The Safety of Breastfeeding While Taking Anti-seizure Medications

A person’s decision whether or not to breastfeed their baby should NOT be based on the fact that they take anti-seizure medications (ASMs). 

Breastfeeding has known benefits for mother and child, including improved neurodevelopment, decreased risk of infections and sudden infant death syndrome, decreased risk of maternal cancers, diabetes, and postpartum depression. 

Parents with epilepsy may feel nervous about breastfeeding while taking ASMs. However, infants are exposed to even less medication during breastfeeding than in utero, and there is little evidence to suggest that ASM exposure from breastmilk has clinical effects on newborns. Patients who take ASM medications under careful supervision throughout their pregnancy and while they breastfeed can be reassured that research supports breastfeeding is safe. 

Breastfeeding is a highly personal decision. Every patient should consider deciding before delivery how they will feed their baby and create a plan. They may be getting confusing messages, and your role is to provide them with accurate, research-backed data that helps them make informed choices.  Formula is also a healthy and effective alternative to breastfeeding that supports babies’ growth and development.

When counseling patients considering breastfeeding, always connect with their neurologist regarding ASM medication recommendations. Keep in mind that when a patient stops breastfeeding, their ASM drug distribution levels may change. As a result, the patient’s neurologist should have the patient’s ASM levels assessed and carefully monitored before, during, and after pregnancy. 

Topics covered on this page include:

ASMs and Breastfeeding

Three important studies — Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD), Neurodevelopmental Effects of Antiepileptic Drugs (NEAD),  and the Norwegian Mother and Child Cohort Study (MoBa) — examined the neurodevelopment of babies who were exposed to ASMs via breast milk, and the results were positive.

MONEAD

Most blood concentrations in breastfed infants of mothers taking carbamazepine, oxcarbazepine, valproate, levetiracetam, and topiramate were quite low, especially in relationship to the mother’s level and what the fetal level would have been during gestation. (Note: valproic acid is NOT a recommended ASM for patients with epilepsy who are considering having children.) More specifically:

  • Median lamotrigine levels in breastfed infants were 28.9% of the maternal levels.
  • Median levetiracetam levels in breastfed infants were 5.3% of maternal levels.

NEAD

Neurodevelopmental outcomes by age 6 were better in children who were breastfed compared to those who were not. This was true despite the breastfed children being continuously exposed to VPA, carbamazepine, lamotrigine, or phenytoin while in utero and during breastfeeding.

MoBa

Infant exposure to newer ASMs (cenobamate, perampanel, brivaracetam, eslicarbazepine, rufinamide, levetiracetam, topiramate, gabapentin, oxcarbazepine, lamotrigine, and vigabatrin) via breastmilk was not associated with negative neurodevelopment (such as lower IQ, autism, and autism spectrum disorder) at 36 months.

Caution should be taken with regular daily doses of ASMs such as benzodiazepines, barbiturates, and clobazam, as these can cause infant sedation. Babies of nursing parents who take these drugs should be carefully monitored for wakefulness and growth. More testing is needed to determine the neurodevelopmental effects of these drugs on babies.

The Benefits of Breastfeeding for Breastfeeding Parents & Babies

The benefits of breastfeeding — for babies and for nursing parents — have been extensively researched and well-documented, and these same benefits apply to patients with epilepsy and their babies.

Breastfed babies have a reduced risk of developing several serious conditions, such as:

  • Asthma
  • Type 1 diabetes
  • Obesity
  • Sudden infant death syndrome (SIDS)
  • Severe lower respiratory disease
  • Gastrointestinal infections

There is also evidence that breastfed babies have improved neurodevelopment and a lower chance of developing attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder.

Parents who breastfeed also have a lower risk of developing certain conditions, such as:

  • Postpartum depression
  • High blood pressure
  • Type 2 diabetes
  • Ovarian cancer
  • Breast cancer

There is a disparity in breastfeeding rates among parents of certain racial groups. The reasons for this disparity include cultural beliefs, limited or lack of access to educational resources regarding lactation, and lack of workplace support. You can learn more about racial and ethnic disparities in breastfeeding here.

Supporting Your Patients During Breastfeeding

Breastfeeding can be challenging. Support is imperative and—luckily—readily available. Encourage your patients who plan to breastfeed to have the following on their team for support and education and ensure that the neurologist, OB-GYN, and pediatrician are on the same page. Some of these clinicians may need to be educated on the safety of ASMs during breastfeeding by the neurologist.

