Getting Integrative in London

Today while on vacation, I hella-hiked to check out a kindred spirit here in London, Snowfields Wellness. Found them online while googling "raw vegan London." They made the list because they offer raw, organic smoothies. I was sufficiently impressed that I decided to walk on over the 3 miles from my hotel.

First, I loved their mission statement:

• Health is for everyone and is attainable by all
• Caring for the environment is an act of health in itself
• Health tastes delicious

We have a lot in common, Snowfields and I. We both take care of patients in a wellness model, we both sell therapeutic teas and organic skin care. We sell transformative books. I do not yet sell organic/ethical foods, but don't you think I should? Hemp seeds, raw cacao bars (my personal favorite is the "I Am Mighty" from Cafe Gratitude).

From the website, I thought they offered a whole-food, vegan restaurant. Turns out they don't, and in fact, the space is tiny. They have just enough room to whip up a smoothie du jour, but it was terrific.

Second thing I loved was their therapeutic tea bar. I could definitely get behind this, and we don't need too much space to do it. Sink? Check. Filtered hot water? Checkety check. Let's do it!

They offered carbon-neutral green tea (above) - love it! And Pukka Ayurvedic Teas.

Am I At Liberty to Say?

 

Unbelievably inspiring to step through the Tudor doors into the transcendent space of Liberty of London today. Still jet-lagged, didn't really know what I was getting into, and then I could hardly breath. If I were a department store, I'd be Liberty of London. Tamara Salman is the creative genius behind the store. Wowness. Check it out.

 

Love the crazy chandlelier thing above, and the room dividers in white. Almost got arrested taking the jewelry pics below. They do not allow photography except by the press!

 

Also learned today that Liberty has designed a new line for Target. I imagine this is a little more in my price range. Launch in 12 days, People!

Here's the super cute founder, Arthur Liberty, and his bride. He opened Liberty's in 1875 mostly to sell fun stuff from Japan.

Above: detail of the Tudor fascade of Liberty's on Regent Street in London, with shoes. Below - my age inspiration of the day: Mary Skinner wearing exclusive Liberty togs. Almost looks like burlap but she rocks it like nobody's business.

This is what I looked like back at the hotel after shopping at Liberty. Hello, Sailor!

 

Above - Liberty also can help a girl out with their Style Service.

 

Don't we need the couch above in the Gottfried Center? 

 

Of course, Liberty still has all those cute cotton prints plus some very cool updates.

To quote Rachel Zoe, "I died."

My Review of Bengal Tech Top

Originally submitted at lucy

The hip-length Bengal Tech Top is made with lucy tech™ fabric, a moisture-wicking, quick drying, breathable material with a textured finish. Offers an invisible zip at the raglan sleeve cuffs, along with a back stash pocket featuring an eyelet hole for MP3-player earphones. Great as the fi...

Bengal Tech Top

I wear this every day!

By Sara the Yoga Teacher & Doctor from Berkeley, CA on 3/1/2010

 

5out of 5

Sizing: Feels true to size

Pros: Comfortable, Stylish, Lightweight, Breathable, Sexy, Dries Quickly

Best Uses: Anytime, Gym, Cold Weather

Describe Yourself: Competitive Athlete

Can't say enough about this amazing top. So great too for travel.

(legalese)

30-day Joy Practice: Join Me!

 

Earlier this month, I was blessed by an impromptu yoga class with a favorite teacher: Shiva Rea. I hadn't studied with her for about 2 years, but in her Venice Beach class I reconnected with what draws me to her teaching - she's the real deal, a true prophetess and mystic, and a great synthesizer of how to bring more joy into our daily lives.

I also was blessed to be asked to teach a class for Up2Yoga. While preparing for my April 1 class on Stress Resilience, I happened to listen to Shiva's session that is downloadable from Up2Yoga's site on Living Yoga Sadhanas. This may not mean much to you, but perhaps it should. Shiva is onto something incredibly juicy and transformative: start with the next new moon cycle (uh, today) and commit to a 30-day practice based on your energy now.

 

I am planning to start my 30-day Bhakti Sadhana starting with the next new moon on March 15, 2010. Care to join me? If so, download her details right here. Or listen to her audio file right here. Prepare for more joy, my friends!

