Breastfeeding recommendations for women taking anti-seizure medications

  • Author Footnotes
    1 Neurology at Boston University School of Medicine, 72 E Albany Street, Boston, MA 02118, United States.
    Abrar O. Al-Faraj
    1 Neurology at Boston University School of Medicine, 72 E Albany Street, Boston, MA 02118, United States.
    Boston Medical Center, Boston University School of Medicine, United States
    Search for articles by this author
  • Author Footnotes
    2 ORCID ID = 0000-0001-5041-1383.
    Trudy D. Pang
    Corresponding author at: Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, West Campus, Boston, MA 02215-3908, United States.
    2 ORCID ID = 0000-0001-5041-1383.
    Beth Israel Deaconess Medical Center, Harvard Medical School, United States
    Search for articles by this author
  • Author Footnotes
    1 Neurology at Boston University School of Medicine, 72 E Albany Street, Boston, MA 02118, United States.
    2 ORCID ID = 0000-0001-5041-1383.


      • Breastfeeding is safe and should be encouraged for most women taking most commonly prescribed anti-seizure medications.
      • Infants breastfed by mothers taking anti-seizure medications do not experience long-term neurodevelopmental side effects and have been shown to have slightly better developmental outcomes compared to non-breastfed infants.
      • Rates of breastfeeding in women with epilepsy remain lower than the general population, which are likely due to factors related to clinicians and unique challenges in women with epilepsy, and highlights the need for effective breastfeeding counseling and additional supportive measures to improve breastfeeding practices in women with epilepsy.


      The literature regarding breastfeeding and effects of anti-seizure medication (ASM) exposure on the breastfed infant has been evolving rapidly over the last decade as new studies advance our understanding of the extent of medication exposure via breastfeeding and the long-term developmental outcomes of breastfed infants. Currently, strong evidence supports the safety of breastfeeding for women with epilepsy (WWE) taking most prescribed ASMs. In this review, we present a comprehensive overview of the data regarding ASM exposure in breastfed infants and neurodevelopmental outcomes in breastfed infants of mothers taking various ASMs. In addition, we present current breastfeeding recommendations and the reported adverse effects of various ASMs to facilitate decision making in the clinical care of WWE.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Epilepsy & Behavior
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. Harden CL, Pennell PB, Koppel BS, Hovinga CA, Gidal B, Meador KJ, et al. Practice Parameter update: Management issues for women with epilepsy—Focus on pregnancy (an evidence-based review): Vitamin K, folic acid, blood levels, and breastfeeding. Neurology 2009;73:142 LP–149.

