Are antiepileptic (seizure) medications, such as lamotrigine and levetiracetam, safe to use during breastfeeding?

Antiepileptic Medications During Breastfeeding

Most standard antiepileptic medications, including lamotrigine and levetiracetam, are considered safe during breastfeeding and mothers with epilepsy should be encouraged to breastfeed with appropriate monitoring. 1, 2

Safety of Common Antiepileptic Drugs During Breastfeeding

Standard First-Line Antiepileptics

• The World Health Organization (WHO) recommends that standard breastfeeding recommendations remain appropriate for mothers taking phenobarbital, phenytoin, carbamazepine, and valproic acid 1
• Levetiracetam is excreted in breast milk, but most studies report infant serum levels well below pharmacological effect thresholds, making it compatible with breastfeeding 3, 2
• Lamotrigine may reach slightly higher levels in breastfed infants (up to approximately 30% of maternal serum concentrations) but is still considered quite safe with low risk during breastfeeding 4, 2

Monitoring Recommendations

• Infants should be monitored for potential side effects when mothers are taking antiepileptic medications, particularly watching for:
  • Sedation or excessive sleepiness 5
  • Poor feeding or weight gain 5
  • Irritability or jitteriness 5
• For medications with higher transfer rates (such as ethosuximide, phenobarbital, and zonisamide), more vigilant monitoring is advised 2

Specific Guidance by Medication Type

Very Low Risk Antiepileptics (Safe for Breastfeeding)

• Carbamazepine, valproic acid, and phenytoin show very low infant serum levels (≤10% of maternal levels) and extensive clinical experience supports their safety 6, 2
• Levetiracetam shows very low concentrations in breastfed infants and is considered compatible with breastfeeding 2, 7

Low to Moderate Risk Antiepileptics (Generally Safe with Monitoring)

• Lamotrigine requires monitoring due to slightly higher transfer rates but is still considered safe 4, 2
• Phenobarbital requires careful monitoring due to its slow elimination by nursing infants 6
• Gabapentin, oxcarbazepine, pregabalin, and topiramate are considered compatible with breastfeeding but with less documented safety profiles 7

High Risk/Contraindicated Antiepileptics

• Ethosuximide and felbamate are considered high risk and potentially incompatible with breastfeeding 4
• Regular use of benzodiazepines in high doses should be avoided, though occasional low-dose use is considered relatively safe 4

Clinical Approach to Breastfeeding on Antiepileptic Drugs

Best Practices

• Maintain seizure control with monotherapy at the minimum effective dose whenever possible 1, 2
• Avoid polytherapy when possible as it increases potential exposure to the infant 1
• For medications with higher transfer rates, consider:
  • Timing breastfeeding when drug concentrations in milk are lowest (typically before the mother's next dose) 5
  • Monitoring infant serum drug levels if concerns arise about potential toxicity 6

Long-Term Outcomes

• Prospective studies have not demonstrated negative developmental effects in children exposed to most antiepileptic drugs via breastmilk 5, 2
• The benefits of breastfeeding (nutritional, immunological, developmental, and psychological) generally outweigh the theoretical risks of antiepileptic medication exposure through breast milk 5

Important Caveats

• Sudden weaning should be avoided to prevent withdrawal symptoms in the infant 4
• The decision to breastfeed should consider not only the specific medication but also:
  • Medication dose and maternal serum levels 4
  • Number of medications being used 4
  • The condition of the newborn (premature infants may be more vulnerable) 4
• Women with epilepsy should be encouraged to breastfeed with appropriate monitoring, as the benefits typically outweigh the risks 5, 2