Here's a little help from Wikipedia on the etymology of bhakti:

The Sanskrit noun bhakti is derived from the verb root bhaj, whose meanings include "to share in", "to belong to", and "to worship". It also occurs in compounds where it means "being a part of" and "that which belongs to or is contained in anything else." Bhajan, or devotional singing to God, is also derived from the same root. "Devotion" as an English translation for bhakti doesn't fully convey two important aspects of bhakti—the sense of participation that is central to the relationship between the devotee and God, and the intense feeling that is more typically associated with the word "love". An advaitic interpretation of bhakti goes beyond "devotion" to the realization of union with the essential nature of reality as ananda, or divine bliss. Bhakti is sometimes used in the broader sense of reverence toward a deity or teacher.

Here's a little more detail from Wikipedia on "sadhana."

The term sadhana means spiritual exertion towards an intended goal. A person undertaking such a practice is known as a sadhu or a sadhaka. The goal of sadhana is to attain some level of spiritual realization, which can be either enlightenment, pure love of God (prema), liberation (moksha) from the cycle of birth and death (Samsara), or a particular goal such as the blessings of a deity as in the Bhakti Sadhana can involve meditation, chanting of mantra (sometimes with the help of a japa mala), puja to a deity. Traditionally in some Hindu and Buddhist traditions in order to embark on a specific path of sadhana, firstly a guru may be required to give the necessary instructions. This approach is typified by some Tantric traditions, in which initiation by a guru is sometimes identified as a specific stage of sadhana. On the other hand, individual renunciates may develop their own spiritual practice without participating in organized groups. traditions.

I'm looking at the next part of the moon cycle, from the full moon today until the next new moon on 3/15/10, as my preparation phase. More on that as it unfolds.

The Big "C" - How to Prevent Aggressively

I want to re-post this provocative blog from today's Huffington Post by David Servan-Schreiber, M.D., Ph.D., who is the author of Anticancer: A New Way Of Life. Great info on how lifestyle choices are behind 85% of the crazy epidemic of cancer we have in the Western World (the other 15% is genetics - smaller than you might think).

Take away message for aggressive prevention:

• cut out sugar (feeds cancer cells & causes inflammation)
• crank up fresh organic fruits, veggies & anti-inflammatory herbs & spices (turmeric, garlic)
• exercise regularly - at least 6 times per week for 30 min
• manage stress better with a contemplative practice
• go green in your home/workplace/anywhere else you spend time

We Can All Fight Cancer Better
by David Servan-Schreiber, M.D, Ph.D.

At age 31, my life took a sudden turn. I was an ambitious physician and neuroscience researcher who reveled in discovery and glittering science projects. Then, slipping into a brain scanner one evening in place of a subject who hadn't shown up, I was suddenly stripped of my white-coat status and thrown into the gray world of patients: That evening, I discovered that I had brain cancer.

Being a physician and scientist is no protection from getting cancer. But it allowed me to dig deeply into the medical and scientific literature to find out everything I could do to help my body resist the disease most efficiently and try to beat the median survival of a few years.

The first thing I learned is that we all carry cancer cells in us. But I also learned we all have natural defenses that generally prevent these cells from turning into an aggressive disease. These include our immune system, the part of our biology that controls and reduces inflammation, and the foods that reduce the growth of new blood vessels needed by developing tumors.

In the West, one out of three people will develop cancer. But two-thirds will not. For these people, their natural defenses will have kept cancer at bay. I understood it would be essential for me to learn how to strengthen these defenses.

A Cancer Epidemic

My own disease is just one case in a cancer epidemic plaguing western societies. Cancer rates have been climbing steadily in the US since 1940. This is not due simply to the increase use of screening tests or the aging of our population: cancer has been rising in children and adolescents at a rate of 1 to 1.5 percent per year in the past 25 years. [1] And cancers that have no screening test (lymphomas, pancreatic and testicular cancers for example) have been increasing as fast or faster than those that do (breast, colon, prostate). [2]

Asian countries did not experience this rise until recently. [3] Yet, Asian immigrants in the US have the same rates of western cancers as Caucasian Americans after one or two generations [4 , 5]

Not a Genetic Lottery

Thus, cancer is not a genetic lottery. A new model has emerged from the last 10 years of research. It moves away from genetics and squarely into life-style factors that we can learn to control.

A New England Journal of Medicine study conducted by the University of Copenhagen showed that people who were adopted at birth had the cancer risk of their adoptive parents rather than that of the parents who gave them their genes [6]. At most, genetic factors contribute 15 percent to our cancer risk. What matters for 85 percent of cancers is what we do -- or do not do enough of -- with our life [3].

