Why does the pediatrician think that the Mestinon (generic -- pyridostigmine) is causing apneic episodes?  Is the baby exhibiting any other symptoms, especially hypotonia or weakness, or parasympathetic stimulation?  I assume thay have ruled out transient neonatal MG, which in itself would warrant use of pyridostigmine for the baby?

Apologies for the overly technical and confusing/disjointed discussion, it's a little complicated to explain:
Pyridostigmine is an acetylcholinesterase inhibitor, meaning that it prevents the breakdown of acetylcholine , making more of it available for transmission of nerve impulses primarily at the neuromuscular junction but also at the parasympathetic autonomic ganglia (patients with MG have antibodies directed towards the post-synaptic acetycholine receptors at the neuromuscular junction so having "extra" acetylcholine around helps them maintain muscular strength).  When too much acetylcholine is present, it is mostly a problem affecting the autonomic nervous system side of things rather than the peripheral nervous system, causing central parasympathetic stimulation -- symptoms such as drooling, bronchoconstriction, diarrhea, bradycardia.  Not apnea.  And in the absence of other signs or symptoms of parasympathetic stimulation such as these, I'm not sure how it can be responsible for apneic episodes in this infant.  It *can* cause muscle weakness and thus respiratory depression but typically only in someone with MG who has received too much (with the lack of receptors that can become paradoxically overstimulated in a cholinergic crisis, causing weakness), and I wouldn't ever expect to see this without the parasympathetic side effects in a normal infant.  It doesn't really make sense, especially from miniscule theoretical milk transfer.

Mom is on a low dose, and Hale does note that milk levels tend to be extremely low.  He rates it as L2 and the AAP lists it as usually compatible with breastfeeding, with no side effects mentioned.

What about sending baby home on a monitor for safety until this resolves?  It sounds like episodes are decreasing in frequency already.

Good luck to this mom,
Sarah Reece-Stremtan M.D. (peds anesthesiologist who administers neostigmine -- same class of drug -- everyday to infants and kids)

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