Dear Lisa,

This is a common problem:  how does one advise a breastfeeding mother (in
this case an epileptic one) when she requires medication?  I usually take
the following steps:

1)  Check in established, peer-reviewed, guidelines.  The best of these
(from my perspective) are the American Academy of Pediatrics Committee of
the Fetus and Newborn.  These are both practical and liberal. I do not have
them on me as I am at home at the moment but do not recollect any mention of
either carbamazepine or valproate being contraindicated in breastfeeding - I
suggest that you obtain a copy of this document from the AAP.

2)  Do a literature search.  I used Medscape (www.medscape.com), which is
free, to search for articles linking the drug with breastmilk or
breastfeeding.  There were few articles.  Normally I would pull the ones
which I thought relevant so that I could come to a rational decision.  My
understanding is that there are case reports of abnormal liver function
tests in nursing infants of mothers on carbamazepine.  This would support
(perhaps) checking liver function at 2-3 weeks of age, particularly if there
is prolonged jaundice.

3)  Draw on my experience or that of colleagues:  You've done that already
by asking the question on the net.  My experience as a Pediatrician and
Neonatologist is that there is usually inadequate information in the
literature for a firm conclusion but that there are usually no serious
adverse effects from these drugs during nursing.  It is worthwhile noting
that most anticonvulsants are teratogenic during pregnancy.

4)  Note that almost every official datasheet on almost every drug says that
the product is not suitable for nursing mothers.  This is usually based on
medicolegal necessity and not clinical evidence.  Parents should be made
aware of this so that they are involved in the decision-making process.  I
usually make parents aware of unlicensed use of medications.

Unfortunately we have colleagues who do not consider cessation of
breastfeeding a serious outcome and therefore take the shortcut of
recommending a bottle.  I suggest that whenever such a question is raised it
be referred to someone with expertise.  Your local neonatologist is usually
a good start.

I don't know if this helps you or not but the answer to you question is not
simple.

Khalid


Khalid Aziz
Memorial University of Newfoundland