        • Meador K.J.
        • Baker G.A.
        • Browning N.
        • Clayton-Smith J.
        • Combs-Cantrell D.T.
        • Cohen M.
        • et al.
        Effects of breastfeeding in children of women taking antiepileptic drugs.
        Neurology. 2010; 75: 1954-1960
        • Meador K.J.
        • Baker G.A.
        • Browning N.
        • Cohen M.J.
        • Bromley R.L.
        • Clayton-Smith J.
        • et al.
        Breastfeeding in children of women taking antiepileptic drugs: Cognitive outcomes at age 6 years.
        JAMA Pediatr. 2014; 168: 729-736
        • Hao N.
        • Jiang H.
        • Wu M.
        • Pan T.
        • Yan B.o.
        • Liu J.
        • et al.
        Breastfeeding initiation, duration and exclusivity in mothers with epilepsy from South West China.
        Epilepsy Res. 2017; 135: 168-175
        • Al-Faraj A.O.
        • Pandey S.
        • Herlihy M.M.
        • Pang T.D.
        Factors affecting breastfeeding in women with epilepsy.
        Epilepsia. 2021; 62: 2171-2179
        • Eidelman A.I.
        • Schanler R.J.
        • Johnston M.
        • Landers S.
        • Noble L.
        • Szucs K.
        • et al.
        Breastfeeding and the use of human milk.
        Pediatrics. 2012; 129: e827-e841
        • Krol K.M.
        • Grossmann T.
        Psychological effects of breastfeeding on children and mothers.
        Bundesgesundheitsblatt - Gesundheitsforsch - Gesundheitsschutz. 2018; 61: 977-985
        • Frank N.M.
        • Lynch K.F.
        • Uusitalo U.
        • Yang J.
        • Lönnrot M.
        • Virtanen S.M.
        • et al.
        The relationship between breastfeeding and reported respiratory and gastrointestinal infection rates in young children.
        BMC Pediatr. 2019; 19: 339
        • Meek J.Y.
        • Feldman-Winter L.
        • Noble L.
        Optimal duration of breastfeeding.
        Pediatrics. 2020; 146 (e2020021063)
        • Guxens M.
        • Mendez M.A.
        • Moltó-Puigmartí C.
        • Julvez J.
        • García-Esteban R.
        • Forns J.
        • et al.
        Breastfeeding, long-chain polyunsaturated fatty acids in colostrum, and infant mental development.
        Pediatrics. 2011; 128: e880-e889
        • Bernard J.Y.
        • De Agostini M.
        • Forhan A.
        • Alfaiate T.
        • Bonet M.
        • Champion V.
        • et al.
        Breastfeeding duration and cognitive development at 2 and 3 years of age in the EDEN mother-child cohort.
        J Pediatr. 2013; 163: 36-42.e1
        • Julvez J.
        • Guxens M.
        • Carsin A.-E.
        • Forns J.
        • Mendez M.
        • Turner M.C.
        • et al.
        A cohort study on full breastfeeding and child neuropsychological development: the role of maternal social, psychological, and nutritional factors.
        Dev Med Child Neurol. 2014; 56: 148-156
        • Dias C.C.
        • Figueiredo B.
        Breastfeeding and depression: a systematic review of the literature.
        J Affect Disord. 2015; 171: 142-154
        • Hamdan A.
        • Tamim H.
        The relationship between postpartum depression and breastfeeding.
        Int J Psychiatry Med. 2012; 43: 243-259
        • Brandt K.A.
        • Andrews C.M.
        • Kvale J.
        Mother-infant interaction and breastfeeding outcome 6 weeks after birth.
        J Obstet Gynecol Neonatal Nurs. 1998; 27: 169-174
        • Birnbaum A.K.
        • Meador K.J.
        • Karanam A.
        • Brown C.
        • May R.C.
        • Gerard E.E.
        • et al.
        Antiepileptic drug exposure in infants of breastfeeding mothers with epilepsy.
        JAMA Neurol. 2020; 77: 441
        • Veiby G.
        • Engelsen B.A.
        • Gilhus N.E.
        Early child development and exposure to antiepileptic drugs prenatally and through breastfeeding: A prospective cohort study on children of women with epilepsy.
        JAMA Neurol. 2013; 70: 1367-1374
        • Rauchenzauner M.
        • Kiechl-Kohlendorfer U.
        • Rostasy K.
        • Luef G.
        Old and new antiepileptic drugs during pregnancy and lactation - report of a case.
        Epilepsy Behav. 2011; 20: 719-720
        • Pennell P.B.
        • Gidal B.E.
        • Sabers A.
        • Gordon J.
        • Perucca E.
        Pharmacology of antiepileptic drugs during pregnancy and lactation.
        Epilepsy Behav. 2007; 11: 263-269
        • Anderson P.O.
        • Sauberan J.B.
        Modeling drug passage into human milk.
        Clin Pharmacol Ther. 2016; 100: 42-52
        • Ito S.
        • Koren G.
        A novel index for expressing exposure of the infant to drugs in breast milk.
        Br J Clin Pharmacol. 1994; 38: 99-102
        • Anderson P.O.
        • Manoguerra A.S.
        • Valdés V.
        A review of adverse reactions in infants from medications in breastmilk.
        Clin Pediatr (Phila). 2016; 55: 236-244
        • Tomson T.
        • Battino D.
        • Bonizzoni E.
        • Craig J.
        • Lindhout D.
        • Perucca E.
        • et al.
        Comparative risk of major congenital malformations with eight different antiepileptic drugs: a prospective cohort study of the EURAP registry.
        Lancet Neurol. 2018; 17: 530-538
        • López-Fraile I.P.
        • Cid A.O.
        • Juste A.O.
        • Modrego P.J.
        Levetiracetam plasma level monitoring during pregnancy, delivery, and postpartum: Clinical and outcome implications.
        Epilepsy Behav. 2009; 15: 372-375
        • Ylikotila P.
        • Ketola R.A.
        • Timonen S.
        • Malm H.
        • Ruuskanen J.O.
        Early pregnancy cerebral venous thrombosis and status epilepticus treated with levetiracetam and lacosamide throughout pregnancy.
        Reprod Toxicol. 2015; 57: 204-206
        • Pennell P.B.
        Antiepileptic drug pharmacokinetics during pregnancy and lactation.
        Neurology. 2003; 61: 35-42
        • Ohman I.
        • Vitols S.
        • Tomson T.
        Lamotrigine in pregnancy: Pharmacokinetics during delivery, in the neonate, and during lactation.
        Epilepsia. 2000; 41: 709-713
        • Nordmo E.
        • Aronsen L.
        • Wasland K.
        • Småbrekke L.
        • Vorren S.
        Severe apnea in an infant exposed to lamotrigine in breast milk.
        Ann Pharmacother. 2009; 43: 1893-1897
        • Mazzucchelli I.
        • Onat F.Y.
        • Ozkara C.
        • Atakli D.
        • Specchio L.M.
        • Neve A.L.
        • et al.
        Changes in the disposition of oxcarbazepine and its metabolites during pregnancy and the puerperium.
        Epilepsia. 2006; 47: 504-509
      2. Btilau P, Paar WD, Von Unruh GE. European Journal of Clinical Pharmacology Pharmacokinetics of Oxcarbazepine and l O-Hydroxy-carbazepine in the Newborn Child of an Oxcarbazepine-Treated Mother. vol. 34. 1988.

