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I have a VLBW infant whose mom would like to provide breast milk but is on keppra. Would you recommend using her breast milk or not?
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boxer3:
Keppra(levetiracetam) does get into milk but the levels are somewhat low, only about 3.36% - 7.8% of the maternal dose transfers into milk.
I would suggest that IF the mom took this drug while pregnant, then the infant can probably metabolize it better and may not be as susceptible. IF it is being introduced anew, then the risk is slightly higher. See below.
Tom Hale Ph.D.
In a study of a single patient who received levetiracetam at 7 days postpartum (dose unreported), the breastmilk concentrations of levetiracetam were 99 µM three hours after administration. The corresponding plasma levels were 32 µM (milk/plasma ratio= 3.09). The mother was also ingesting phenytoin (3 x 100 mg/day) as well as valproic acid (4 x 500mg/day). The infant was preterm (36 weeks) and unstable at birth. After the addition of levetiracetam at day 7, the infant became increasingly hypotonic and fed poorly. The infant was removed from the breast and 96 hours later the infant's plasma levetiracetam levels were 6 µM. The authors strongly advise avoidance of levetiracetam and close monitoring of the infant in breastfeeding mothers.[1] In this case, the infant was exposed to three anticonvulsants, and it is difficult to suggest that levetiracetam was solely responsible for the hypnotic condition. This is further supported by the study below. In a new study of 8 women receiving from 1500 to 3500 mg/day who were studied at birth (seven patients) and one at 10 months, the mean umbilical cord serum/maternal serum ratio was 1.14 (n= 4) at birth suggesting extensive transport of levetiracetam to the fetus.[2] The mean milk/maternal serum concentration ratio was 1.00 (range, 0.7-1.33) at 3 to 5 days after delivery (n= 7). Maternal milk levels ranged from 28 to 153 µM (4.8-26 µg/mL) but averaged 74 µM (12.6 mg/L). At 3 to 5 days after delivery, the infants had very low levetiracetam serum concentrations (<10-15 µM) (1.7-2.5 µg/mL), a finding that persisted during continued breastfeeding. One infant had a levetiracetam level of 77 uM (13 µg/mL) at day 1, but <10 µM at day 4, suggesting infants clear this product rapidly, and that breastfeeding contributes only a minimal dose. No malformations were detected at birth. No adverse effects were noted in any of the breastfeeding infants. The authors conclude that levetiracetam passes to the infant, but breastfed infants have very low serum concentrations, suggesting a rapid elimination of levetiracetam. Another study of 14 women receiving 1,000 to 3,000 mg per day had a milk-to-plasma ratio of 1.05, with an infant dose of 2.4 mg/kg/day, or 7.9% of the maternal dose. Plasma concentrations in the infants were 13% of those in the mother's plasma, ranging from 4 to 20 µmol/L. There was no evidence of accumulation of levetiracetam in this study. The authors suggest that this study should be reassuring for breastfeeding mothers taking levetiracetam.[3] -
keppra
Thank you for the reply. I did see the information regarding the keppra. Mom has been on the medication during the pregnancy however the infant is <30 weeks gestation. hesitant to use due to prematurity.Comment
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