Life-style Choices Trump Genes

Indeed, a new Cambridge University study has shown that people who follow simple healthy life-style rules reduce their chances of dying from cardiovascular disease or cancer by roughly a factor of four. [7]

At Ohio State University, another team followed women with breast cancer (stage II) who all had surgery and conventional treatment. Some did not do any more than that, but others participated in an education group focused on better nutrition, more physical activity, and simple relaxations methods such as "progressive muscle relaxation", similar to yoga. Those who learned to change their life-style were 68 percent less likely to die from their cancer in the next 11 years. [8]

Other recent studies -- from the University of San Francisco -- found that such simple life-style changes in men with prostate cancer, completely change the way genes behave, including the genes of cancer cells. This research shows that life-style choices play on our genes like a pianist's fingers play on a keyboard ... transforming the body's ability to resist cancer growth. [9-11]

And in 2009 a stunning reversal of groupthink on the role of genes in breast cancer: Women with the ominous BRCA-1 or 2 genes (80 percent chance of developing breast cancer), reduce their risk by 73 percent if they eat a good variety of vegetables and fruits, showed University of Montreal researchers. [12] Are these really "breast cancer genes" then, as they've been touted to be all along? Or are they simply junk-food intolerance genes?

Changing the "Terrain"

When it comes to treating cancer, there is no alternative to conventional treatments: surgery, chemotherapy, radiotherapy, immunotherapy or, soon, molecular genetics.

However, these treatments target the tumor much like an army wages war: focusing on destroying the cancerous cells. They do not help prevent the disease if we don't have it, and, if we do, they do not help the body build up it's natural resistance to make the treatments work better.

For prevention or better disease management, it is important to change the environment --- the "terrain" -- that supports the growth of new cancer cells, even if treatment pounds them with targeted attacks.

Modern research suggests that cancer cells grow much faster under three circumstances:

1. When our immune system is weakened and less capable of detecting and destroying budding tumors.

2. When low-grade chronic inflammation in our body supports the multiplication of cells and the invasion of neighboring tissue.

3. When tumors are allowed to develop new blood vessels to expand to a larger size, much like a city expands when allowed to develop new roadways.

When we strengthen our immune system, reduce inflammation and reduce the growth of new blood vessel, we help create an anticancer "terrain".

Anticancer Choices

For better prevention, or better treatment results, nothing can beat the combination of conventional medicine (early screenings, or chemotherapy, surgery, radiotherapy, etc.) with an anticancer way of life: A way of living through which we begin to nourish every aspect of health within our bodies:

1. Cleaning up our diet: reducing sugar -- which feeds cancer growth and inflammation. Refined sugar is abundant in desserts, soft drinks (one can of Coke contains 12 coffee-size packs of sugar...), sauces (Ketchup, ready-made salad dressing, etc.), white flour which is equivalent to sugar as far as the body is concerned (white bread, bagels, muffins, etc.), and reducing pro-inflammatory omega-6 fatty acids (red meats, dairy, corn, sunflower, soybean and safflower oils, and trans-fats).

2. Adding anti-cancer foods: including in our diet every day, three times a day, foods that help fight cancer. Such as anticancer herbs and spices (green tea, turmeric, ginger , thyme, rosemary, mint, basil, sage), omega-3 rich foods (salmon, sardines, mackerel, walnuts, green vegetables), cruciferous vegetables (broccoli, cauliflower, cabbage), garlic, onions and leeks, red berries, plums, blueberries for dessert, dark chocolate (more than 70 percent cocoa), and even a little bit of red wine.

3. Engaging in physical activity: it doesn't have to be marathon training, not even jogging. Just rapid walking 30 minutes six times a week already dramatically reduces the chances of a relapse after breast cancer treatment or the risk of advanced prostate cancer. And physical activity has been found to help survival with many different types of cancer. [13]

4. Managing our response to stress: we can't avoid stress in our life, but we can learn to respond differently than with clenched teeth, stone-hard back muscles and pressure in our chest. Basic breathing techniques that have been around as part of oriental mental and physical hygiene techniques for thousands of years (Yoga, Chi Gong, mindfulness meditation) can transform our response to stress and strengthen our resistance to disease. And simply reaching out to one or two friends during hard times can even reduce the risk of dying from breast cancer by a factor of four. [14]

5. Cleaning up our immediate environment: in-door pollutants, parabens and phthalates in cosmetics, scratched Teflon pans, percholorethylene of dry-cleaning, PVCs and bisphenol A from liquids in contact with hard plastics, radiomagnetic fields of prolonged cell phone exposures are the leading and most easily controlled causes.

