Antiepileptic Drug Exposure in Infants of Breastfeeding Mothers with Epilepsy

Angela K. Birnbaum, Kimford J. Meador, Ashwin Karanam, Carrie Brown, Ryan C. May, Elizabeth E. Gerard, Evan R. Gedzelman, Patricia E. Penovich, Laura A. Kalayjian, Jennifer Cavitt, Alison M. Pack, John W. Miller, Zachary N. Stowe, Page B. Pennell

Research output: Contribution to journalArticlepeer-review

77 Scopus citations


Importance: There is limited information on infant drug exposure via breastfeeding by mothers who are receiving antiepileptic drug therapy.

Objective: To provide direct, objective information on antiepileptic drug exposure through breast milk.

Design, Setting, and Participants: This prospective cohort study was conducted between December 2012 to October 2016, with follow-up in children until 6 years of age at 20 sites across the United States. Data were collected via an observational multicenter investigation (Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs [MONEAD]) of outcomes in pregnant mothers with epilepsy and their children. Pregnant women with epilepsy who were aged 14 to 45 years, had pregnancies that had progressed to less than 20 weeks' gestational age, and had measured IQ scores of more than 70 points were enrolled and followed up through pregnancy and 9 postpartum months. Their infants were enrolled at birth. Data were analyzed from May 2014 to August 2019.

Exposures: Antiepileptic drug exposure in infants who were breastfed.

Main Outcomes and Measures: The percentage of infant-to-mother concentration of antiepileptic drugs. Antiepileptic drug concentrations were quantified from blood samples collected from infants and mothers at the same visit, 5 to 20 weeks after birth. Concentrations of antiepileptic drugs in infants at less than the lower limit of quantification were assessed as half of the lower limit. Additional measures collected were the total duration of all daily breastfeeding sessions and/or the volume of pumped breast milk ingested from a bottle.

Results: A total of 351 women (of 865 screened and 503 eligible individuals) were enrolled, along with their 345 infants (179 female children [51.9%]; median [range] age, 13 [5-20] weeks). Of the 345 infants, 222 (64.3%) were breastfed; the data collection yielded 164 matching infant-mother concentration pairs from 138 infants. Approximately 49% of all antiepileptic drug concentrations in nursing infants were less than the lower limit of quantification. The median percentage of infant-to-mother concentration for all 7 antiepileptic drugs and 1 metabolite (carbamazepine, carbamazepine-10,11-epoxide, levetiracetam, lamotrigine, oxcarbazepine, topiramate, valproate, and zonisamide) ranged from 0.3% (range, 0.2%-0.9%) to 44.2% (range, 35.2%-125.3%). In multiple linear regression models, maternal concentration was a significant factor associated with lamotrigine concentration in infants (Pearson correlation coefficient, 0.58; P < .001) but not levetiracetam concentration in infants.

Conclusions and Relevance: Overall, antiepileptic drug concentrations in blood samples of infants who were breastfed were substantially lower than maternal blood concentrations. Given the well-known benefits of breastfeeding and the prior studies demonstrating no ill effects when the mother was receiving antiepileptic drugs, these findings support the breastfeeding of infants by mothers with epilepsy who are taking antiepileptic drug therapy.

Original languageEnglish (US)
Pages (from-to)441-450
Number of pages10
JournalJAMA Neurology
Issue number4
StatePublished - Apr 2020

Bibliographical note

Publisher Copyright:
© 2019 American Medical Association. All rights reserved.


  • Adolescent
  • Adult
  • Anticonvulsants/blood
  • Breast Feeding
  • Child
  • Child, Preschool
  • Epilepsy/drug therapy
  • Female
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Middle Aged
  • Mothers
  • Prospective Studies
  • Young Adult

PubMed: MeSH publication types

  • Journal Article
  • Research Support, N.I.H., Extramural


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