the mother was what is
medically referred to as an "ultra rapid metabolizer" of 2D6, a liver
enzyme, that transforms codeine into morphine. This enzyme is in the
cytochrome P450 family, which processes 25 per cent of all drugs,
including those that can cause the most adverse reactions.

This mother exhibited telltale signs of having multiple copies of the
2D6 gene: she suffered constipation and severe drowsiness after taking
codeine, Dr. Koren said.

To deal with severe episiotomy pain, she was instructed to take two
tablets, each containing a mixture of 30 milligrams of codeine and 500
milligrams of acetaminophen, four times a day or every six hours. On
the second day, the dose was cut in half -- she was told to take one
tablet every six hours, Dr. Koren said.

Doctors were able to solve the mystery, in part, because she had stored
the breast milk she had pumped when her baby wasn't feeding well.

When Dr. Koren tested it, high levels of morphine were revealed. The
levels were about ten-fold what the infant would have been given for
pain after an operation.

Though the Ontario mother did not want to be identified, she wanted
others to know about the problem. She has since given birth to another
child, Dr. Koren said.

"She's very eager for other women to know," he said.

"If moms know the dose should be limited, it's important. And anything
that looks unusual, mothers should seek medical advice."


Wow, thanks for posting the info!


Jo

Wouldn't codeine usually be given while in the hospital, so the baby could
be observed before the mother went home? I know I've been on codeine pretty
much as soon as the epidural was taken out after both C-sections, but even
with Alli, it was several days before we went home.

--
Donna DeVore Metler
Orff Music Specialist/Kindermusik
Mother to Angel Brian Anthony 1/1/2002, 22 weeks, severe PE/HELLP
And Allison Joy, 11/25/04 (35 weeks, PIH, Pre-term labor)

"Donna Metler" wrote in message
. ..
Wouldn't codeine usually be given while in the hospital, so the baby could
be observed before the mother went home? I know I've been on codeine
pretty
much as soon as the epidural was taken out after both C-sections, but even
with Alli, it was several days before we went home.



I was given codeine while at the hospital and a prescription to take home
with me. I was in the hospital for less than 24 hrs after the birth (my
choice) and was told it "might make the baby sleepy, but won't hurt her".
If I were the mom, I would have thought the sleepiness was due to the
codeine and was harmless. It took days for the full symptoms to develop and
by then it was too late.
Tragic.

Amy

Several comments:

Let's see, 150,000 women are given codiene a year and we have one
reported death. Yes, I'd say it is pretty rare.

They said codiene is most commonly given for episiotomies and
c-sections. I have an idea. Let's quit doing episiotomies and
reduce the c-section rate. The blantent stupidity of the medical
profession at times amazes me. I'm sure the formula companies
will find some way to use it to discourage breastfeeding. Grrrrr!

Some of the other comments in the article really bothered me.

The mom had mumtiple markers for the gene, and the possibility
of morphine poisoning was not even considered.

The doctor saw the baby at one week of increasing legarthy and
said "let's wait" without any kind of diagnostic. Unwise advice!

Based on this he was obviously not adequately trained in either
breastfeeding or drug toxicology. Grrrrr, again!

This is not just tragic; it is inexcusable!

Larry

Given that I'm going to give birth again in a few months, this is rather
disturbing for me. I needed no pain management with my first and was
disturbingly healthy all through the breastfeeding stage, but you never know
what will happen with the next one...

Another disturbing thing is that this reminded me that when my sister gave
birth by cesarian section she was offered morphine for pain management.
Given it transfers to a breastfed child, this is a rather scary practice our
hospitals are employing. Now I'm glad she refused the morphine, given that
she had given birth to tiny premature twins (both under 1kg each)!

wrote in message
oups.com...
This is super-rare, but as they mention in the article codeine is
prescribed to so many women, even though such a death is very rare it
is important to get the message out that codeine can be dangerous to
nurslings.

Elle

Codeine can turn toxic in nursing mothers: Gene transformed drug into
morphine, which killed infant

The Globe and Mail.

Wed 10 May 2006

LISA PRIEST TORONTO Some mothers prescribed codeine after childbirth
carry multiple copies of a gene capable of transforming the common pain
reliever into morphine, producing a toxic breast milk that in one case
killed a newborn.

The case, to be presented today at a scientific meeting in Toronto,
will reveal what is described as the first documented fatality of its
kind -- a morphine overdose through the ingestion of breast milk, said
Gideon Koren, director of the Hospital for Sick Children's Motherisk
Program.

"An estimated 150,000 women a year receive codeine following
childbirth," said Dr. Koren, adding that it is commonly prescribed to
alleviate the pain of episiotomies and cesarean sections. "Even if the
gene is relatively rare, you're talking about a large number of kids at
risk."

In this case, the mother of a baby boy was prescribed the tablets, a
mixture of codeine and acetaminophen last spring, after an episiotomy,
a surgical procedure used to enlarge the vaginal opening before
childbirth.

For two weeks, the woman took the drug, not knowing she had multiple
copies of the gene, which rapidly metabolizes the drug, Dr. Koren said.
As the first-time mother nursed her newborn son, he became very sleepy.
He became more difficult to breastfeed and more lethargic by his
seventh day.

Concerned, she brought the baby to the doctor. Her physician told her:
"Let's wait," according to Dr. Koren, adding that most doctors are not
aware of the problem.

By the 12th day, the boy had grey skin and decreased milk intake. He
died at home on the 13th day.

