Feeding practice in mother with polypharmacy.

Dear NICU-colleagues

I would like your expertise in a patient case. We have a preterm infant born at 28+2 weeks of gestation following PPROM and chorioamnionitis, treated with SALSA for RDS, and subsequently managed on HFNC until a week ago. The infant is now at 34+0 weeks postmenstrual age and is off all respiratory support. Aside from this, the infant is very healthy, with no IVH, no PDA, and adequate growth. Enteral nutrition was initiated with donor breast milk, and the infant reached full enteral feeds of 150 mL/kg by 7 days of age.

The infant’s mother has complex epilepsy and was maintained on Tegretol (carbamazepine) 800 mg + 1200 mg/day, Briviact (brivaracetam) 200 mg + 200 mg/day, and mirtazapine 45 mg once daily throughout the entire pregnancy. She began pumping early on and expressed a strong desire to feed the baby with her own milk. Initially we were hesitant, however, given her strong wishes and our goal to promote the use of mother's own milk, we have permitted partial feeding with MOM 12 mL out of 50 mL per feed, 8 times a day. The infant currently weighs 2340 g.

We now need to decide whether to allow her to transition to full breastfeeding. While we do use Briviact to treat some of our pediatric patients, this scenario presents a complex preterm polypharmacy issue, and our experience with Briviact safety during breastfeeding is limited. The straightforward approach would be to transition directly to formula, but the mother has worked incredibly hard for this, and we want to support her wishes if it is safe to do so. I read @Dotan S framework on polypharmacy (https://www.nature.com/articles/s41390-025-04416-z) and I know that @Mariana Oliveira usually has great insights on this topic.

What would be an acceptable approach according to you? Allt toughts are welcome to help us make the most reasonable decision.

Best Gustaf