Conclusion

As a physician with cancer, I've discovered that we can all create an anticancer biology for ourselves through the choices we make in our lives. They cannot replace the benefits of surgery, chemotherapy or radiotherapy, and do not have the same support from aqs many large controlled trials to back them up. However, the life-style changes discussed above are demonstrated to improve health and new scientific evidence suggests they slow down cancer too.

Indeed, as strange as it may seem, I'm in better health and happier today than before I was ever ill. I feel more at peace, lighter, with more energy and drive and passion for life. A few years ago, my neuro-oncologist unwillingly reminded me of the odds against this happening when he told me "I don't if I should tell you this, but I'm always happy to see you at your follow-up visits, because you're one of the very rare patients I have who is doing well!"

Most people who start on this health journey notice a difference within a few weeks. Recent studies suggest that such life-style changes start improving mood and well-being after two to four months, and can have an impact on cancer statistics within a year or two of follow-up. (Andersen et al. 2004, 2008; Blake-Mortimer et al. 1999; Fawzy et al. 1990, 1993; Monti et al. 2006, Spiegel et al. 1989)
What I've learned in my own journey of 17 years with cancer is that the best way to go on living is to nourish life at all levels of my being: through my meals three times a day, through my walks in nature, through the meaning and purpose in my work, through the flow of love in my relationships, and through the protection of our environment. Science told me that this slows down cancer, but, perhaps even more importantly, it brings to my life, every day, a new light and a new purpose.

References

1. Steliarova-Foucher, E., et al., Geographical patterns and time trends of cancer incidence and survival among children and adolescents in Europe since the 1970s (the ACCIS project): an epidemiological study. The Lancet, 2004. 364(9451): p. 2097-2105.

2. Parkin, D., et al., Cancer Incidence in Five Continents, Volumes I to VIII., in IARC CancerBase No. 7. 2005, World Health Organization: Lyon, France.

3. Stewart, B.W. and P. Kleihues, eds. World Cancer Report. 2003, W.H.O IARC Press: Lyon, France.
4. Yatani, R., et al., Trends in frequency of latent prostate carcinoma in Japan from 1965-1979 to 1982-1986. Journal of the National Cancer Institute, 1988. 80(9): p. 683-7.

5. Sasco, A.J., [Migration and cancer]. Revue de Medecine Interne, 1989. 10(4): p. 341-8.

6. Sorensen, T.I.A., et al., Genetic and environmental influences on premature death in adult adoptees. New England Journal of Medicine, 1988. 318: p. 727-32.

7. Khaw, K.-T., et al., Combined Impact of Health Behaviours and Mortality in Men and Women: The EPIC-Norfolk Prospective Population Study. PLoS Medicine, 2008. 5(1): p. e12.

8. Andersen, B.L., et al., Psychologic Intervention Improves Survival for Breast Cancer Patients: A Randomized Clinical Trial. Cancer, 2008. 113: p. 3450-3458.

9. Ornish, D., et al., Increased telomerase activity and comprehensive lifestyle changes: a pilot study. The Lancet Oncology, 2008: p. doi:10.1016/S1470-2045(08)70234-1.

10. Ornish, D., et al., Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proceedings of the National Academy of Sciences, 2008. 105: p. 8369-8374.

11. Ornish, D., et al., Intensive lifestyle changes may affect the progression of prostate cancer. Journal of Urology, 2005. 174(3): p. 1065-9; discussion 1069-70.

12. Ghadirian, P., et al., Breast cancer risk in relation to the joint effect of BRCA mutations and diet diversity. Breast Cancer Research & Treatment, 2009. 117: p. 417-422.

13. World_Cancer_Research_Fund, Food, Nutrition and the Prevention of Cancer: A Global Perspective, W.C.R.F.a.A.I.f.R.o. Cancer, Editor. 2007, World Cancer Research Fund and American Institute for Research on Cancer: London, UK.

14. Kroenke, C.H., et al., Social networks, social support, and survival after breast cancer diagnosis. Journal of Clinical Oncology, 2006. 24(7): p. 1105-11.

Patch That Leaky Gut

Wanted to post some info on Leaky Gut Syndrome. Here's a start - an informative post by Dr. Leo Galland, MD.

