How to manage severe asthma when breastfeeding?

Question

Hello doctor,

I am a 27-year-old, and my asthma has been getting progressively worse since I had my twins 14 months ago. It used to be well controlled on just Albuterol as needed, but now I need my rescue inhaler multiple times every day and still feel short of breath. My allergist added Budesonide or Formoterol 160/4.5mcg twice daily, but I am worried about long-term steroid effects, especially since I am still breastfeeding both babies. The nighttime symptoms are the worst. I wake up wheezing and coughing almost every night, which means the babies wake up too, and none of us gets sleep.

My peak flow has dropped from 420 L/min before pregnancy to 280 L/min now, and my FeNO test showed 68 ppb, indicating lots of inflammation. I tried Omalizumab injections, but insurance denied coverage. The stress of managing twins plus work plus severe asthma is overwhelming, and my husband thinks the breathing problems are just anxiety, but they are definitely real. Could pregnancy hormones have permanently changed my asthma? Are there safe treatment options while nursing that would not affect milk production or the baby's development?

Thanks.

Answer 1

Hi,

Welcome to icliniq.com.

I can understand your concern.

I hear how exhausting and frightening this has been for you, caring for twins, managing work, and now struggling with asthma that feels so out of control, which would overwhelm anyone, and it is important to know that what you are experiencing is very real and not just anxiety.

Pregnancy and the postpartum period can definitely change asthma patterns in some women, with hormone shifts, immune changes, and the added demands of caring for infants making symptoms harder to control. Your drop in peak flow and elevated FeNO (fractional exhaled nitric oxide) clearly show significant airway inflammation, which explains the nightly wheezing and frequent need for your rescue inhaler.

The good news is that many asthma treatments, including inhaled corticosteroids like Budesonide and combination inhalers with Formoterol, are considered safe while breastfeeding, as only tiny amounts, if any, enter breast milk and they do not harm infant growth or development. If control remains poor, there are additional safe options such as Montelukast or even certain biologics, Dupilumab and Omalizumab, for example, have some reassuring data in breastfeeding, though insurance coverage can be a hurdle. Long-term steroid exposure is a valid concern, but the risks of uncontrolled asthma, low oxygen, frequent attacks, poor sleep, and stress on your heart and lungs are much greater for both you and your babies.

Working closely with your allergist or pulmonologist to adjust therapy, appeal insurance denials for biologics, and build a rescue plan can help you feel safer and more stable. It may also help to involve a lactation consultant, who can reassure you about medication safety while nursing, so you can focus on your health without guilt. You deserve rest, breathing comfort, and support. Addressing your asthma properly will not only protect your lungs but also give you the strength you need for yourself and your family.

I hope this information is helpful to you.

Thanks.