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(Abst. 1.246), 2019

Factors Affecting Breastfeeding Patterns in Women with Epilepsy
Authors: Abrar O. Al-faraj, Beth Israel deaconess Medical center/Harvard medical school.; Rebekah Wigton, Beth Israel Deaconess Medical Center; Trudy D. Pang, Beth Israel Deaconess Medical Center/Harvard Medical School
Content: Rationale: The benefits of breastfeeding are well-established in the general population, and recent studies confirmed safety and possible additional benefits in neurodevelopment children born to women with epilepsy (WWE) (Lancet Neurol 2013; 3:244-252). However, studies suggest that breast-feeding rates in WWE are significantly lower than that of the general population (JAMA Neurol. 2013; 70(11):1367-1374; Lancet Neurol 2013; 3:244-252). In this study, we aimed to: 1) Compare the rate of initiation and adherence of breastfeeding in WWE with healthy controls. 2) Identify potential factors that affect breastfeeding in WWE. 3) Assess the influence of support systems on breastfeeding, such as lactation consult services. By understanding these various factors, we hope to propose next steps in potential intervention strategies to maximize the benefits of breastfeeding in WWE. Methods: We retrospectively studied WWE in the Beth Israel Deaconess Medical center (BIDMC) Epilepsy Clinic who underwent pregnancies (N=102) and compared them to healthy controls without epilepsy (N=113) from the obstetrical service at BIDMC (between 2009 and 2018). Medical records were reviewed for the following: demographic characteristics, epilepsy type, degree of seizure control during pregnancy and postpartum, number of antiepileptic medications (AEDs), breastfeeding education by providers (neurologists and epilepsy nursing), lactation consult, and rate of initiation and adherence to breastfeeding at the following time points: 6 weeks, 3 months, and 6 months. Patients with other chronic medical conditions or taking medications other than AED that may impact breastfeeding or with limited follow up during pregnancy and postpartum periods were excluded from the analysis.  Results: In the 102 WWE and 113 healthy controls with age range between 20-40 years old who met the inclusion criteria, breastfeeding initiation rate was significantly lower in WWE at 51% compared to 87% in the control group; this rate declined significantly to 38.2% at 6 weeks compared to 76% in the control group. Adherence was even lower in WWE at 36.2% at 3 months and 18.6% at 6 months. In WWE, reasons for not breastfeeding were known in 17.6% of the patients and included fear of AED exposure through breast milk, recommendations by different providers (pediatricians, obstetricians) not to breastfeed, failed breastfeeding trials due to technical difficulties, and lack of milk supply. Discussion about breastfeeding by the treating neurologist occurred in 52.9% of WWE and 91% by the epilepsy nurse. Among the 66% of patients who received their obstetrical care at BIDMC, only 13% of WWE received lactation consultation postpartum compared to 58% in the healthy control group.  We found a statistically significant positive correlation between breastfeeding education by the treating neurologist and decision to breastfeed χ2=9.16, 1 df, p<0.005 and initiation of breastfeeding (χ2=5.29, 1 df, p<0.05). Postpartum lactation consult support was also associated with significantly higher rate of initiation of breastfeeding (χ2=5.88, 1 df, p<0.05), adherence at 6 weeks (χ2=8.96, 2 df, p=0.01), at 3 months (χ2=8.42, 2 df, p=0.01), and at 6 months (χ2=6.80, 2 df, p<0.05). Last, we found that women with well-controlled seizures were more likely to continue breastfeeding at 6 weeks, compared to women with uncontrolled seizures (χ2=5.98, 1 df, p=0.01). However, there was no statistically significant difference in breast-feeding initiation rate between women with controlled versus uncontrolled seizure. Conclusions: In this retrospective study, the rates of breastfeeding initiation and adherence in WWE at 6 months were significantly lower than the general population as well as the healthy controls and those reported in NEAD study.  Factors with positive correlation with adherence of breastfeeding were seizure control, education by the treating neurologist, and postpartum lactation consultative support.  Women with poor seizure control are a particularly vulnerable group and has the greatest need for intervention to improve breastfeeding rates.  Focused physician education as well as supports measures, such as lactation consultation, were associated with adherence and success in breastfeeding and may represent potential intervention to improve the treatment. This is the first study to investigate factors that may contribute to lower rates of initiation and adherence of breastfeeding in WWE and highlight the gap in breastfeeding patterns that limit potential general health and neurodevelopmental benefits for the offspring of WWE.  Further prospective investigations are needed to identify other factors that prevent the decision to initiate or adhere to breastfeeding in WWE and evaluate interventions that may be implemented as a public health measure to support this vulnerable population.   Funding: No funding