  • Neurologist. The patient’s neurologist will devise an ASM tapering and level testing plan. The neurologist may also educate other care providers as needed regarding ASM safety in breastfeeding. 
  • Obstetrician. A patient’s obstetrician (OB) carefully monitors their postpartum health, both physical and mental. Patients can also rely on their OB to find support for breastfeeding, postpartum depression, and other postpartum concerns. A patient should also work with their OB on returning to the appropriate postpartum contraception immediately after delivery. 
  • Maternal fetal medicine specialist. A maternal-fetal medicine specialist (MFM), also known as a perinatologist, cares for those having complicated or high-risk pregnancies. As a patient with epilepsy, they may work with an MFM prior to pregnancy or if they develop a medical condition during pregnancy or have problems during delivery. They may also need to see an MFM during pregnancy if a problem is discovered with their fetus.
  • Gynecologist. The patient’s gynecologist will oversee their annual gynecological care, including preventive care, cancer screenings, and physical exams. 
  • Certified lactation consultant. Lactation consultants can offer informed advice on topics such as lactation techniques, latching, and pumping. They can also help patients work with their health insurance companies to procure effective lactation equipment, such as pumps and accessories. (Some lactation consultants may need to be educated on the safety of ASMs during breastfeeding, including the latest research that supports this.)
  • Pediatrician. Pediatricians focus on the baby’s health. They carefully monitor the baby’s growth and development and advise parents about infant care, and they should be informed about ASM safety in breastfeeding. Encourage patients to talk to their pediatricians during pregnancy about their breastfeeding plans. 
  • Partner and family. Lactating parents need the support of their loved ones to navigate what can be an overwhelming time. Encourage your patients to bring their support system into the planning process as early as their second trimester.
  • Third-party support. There are many organizations dedicated to providing support for breastfeeding parents, including  Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), kellymom, and the American Academy of Pediatrics (AAP).

Safe Breastfeeding Practices for Patients with Epilepsy

Establishing a breastfeeding routine is challenging for all parents. For parents with epilepsy, there are additional factors to consider to ensure their safety and the safety of their baby, including:

  • Seizure control is a priority. It is not uncommon for parents to put their child’s welfare ahead of their own. Help patients understand that seizure control, and thus prioritizing their own health and wellbeing, is an important part of caring for their baby.
  • Sleep is imperative. Sleep deprivation is a common seizure trigger for people with epilepsy. People with epilepsy should get at least one uninterrupted four-hour stretch of sleep at night and an additional two hours of naps during the day to reduce risk of seizure. Counsel your patients to set up feeding plans that include their baby’s other caregivers. Their plans should emphasize having help readily available so they can get the rest they need and should include shifts with other caregivers and passing the baby to a partner or helper for a bottle. 
  • Pump extra milk. Patients should invest in a high-grade pump and pump extra milk to be available for bottle feeding. Pumping is another strategy to help patients get sleep when they need it if they are breastfeeding.
  • Use formula to supplement. The decision to breastfeed doesn’t need to be all or nothing. The pressure to breastfeed exclusively can be overwhelming for new parents. Because sleep is so critical for patients with epilepsy, supplementing a breastfeeding plan with formula is a perfectly healthy way to feed a baby.
  • Ensure physical safety while feeding. Patients with epilepsy should always breastfeed in a seated position, either in a low chair or on the floor. And, for safety and sleep, parents should avoid having the baby sleep in bed with them. See our Safety and Support page for additional safety advice.

Breastfeeding & Folic Acid

All patients with epilepsy and childbearing potential should take at least 400-1000 mcg of folic acid (can be prescription, offered in the United States as tablets) and a prenatal vitamin daily, for at least three months before trying to get pregnant. The prenatal vitamin will add an additional 800-1000 mcg of folic acid to their daily intake. 

They should continue folic acid supplementation throughout the childbearing years, including during pregnancy, breastfeeding, and between babies. See our Folic Acid & Supplements page for additional information on taking folic acid before, during, and after pregnancy.

Breastfeeding & Contraception

This is one of the many myths that persist about breastfeeding. Nursing parents can and do get pregnant. Some studies found that up to 65% of women with epilepsy reported at least one unplanned pregnancy. Clinicians must discuss postpartum contraception options with their patients and care team before the birth of the baby and stress the need to restart contraception immediately after delivery. Visit our Contraception page for more details.

Guide Your Patients 

Research supports that breastfeeding is safe for parents who take ASMs and breastfeed, as well as for their babies. The known benefits of breastfeeding outweigh the risks, and a patient’s decision to breastfeed shouldn’t change because they’re on an anti-seizure medicine. This is great news to share with your patients looking for epilepsy and breastfeeding guidance. 

The postpartum period can be a challenging and confusing time. Infant care is a highly charged topic, and new parents often have advice and opinions coming at them from every direction. Be there for your patients with epilepsy who are considering breastfeeding. Listen without judgment to their concerns, advocate for them, and help them find the answers and the care they need. 

Reviewed by: Laura Kirkpatrick, MD, August 2023