It's a little techy, so thought I'd also post some help understanding the matter from Dr. Andy Weil, MD's website:

Leaky gut syndrome is not generally recognized by conventional physicians, but evidence is accumulating that it is a real condition that affects the lining of the intestines. The theory is that leaky gut syndrome (also called increased intestinal permeability), is the result of damage to the intestinal lining, making it less able to protect the internal environment as well as to filter needed nutrients and other biological substances. As a consequence, some bacteria and their toxins, incompletely digested proteins and fats, and waste not normally absorbed may "leak" out of the intestines into the blood stream. This triggers an autoimmune reaction, which can lead to gastrointestinal problems such as abdominal bloating, excessive gas and cramps, fatigue, food sensitivities, joint pain, skin rashes, and autoimmunity. The cause of this syndrome may be chronic inflammation, food sensitivity, damage from taking large amounts of nonsteroidal anti-inflammatory drugs (NSAIDS), cytotoxic drugs and radiation or certain antibiotics, excessive alcohol consumption, or compromised immunity.

My colleague, pediatrician Sandy Newmark, M.D., who deals with leaky gut syndrome in children, tells me that it isn't clear how many people have this disorder or exactly what problems can be attributed to it. Dr. Newmark says that it has been established that a significant percentage of children with autism have increased intestinal permeability, but it isn't known whether this is a cause or an effect of food sensitivities and an underlying metabolic problem.

Psychiatric Medications - Effects on Breastfeeding

Fantastic compilation of what psych drugs can do to our babies and how much gets in our breastmilk by Dr. Richard Oliva at UCSF.

