Except in rare circumstances, women with epilepsy are encouraged to breast-feed.1 Most anti-epileptic medications pass into breast milk, but concentrations depend on drug type, dosage and the way that the mother and baby both metabolise the drug.1-3 Total amounts of anti-epileptic drug transferred to the baby through breast milk are usually smaller than amounts transferred through the placenta.4,5The team involved in managing the mother’s epilepsy can advise on issues relating to drug metabolism and secretion of anti-epileptic drugs into breast milk. If you suspect that the breast-fed baby shows symptoms of hypersensitivity to anti-epileptic drugs (e.g. rash, drowsiness, lethargy, reduced feeding6), seek guidance from the mother’s specialist epilepsy team.  It may be necessary to measure the plasma level of anti-epileptic drugs in the baby; mixed feeding can be advisable.7 There may be a delay in the baby showing symptoms suggestive of hypersensitivity or toxicity. Anti-epileptic drugs may accumulate because drug elimination mechanisms are not fully developed in early infancy.4 Babies who exhibit sedative effects from anti-epileptic drugs may fail to suckle adequately. Therefore, in the early days post-birth the mother may need extra help to stimulate the let-down reflex (e.g. expression, massage, taking a warm bath and regularly offering the breast). If there are signs that the baby’s growth and nutrition is suboptimal, supplementation may be necessary, ideally using expressed breast milk. Full breast-feeding can be undertaken once an adequate milk supply is established and the mother remains seizure-free.
Good support from the mother’s friends and family is particularly important for maintaining her well-being while breast-feeding.8 Disturbed sleep patterns may cause some mothers with epilepsy to have more frequent seizures. To reduce disruption to her sleep pattern, the mother can consider expressing milk during the day, and asking a partner or friend to feed the baby at night. The mother may also be eligible for disability living allowance to help her look after her baby, even if this is something to which she is not usually entitled.
Mothers and fathers with epilepsy may need practical advice on maintaining their child’s safety, should they have a seizure. For example, it may be helpful to evaluate how the mother is positioned when feeding. It may be safer for her to “nest” on the floor, on cushions or blankets, or sitting in an easy chair during feeds, to help protect the baby in case a seizure occurs. When sitting, the mother should elevate her feet so that the baby will roll onto her lap if she has a seizure. Epilepsy Action has produced a comprehensive safety guide for parents with epilepsy (see Further Information, below).

References1. Sabers A et al. Managing antiepileptic drugs during pregnancy and lactation. Curr Opin Neurol  2009; 22: 157–161.

2. Pack AM. Therapy insight: clinical management of pregnant women with epilepsy. Nat Clin Pract Neurol 2006; 2: 190–200.

3. Harden CL et al. Management issues for women with epilepsy--focus on pregnancy (an evidence-based review): III. Vitamin K, folic acid, blood levels, and breast-feeding: Report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Epilepsia 2009; 50: 1247–1255.

4. Crawford P. Epilepsy and pregnancy. Seizure 2001; 10:  212–219. 

5. Aguglia U et al. Italian Consensus Conference on Epilepsy and Pregnancy, Labour and Puerperium. Epilepsia 2009; 50: 7–23.

6. Winterbottom J. Mothers in Mind resource pack for health visitors and community practitioners. Epilepsy Action, 2008 (see Further information, below).

7. Crawford P. Best practice guidelines for the management of women with epilepsy. Epilepsia 2005; 46: 117–124.

8. Rousseau JB. Meeting the needs of the postpartum woman with epilepsy. MCN Am J Matern Child Nurs 2008; 33: 84–89.

ResourcesEpilepsy Action Resource Pack for Health Care Professionals. Available at: http://www.epilepsy.org.uk/info/women/breastfeeding.html. Accessed 24 Sep 2009.

Epilepsy Action. Safety Guide for Parents with Epilepsy. Available at: http://www.epilepsy.org.uk/info/caringforchildren.

From: Journal of Family Health Care Bulletin. Directory of Breast-Feeding Advice. December 2009. Published with JFHC 2009; 19(6). http://www.jfhc.co.uk/images/stories/breastfeeding.pdf