        • Bülau P.
        • Paar W.D.
        • von Unruh G.E.
        Pharmacokinetics of oxcarbazepine and 10-hydroxy-carbazepine in the newborn child of an oxcarbazepine-treated mother.
        Eur J Clin Pharmacol. 1988; 34: 311-313
        • Wegner I.
        • Edelbroek P.
        • De Haan G.J.
        • Lindhout D.
        • Sander J.W.
        Drug monitoring of lamotrigine and oxcarbazepine combination during pregnancy.
        Epilepsia. 2010; 51: 2500-2502
        • Chen C.-Y.
        • Li X.
        • Ma L.-Y.
        • Wu P.-H.
        • Zhou Y.
        • Feng Q.i.
        • et al.
        In utero oxcarbazepine exposure and neonatal abstinence syndrome: case report and brief review of the literature.
        Pharmacotherapy. 2017; 37: e71-e75
      3. Drugs and Lactation Database (LactMed) [Internet]. Bethesda (MD): National Library of Medicine (US); 2006-. Available from: No Title n.d.

        • Westergren T.
        • Hjelmeland K.
        • Kristoffersen B.
        • Johannessen S.I.
        • Kalikstad B.
        Probable topiramate-induced diarrhea in a 2-month-old breast-fed child - A case report.
        Epilepsy Behav Case Reports. 2014; 2: 22-23
        • Kawada K.
        • Itoh S.
        • Kusaka T.
        • Isobe K.
        • Ishii M.
        Pharmacokinetics of zonisamide in perinatal period.
        Brain Dev. 2002; 24: 95-97
        • Ando H.
        • Matsubara S.
        • Oi A.
        • Usui R.
        • Suzuki M.
        • Fujimura A.
        Two nursing mothers treated with zonisamide: Should breast-feeding be avoided?.
        J Obstet Gynaecol Res. 2014; 40: 275-278
        • Tomson T.
        • Battino D.
        • Bromley R.
        • Kochen S.
        • Meador K.
        • Pennell P.
        • et al.
        ILAE report Management of epilepsy in pregnancy: a report from the International League Against Epilepsy Task Force on Women and Pregnancy.
        Epileptic Disord. 2019; 21: 497-517
        • Finch E.
        • Lorber J.
        Methaemoglobinaemia in the newborn probably due to phenytoin excreted in human milk.
        J Obstet Gynaecol Br Emp. 1954; 61: 833-834
        • Maloney J.
        O Lo O. 2006; 42: 31-42
        • Bar-Oz B.
        • Nulman I.
        • Koren G.
        • Ito S.
        Anticonvulsants and breast feeding: A critical review.
        Paediatr Drugs. 2000; 2: 113-126
        • Fisher J.B.
        • Edgren B.E.
        • Mammel M.C.
        • et al.
        Neonatal apnea associated with maternal clonazepam therapy. A case report.
        Obstet Gynecol. 1985; 66
      4. Landmark CJ. Pharmacokinetic data on brivaracetam, lacosamide and perampanel during pregnancy and lactation n.d.

        • Hägg S.
        • Spigset O.
        Anticonvulsant use during lactation.
        Drug Saf. 2000; 22: 425-440
        • Johnson E.L.
        • Burke A.E.
        • Wang A.
        • Pennell P.B.
        Unintended pregnancy, prenatal care, newborn outcomes, and breastfeeding in women with epilepsy.
        Neurology. 2018; 91: e1031-e1039
        • Grubesic T.H.
        • Durbin K.M.
        A spatial analysis of breastfeeding and breastfeeding support in the United States: The leaders and laggards landscape.
        J Hum Lact. 2019; 35: 790-800
        • Figueiredo B.
        • Canário C.
        • Field T.
        Breastfeeding is negatively affected by prenatal depression and reduces postpartum depression.
        Psychol Med. 2014; 44: 927-936
        • H. Bjørk M.
        • Veiby G.
        • A. Engelsen B.
        • Gilhus N.E.
        Depression and anxiety during pregnancy and the postpartum period in women with epilepsy: A review of frequency, risks and recommendations for treatment.
        Seizure. 2015; 28: 39-45
        • Gerard E.E.
        Breastfeeding and the neurologist: an important role for us.
        Epilepsy Curr. 2022; 22: 108-110
        • Roberts J.I.
        • Metcalfe A.
        • Abdulla F.
        • Wiebe S.
        • Hanson A.
        • Federico P.
        • et al.
        Neurologists’ and neurology residents’ knowledge of issues related to pregnancy for women with epilepsy.
        Epilepsy Behav. 2011; 22: 358-363
        • Vazquez B.
        • Gibson P.
        • Kustra R.
        Epilepsy and women’s health issues: Unmet needs-Survey results from women with epilepsy.
        Epilepsy Behav. 2007; 10: 163-169
        • Patel S.
        • Patel S.
        The effectiveness of lactation consultants and lactation counselors on breastfeeding outcomes.
        J Hum Lact. 2015; 32: 530-541
      5. World Health Organization. Guideline: counselling of women to improve breastfeeding practices. 2018.

        • Tomson T.
        • Battino D.
        • Bromley R.
        • Kochen S.
        • Meador K.
        • Pennell P.
        • et al.
        Management of epilepsy in pregnancy: a report from the International League Against Epilepsy Task Force on Women and Pregnancy.
        Epileptic Disord. 2019; 21: 497-517