	Summary of Data published on LactMed (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT) as of 02/01/10
Drug	Into Breastmilk?	Effect on Infant/Safety/ Summary
Fluoxetine	The average amount of drug in breastmilk is higher with fluoxetine than with most other SSRIs and the long-acting, active metabolite, norfluoxetine, is detectable in the serum of most breastfed infants during the first 2 months postpartum and in a few thereafter.	Adverse effects such as colic, fussiness, and drowsiness have been reported in some breastfed infants. Decreased infant weight gain was found in one study, but not in others. No adverse effects on development have been found in a few infants followed for up to a year. If fluoxetine is required by the mother, it is not a reason to discontinue breastfeeding. If the mother was taking fluoxetine during pregnancy or if other antidepressants have been ineffective, most experts recommend against changing medications during breastfeeding.
Paroxetine	Because of the low levels of paroxetine in breastmilk, amounts ingested by the infant are small and paroxetine has not been detected in the serum of most infants tested.	Occasional mild side effects (alertness, constipation, sleepiness and irritability) have been reported, especially in the infants of mothers who took paroxetine during the third trimester of pregnancy, but the contribution of the drug in breastmilk is not clear. Most authoritative reviewers consider paroxetine one of the preferred antidepressants during breastfeeding.
Sertraline	Because of the low levels of sertraline in breastmilk, amounts ingested by the infant are small and is usually not detected in the serum of the infant, although the weakly active metabolite desmethylsertraline is often detectable in low levels in infant serum.	Most authoritative reviewers consider sertraline one of the preferred antidepressants during breastfeeding.
Citalopram	Infants receive citalopram in breastmilk and it is detectable in low levels in the serum of some. The dosage that the infant receives and serum level achieved are probably related to the genetic metabolic capacity of the mother and infant.	A few cases of minor behavioral side effects such as drowsiness or fussiness have been reported, but no adverse effects on development have been found in infants followed for up to a year. If citalopram is required by the mother, it is not a reason to discontinue breastfeeding. If the mother was taking citalopram during pregnancy or if other antidepressants have been ineffective, most experts recommend against changing medications during breastfeeding.
Escitalopram	Limited information indicates that maternal doses of escitalopram up to 20 mg daily produce low levels in milk and would not be expected to cause any adverse effects in breastfed infants, especially if the infant is older than 2 months.	Based on limited data, escitalopram appears to be preferable to racemic citalopram during breastfeeding because of the lower dosage and milk levels and general lack of adverse reactions in breastfed infants. Monitor the infant for drowsiness, especially in younger, exclusively breastfed infants and when using combinations of psychotropic drugs.
Bupropion	Limited information indicates that maternal bupropion doses of up to 300 mg daily produce low levels in breastmilk and would not be expected to cause any adverse effects in breastfed infants.	There is little reported use in breastfed newborn infants and one case report of a possible seizure in a partially breastfed 6-month-old. If bupropion is required by a nursing mother, it is not a reason to discontinue breastfeeding. However, another drug may be preferred, especially while nursing a newborn or preterm infant. Exclusively breastfed infants should be monitored if this drug is used during lactation, possibly including measurement of serum levels to rule out toxicity if there is a concern.
Duloxetine	No published information is available on the use of duloxetine during breastfeeding; however, the dose in milk is low.	An alternate drug that has been better studied may be preferred, especially while nursing a newborn or preterm infant. If duloxetine is required by the mother, it is not a reason to discontinue breastfeeding. Monitor the infant for drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants and when using combinations of psychotropic drugs.
Venlafaxine	Infants receive venlafaxine and its active metabolite in breastmilk, and the metabolite of the drug can be found in the plasma of most breastfed infants, but no proven drug-related side effects have been reported.	Breastfed infants, especially newborn or preterm infants, should be monitored for excessive sedation and adequate weight gain if this drug is used during lactation, possibly including measurement of serum levels of desvenlafaxine [O-desmethylvenlafaxine], to rule out toxicity if there is a concern. However, newborn infants of mothers who took the drug during pregnancy may experience poor neonatal adaptation syndrome as seen with other antidepressants such as SSRIs or SNRIs. Use of venlafaxine during breastfeeding has been proposed as a method of mitigating infant venlafaxine withdrawal symptoms,[1] but only one apparently successful case of this use has been reported.
Desvenlafaxine	Although no data are available for the use of desvenlafaxine during breastfeeding, it is the active metabolite of venlafaxine. Venlafaxine study data indicate that relatively large amounts of desvenlafaxine are likely to be excreted into breastmilk.	Other agents may be preferred, especially while nursing a newborn or preterm infant. Breastfed infants should be monitored for excessive sedation and adequate weight gain if this drug is used during lactation, possibly including measurement of serum levels of desvenlafaxine to rule out toxicity if there is a concern. Because desvenlafaxine is available only as a sustained-release product, timing of nursing with respect to doses would not be useful.
