Keppra and Breastfeeding

[emilyc]

I am 6 months postpartum and have been exclusively breastfeeding my daughter as encouraged my neurologists. I took Keppra throughout my pregnancy at quite high dosages but am now taking 500mg twice a day. My daughter appears to be doing well and I have not noticed any negative impacts of Keppra so far. I can't seem to find longitudinal studies focusing on Keppra and breastfeeding and am wondering if there are any known negative impacts through the development of infancy to childhood and so on.
Additionally, would it be beneficial to "pump and dump"? I aim to feed my daughter right before I take my dose, however, from what I now Keppra is at its highest blood concentration within 1-2 hours. My daughter is currently nursing approximately every 3-4 hours. Would it be advisable to supplement with formula throughout the day while concentrations are highest while "pumping and dumping" to keep milk supply up and to continue nursing while concentrations are low, ex- in the evening/night and early morning?

[nicholec]

If she has been doing well and meeting milestones without complications, I don't think that adding formula or pumping and dumping is necessary. We do have some data on pediatric outcomes to infants exposed to antiepileptic drugs. This information is from our book (Hale's Medications and Mother's Milk):

A Norwegian study published in 2013 assessed the adverse effects of antiepileptic medications via breast milk in infants who were also exposed in utero. The study evaluated mothers' reports of their child's behavior, motor, social, and language skills at 6, 18, and 36 months using validated screening tools. At age 6 months, infants of mothers using antiepileptic drugs in utero had a significantly higher risk of impaired fine motor skills when compared to control group infants. In addition, infants exposed to multiple antiepileptics also had a greater risk of fine motor and social impairment when compared to control group infants. However, it was noted that continuous breastfeeding in the first 6 months did demonstrate a trend toward improvement in all of the developmental domains. In addition, the study demonstrated that continuous breastfeeding (daily for more than 6 months) in children of women using antiepileptic drugs in utero reduced the impairment in development at 6 and 18 months when compared with those with no breastfeeding or breastfeeding for less than 6 months. At 18 months, children in the drug-exposed group had an increased risk of impaired development compared with the reference group; the risks were highest in children who stopped breastfeeding early. Within the drug-exposed group, this impairment was statistically significant for autistic traits, 22.4% with discontinued breastfeeding were affected compared with 8.7% with prolonged breastfeeding. By 36 months, prenatal antiepileptic drug exposure was associated with impaired development such as autistic traits, reduced sentence completeness and aggressive symptoms, regardless of breastfeeding during the first year of life. The authors concluded that women with epilepsy should be encouraged to breastfeed regardless of their antiepileptic medication.

In 2014, a prospective observational study looked at long-term neurodevelopment of infants exposed to antiepileptic drugs in utero and lactation. This study included women taking carbamazepine, lamotrigine, phenytoin, or valproate as monotherapy for epilepsy. In this study, 42.9% of the infants were breastfed for a mean of 7.2 months. The IQ of these children at 6 years of age was statistically significantly lower in children who were exposed to valproate in utero (7-13 IQ points lower). It was also noted that higher doses of medication (primarily with valproate) were associated with lower IQ scores. The children’s IQ scores were found to be higher if the maternal IQ was higher, the mother took folic acid near the time of conception and if the child was breastfed (4 points higher). In addition, verbal abilities were also found to be significantly higher in children that were breastfed. Although this study has many limitations (e.g., small sample size, difficulties with patient follow-up) it does provide data up to age 6 that suggest benefits of breastfeeding are not outweighed by risks of maternal drug therapy in milk.

I also want you to keep in mind that the RID of Keppra is 3.4% - 7.8%. This does not mean that your daughter is getting 3.4% - 7.8% of your dose, however. It means that if she were given a prescription of Keppra for someone her size, that she would only be receiving 3.4%-7.8% of that dosage.

I hope this makes sense and eases your mind. Please let me know if you have any additional questions.

Nichole Campbell, MSN, APRN, NP-C

[url]https://pubmed.ncbi.nlm.nih.gov/24061295/[/url]
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[url]https://www.sciencedirect.com/science/article/abs/pii/S0028384316302067?via%3Dihub[/url]