Lamotrigine and Keppra (Levetiracetam) in Breast Milk
Both lamotrigine and levetiracetam (Keppra) are considered safe during breastfeeding, and mothers taking these medications should be encouraged to breastfeed with appropriate infant monitoring. 1
Evidence-Based Safety Profile
Lamotrigine
- Lamotrigine is safe for breastfeeding with rare and usually mild adverse effects in exposed infants, even at high milk concentrations 2
- The relative infant dose (RID) can reach up to 36.33%, which is higher than many other antiepileptic drugs, but clinical significance remains low 3
- Close periodic monitoring of breastfed infants is recommended to detect any potential side effects early 2
Levetiracetam (Keppra)
- Levetiracetam is considered safe during breastfeeding according to current guidelines 1
- The RID is approximately 12.50%, which is moderate compared to other antiepileptic medications 3
- The FDA label states that levetiracetam is excreted in breast milk and recommends weighing the importance of the drug to the mother against potential risks to the infant 4
Clinical Management Algorithm
Step 1: Optimize Maternal Therapy
- Maintain seizure control with monotherapy at the minimum effective dose whenever possible 1
- Avoid polytherapy as it increases infant exposure to multiple medications 1
Step 2: Encourage Breastfeeding
- Do not discontinue breastfeeding based solely on antiepileptic drug use 1
- The benefits of breastfeeding for both mother and infant typically outweigh theoretical medication risks 5
Step 3: Monitor the Infant
Watch for these specific signs in breastfed infants:
- Excessive sedation or drowsiness 3
- Poor weight gain or feeding difficulties 3
- Irritability or unusual behavior 4
- Developmental milestones 2
Step 4: Consider Serum Monitoring (Optional)
- Infant serum drug concentration monitoring is advisable but not compulsory 6
- Consider checking levels if infant shows concerning symptoms or with high maternal doses 3
Important Caveats
Timing of feeds: While not strictly necessary, some mothers may choose to breastfeed just before taking their medication dose to minimize peak drug levels in milk, though this strategy has limited clinical evidence 5
Combination therapy concerns: If the mother is taking both lamotrigine and levetiracetam together (polytherapy), infant monitoring becomes more important due to cumulative exposure 1
Premature or ill infants: Exercise additional caution with premature infants or those with hepatic/renal impairment, as drug clearance may be reduced 5
Key Distinction from FDA Labeling
The FDA label for Keppra suggests considering discontinuation of either nursing or the drug 4, but current clinical guidelines from WHO and expert consensus strongly support continuing both breastfeeding and antiepileptic therapy 1. This reflects the evolution of evidence showing that untreated maternal seizures pose greater risks than medication exposure through breast milk 5.