Lithium	Random milk levels have been reported to range from 0.12 to 0.7 mEq/L and appear to be rather consistent at about 40 to 45% of the simultaneous maternal serum level.	Limited data suggest that lithium in milk can adversely affect the infant when its elimination is impaired, as in dehydration or in newborn or premature infants. Neonates may also have transplacentally acquired serum lithium levels. The long-term effects of lithium on infants are not known, but limited data indicate no obvious problems in growth and development. Although lithium appears on many lists of drugs contraindicated during breastfeeding, other sources do not consider it a contraindication, especially in infants over 2 months of age and during lithium monotherapy. Lithium may be used in mothers of full-term infants who are willing and able to monitor their infants. Some investigators recommend monitoring infant serum lithium, serum creatinine, BUN, and TSH every 4 to 12 weeks during breastfeeding and maternal lithium therapy.[2][3] Breastfeeding should be discontinued immediately if the infant appears restless or looks ill.
Valproic Acid	Because of the low levels of valproic acid in breastmilk and infant serum, no unquestionable adverse reactions to valproic acid during breastfeeding have been reported.	Theoretically, breastfed infants are at risk for valproic acid-induced hepatotoxicity, so infants should be monitored for jaundice and other signs of liver damage during maternal therapy. A questionable case of thrombocytopenia has been reported, so monitor the infant for unusual bruising or bleeding. One author recommends monitoring infant serum valproate levels, platelets and liver enzymes during therapy. Combination therapy with sedating anticonvulsants or psychotropics may result in infant sedation or withdrawal reactions.
Carbamazepine	Carbamazepine has relatively high levels in breastmilk and breastfed infants have serum levels that are measurable, but usually below the anticonvulsant therapeutic range.	Most infants have had no adverse reactions, but sedation, poor sucking, withdrawal reactions and 3 cases of hepatic dysfunction have been reported. These have all been complicated because of intrauterine exposure and, in some cases, concurrent drug therapy. If carbamazepine is required by the mother, it is not a reason to discontinue breastfeeding. Monitor the infant for jaundice, drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants and when using combinations of anticonvulsant or psychotropic drugs.
Oxcarbazepine	The relationship of the maternal dosage to the concentration in breastmilk can be quite variable, making calculation of the weight-adjusted percentage of maternal dosage less meaningful than usual.	Limited information indicates that oxcarbazepine would not be expected to cause any adverse effects in breastfed infants, especially if the infant is older than 2 months. Monitor the infant for drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants and when using combinations of anticonvulsants.
Lamotrigine	Breastfed infants whose mothers are taking lamotrigine have relatively high plasma lamotrigine levels, averaging 30 to 35% of maternal serum levels; infant plasma levels up to 50% of maternal levels have been reported. Neonates are particularly at risk for high plasma levels because their ability to metabolize the drug by glucuronidation is limited and maternal plasma and milk levels can rise dramatically in the immediate postpartum period if the dosage is not reduced to the prepregnancy dosage.	Additionally, lamotrigine can cause rare, but potentially fatal skin reactions. If lamotrigine is required by the mother, it is not necessarily a reason to discontinue breastfeeding, because many infants have been breastfed without adverse reactions. However, breastfed infants should be carefully monitored for side effects such as rash, drowsiness or poor sucking, including measurement of serum levels to rule out toxicity if there is a concern. If an infant rash occurs, breastfeeding should be discontinued until the cause can be established.
Gabapentin	Limited information indicates that maternal doses of gabapentin up to 2.1 grams daily produce relatively low levels in infant serum.	Monitor the infant for drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants and when using combinations of anticonvulsant or psychotropic drugs.
Haloperidol	Limited information indicates that maternal doses of haloperidol up to 10 mg daily produce low levels in milk and do not affect the breastfed infant.	Very limited long-term follow-up data indicate no adverse developmental effects when haloperidol is used alone. However, combinations of antipsychotic agents can negatively affect development. Monitor the infant for developmental milestones, especially if other antipsychotics are used concurrently. In a small prospective study on the long-term effects of antipsychotics in breastfed infants, a decline in developmental scores was found at 12 to 18 months of age in 2 of the 4 the infants of mothers taking both chlorpromazine and haloperidol. The other 2 infants and all infants exposed to either drug alone developed normally.
Risperidone	Limited information indicates that maternal risperidone doses of up to 6 mg daily produce low levels in milk.	Because there is little published experience with risperidone during breastfeeding and few long-term follow-up data, other agents may be preferred, especially while nursing a newborn or preterm infant.
Olanzapine	Limited information indicates that maternal doses of olanzapine up to 20 mg daily produce low levels in milk and undetectectable levels in the serum of breastfed infants.	In most cases, short-term side effects have not been reported, but sedation has occurred. Very limited long-term follow-up of infants exposed to olanzapine indicates that infants generally developed normally, but combinations of antipsychotic agents can negatively affect development. Monitor the infant for drowsiness and developmental milestones, especially if other antipsychotics are used concurrently.
Quetiapine	Limited information indicates that maternal quetiapine oral doses of up to 400 mg daily produce low levels in milk. A 3-month-old infant who was breastfed 6 to 7 times daily during maternal use of 400 mg daily of quetiapine had a plasma quetiapine level of 1.4 mcg/L. This level was 6% of the mother's quetiapine plasma level at the same time.	Because there is little published experience with quetiapine during breastfeeding and little long-term follow-up data, other agents may be preferred, especially while nursing a newborn or preterm infant.
Clozapine	A woman taking oral clozapine 50 mg daily had a milk clozapine level of 63.5 mcg/L one day postpartum. At 3 days postpartum her dose was increased to 100 mg daily, and at 7 days postpartum clozapine in milk was 115.6 mcg/L. Her infant was not breastfed and timing of the samples with respect to the doses was not stated.	Because there is little published experience with clozapine during breastfeeding, and sedation and adverse hematologic effects have been reported in breastfed infants, other agents are preferred. If breastfeeding is undertaken by a mother who is taking clozapine, close monitoring of the infant for excessive sedation and periodic monitoring of the infant's white blood cell count is advisable.