About 1 per cent of Caucasians are estimated to have multiple copies of
the gene. That compares with 30 per cent of Ethiopians and 10 per cent
of Southern Europeans, who are estimated to have the gene in multiple
copies.

Strategies to prevent overdoses include not prescribing codeine to
nursing mothers, using the drug in lower amounts, and watching babies
for signs of morphine overdose and in suspected cases, giving its
antidote, naloxone. Testing mothers for the gene is considered a less
plausible approach, largely because of cost, Dr. Koren said.

"The fact that codeine is taken by so many women and some have this
gene duplication makes it a serious situation," said Dr. Koren, who is
also professor of pediatrics, pharmacology, pharmacy and medical
genetics at the University of Toronto.

He is to present his findings to the Canadian Therapeutic Congress, a
meeting of doctors, scientists and pharmacists who specialize in
pharmaceuticals.

Although the American Academy of Pediatrics lists codeine as compatible
with breastfeeding, Dr. Koren said there is a "lack of sufficient
published data to support this recommendation."

Whatever the case, the drug is popular and is used to alleviate all
forms of pain.

Canadian pharmacies dispensed more than 8.7 million prescriptions for
the codeine and acetaminophen combination pills from April of 2005 to
March of 2006, according to Sue Cavallucci of IMS Health, a private
health-information and consulting-services company that serves the
pharmaceutical and health-care industries. The drug is made by several
drug companies.

In this case, solving the mystery of how the baby died was no easy
feat; it required medical detective work worthy of a novel.

When the baby boy was sent to the coroner's office, they initially
thought he likely succumbed to sudden infant death syndrome, said Jim
Cairns, deputy chief coroner for Ontario.

Toxicology tests were performed on the baby, routine for all sudden and
unexplained deaths of children under 2. The tests revealed a morphine
level that "wasn't just at the lower end of fatal, it was sky high,"
Dr. Cairns said. "There was a huge level of morphine that none of us
could figure out."

Dr. Cairns contacted Dr. Koren who had a hunch the mother was what is
medically referred to as an "ultra rapid metabolizer" of 2D6, a liver
enzyme, that transforms codeine into morphine. This enzyme is in the
cytochrome P450 family, which processes 25 per cent of all drugs,
including those that can cause the most adverse reactions.

This mother exhibited telltale signs of having multiple copies of the
2D6 gene: she suffered constipation and severe drowsiness after taking
codeine, Dr. Koren said.

To deal with severe episiotomy pain, she was instructed to take two
tablets, each containing a mixture of 30 milligrams of codeine and 500
milligrams of acetaminophen, four times a day or every six hours. On
the second day, the dose was cut in half -- she was told to take one
tablet every six hours, Dr. Koren said.

Doctors were able to solve the mystery, in part, because she had stored
the breast milk she had pumped when her baby wasn't feeding well.

When Dr. Koren tested it, high levels of morphine were revealed. The
levels were about ten-fold what the infant would have been given for
pain after an operation.

Though the Ontario mother did not want to be identified, she wanted
others to know about the problem. She has since given birth to another
child, Dr. Koren said.

"She's very eager for other women to know," he said.

"If moms know the dose should be limited, it's important. And anything
that looks unusual, mothers should seek medical advice."

Another disturbing thing is that this reminded me that when my sister gave
birth by cesarian section she was offered morphine for pain management.
Given it transfers to a breastfed child, this is a rather scary practice
our hospitals are employing. Now I'm glad she refused the morphine, given
that she had given birth to tiny premature twins (both under 1kg each)!

c-section is a major operation, weaker painkillers just may not kick it yes
it transfers, but at least it's know in what amounts it transfers, yes, if
you can manage without it then you should, but if you need it you should get
it. I've not had the issue of pain relief post birth (both vaginal
deliveries, with tears, but unstitched), but I have had morphine both IV and
orally for various reasons whilst breastfeeding both children and each time
I had it, I would have to have been a very strong willed person to deny it
when I was in agony, I've always waited as long as possible to breastfeed
afterwards.

Anne

Yeah, I fully understand that sometimes the pain is strong enough to warrant
it. And that no-one here is out to hurt their baby.

I was just thinking of the effect even that known amount might have had on
premature, underdeveloped babies, barely surviving in humidicribs, one of
them on breathing apparatus.

"Anne Rogers" wrote in message
...
Another disturbing thing is that this reminded me that when my sister
gave birth by cesarian section she was offered morphine for pain
management. Given it transfers to a breastfed child, this is a rather
scary practice our hospitals are employing. Now I'm glad she refused the
morphine, given that she had given birth to tiny premature twins (both
under 1kg each)!

c-section is a major operation, weaker painkillers just may not kick it
yes it transfers, but at least it's know in what amounts it transfers,
yes, if you can manage without it then you should, but if you need it you
should get it. I've not had the issue of pain relief post birth (both
vaginal deliveries, with tears, but unstitched), but I have had morphine
both IV and orally for various reasons whilst breastfeeding both children
and each time I had it, I would have to have been a very strong willed
person to deny it when I was in agony, I've always waited as long as
possible to breastfeed afterwards.

Anne

I was just thinking of the effect even that known amount might have had on
premature, underdeveloped babies, barely surviving in humidicribs, one of
them on breathing apparatus.

isn't that what donor breastmilk is for, she might have needed 24 hrs
recover before trying to express colostrum, which isn't the easiest of
things to do, but you're right, exposing an almost 1 year old to a bit of
morphine is not the same as a tiny preemie to a regular dose of it

Anne