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I have a client with a hx of bipolar disorder. Prior to pregnancy she took divalproex regularly. She went off this med before pregnancy and has been monitored closely by her healthcare team. She is now 2 months post oartum and breastfeeding. She just began having manic episodes and needs medication. Her partner is terrified she isn't coping. There are mixed studies on this medication on Lactmed. 1) is it safe for her to take this medication and breastfeed 2) what signs and symptoms may the baby have that I can monitor for?
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Hi, thanks for your post.
Divalproex is an extended release form of valproic acid. Several studies have shown that exposure to valproic acid during pregnancy significantly increases the risk of autism spectrum and other mental disorders. This effect could presumably continue on during lactation as the brain is still developing. A study published just this year associated valproic acid exposure in infants with a drop in IQ slightly larger than the IQ boost from breastfeeding. In short, this product should not be the first choice for breastfeeding mothers. A careful risk-benefit analysis is required for continued use in this population.
In the short-term, monitor the baby for sedation, irritability, elevated liver enzymes, and poor weight gain. In the long-term, make sure the baby is meeting all developmental milestones.
Please call us at the InfantRisk Center if this has not completely answered your question.*(806)352-2519
-James Abbey, MD
The following references may be useful to your physician if he or she needs more information:
Veiby G, Engelsen BA, Gilhus NE. 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:E1-E8.
Meador KJ, Baker GA, Browning N et al. Breastfeeding in children of women taking antiepileptic drugs cognitive outcomes at age 6. JAMA Pediatr 2014;168(8):729-36.
Meador KJ, Baker GA, Browning N, Clayton-Smith J, Combs-Cantrell DT, Cohen M, Kalayjian LA, Kanner A, Liporace JD, Pennell PB, Pivitera M, Loring DW. Cognitive function at 3 years of age after fetal exposure to antiepileptic drugs. N Eng J Med. 2009 Apr 16; 360 (16): 1597-1605. -
Alternatives
I also have a client whose doctor would like to prescribe divalproex for bipolar disorder. Based on the concerns noted for this drug, is there something else that might be suggested in this case to recommend for the doctor to try first?Comment
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Have a look at the last post in the thread linked below. Please post again if you have any follow-up questions.
https://www.infantrisk.com/forum/showthread.php?722-Trileptal-and-breastfeedingComment
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