Aripirazole	A women who was 6 months postpartum was taking aripiprazole 15 mg by mouth daily. Milk levels after 11 and 12 days of therapy (times not stated) at that dose were 13 and 14 mcg/L.	Because there is little published experience with aripiprazole during breastfeeding, other antipsychotic agents are preferred.
Ziprazidone	Relevant published information was not found as of the revision date.	Because there is no published experience with ziprasidone during breastfeeding, other antipsychotic agents are preferred.
Clonazepam	A mother taking clonazepam 2 mg twice daily had several milk level measurements on days 2 to 4 postpartum. The highest milk level was 10.7 mcg/L 4 hours after a dose. The authors calculated that an exclusively breastfed infant would receive a maximum of 2.5% of the maternal weight-adjusted dosage of clonazepam.	Only a small number of cases of breastfeeding with clonazepam have been reported. If clonazepam is required by the mother, it is not a reason to discontinue breastfeeding. Monitor the infant for drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants and when using combinations of psychotropic drugs. Monitoring of the infant's serum concentration may be indicated if excessive sedation occurs.
Diazepam	Diazepam is excreted into breastmilk and it and its active metabolite, nordiazepam, accumulate in the serum of breastfed infants with repeated doses. Because the half-life of diazepam and nordiazepam are long, timing breastfeeding with respect to the dose is of little or no benefit in reducing infant exposure.	Other agents are preferred, especially while nursing a newborn or preterm infant. After a single dose of diazepam, as for sedation before a procedure, there is usually no need to wait to resume breastfeeding, although with a newborn or preterm infant, a cautious approach would be to wait a period of 6 to 8 hours before resuming nursing.
Alprazolam	The authors calculated that an exclusively breastfed infant whose mother was taking alprazolam in the normal dosage range would receive a dose of 0.5 to 5 mcg/kg/day or about 3% of the maternal weight-adjusted dosage.	Because of reports of effects in infants, including sedation, alprazolam is probably not the best benzodiazepine for repeated use during nursing, especially with a neonate or premature infant. A shorter-acting benzodiazepine without active metabolites is preferred. After a single dose of alprazolam, there is usually no need to wait to resume breastfeeding.
Lorazepam	Lorazepam has low levels in breastmilk, a short half-life relative to many other benzodiazepines, and is administered directly to infants.	Lorazepam would not be expected to cause any adverse effects in breastfed infants with usual maternal dosages. No special precautions are required.
Trazodone	Trazodone levels in milk are low	Limited information indicates that trazodone levels in milk are low and would not be expected to cause any adverse effects in breastfed infants, especially if the infant is older than 2 months or when doses of 100 mg or less are used at bedtime for sleep.
Clonidine	Using the average milk level data from this study, an exclusively breastfed infant would receive an estimated 4.1 to 8.4% of the maternal weight-adjusted dosage.	Because of the high serum levels found in breastfed infants and the possible negative effects on lactation, other agents may be preferred, especially while nursing a newborn or preterm infant. Clonidine has complex, dose-related actions on both oxytocin and prolactin secretion. The net effect of the drug on nursing mothers has not been well studied. A case of hyperprolactinemia and gynecomastia occurred in a 6-year-old boy taking clonidine for hyperactivity and valproic acid for a seizure disorder. Galactorrhea ceased within 3 weeks of discontinuing clonidine. A case of clonidine-induced postpartum galactorrhea has also been reported.
Prazosin	Relevant published information was not found as of the revision date.	Because no information is available on the use of prazosin during breastfeeding, an alternate drug may be preferred, especially while nursing a newborn or preterm infant.
Hydroxyzine	Relevant published information was not found as of the revision date.	Small occasional doses of hydroxyzine would not be expected to cause any adverse effects in breastfed infants. Larger doses or more prolonged use may cause drowsiness and other effects in the infant or decrease the milk supply, particularly in combination with a sympathomimetic or before lactation is well established. Single bedtime doses after the last feeding of the day may be adequate for many women and will minimize any effects of the drug. The nonsedating antihistamines are preferred alternatives.
Imipramine	Milk levels of imipramine and its metabolite are low and have been detected in only small quantities in the serum of breastfed infants.	Immediate side effects have not been reported and a limited amount of follow-up has found no adverse effects on infant growth and development. Imipramine use during breastfeeding would usually not be expected to cause any adverse effects in breastfed infants, especially if the infant is older than 2 months. Other agents may be preferred when large doses are required or while nursing a newborn or preterm infant.
Clomipramine	Using the average of the above concentrations, a fully breastfed infant would receive about 2.2% of the maternal weight-adjusted dosage of clomipramine in breastmilk.	Limited evidence indicates that use of clomipramine during breastfeeding is acceptable. For use as an antidepressant, clomipramine may be less desirable than other tricyclic antidepressants that have been studied more thoroughly.
Nortriptyline	Because of the low levels of nortriptyline in breastmilk, amounts ingested by the infant are small and usually not been detected in the serum of the infant, although the less active metabolites are often detectable in low levels in infant serum.	Immediate side effects have not been reported and a limited amount of follow-up has found no adverse effects on infant growth and development. Most authoritative reviewers consider nortriptyline one of the preferred antidepressants during breastfeeding.