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While much of the current public health focus regarding pregnant women and couples trying to become pregnant is devoted to tackling major gestational risks such as smoking and alcohol consumption, other key factors such as dietary supplements, safe medicines usage, vaccinations and screening also have an important role to play.
Eating a healthy balanced diet should ensure a woman gets the vast majority of vitamins and minerals required for a healthy pregnancy. However, female customers will still require guidance when it comes to navigating the vast landscape of vitamins and supplements now available for use during preconception, pregnancy, breastfeeding and beyond.
Folic acid is the cornerstone of supplementation during preconception/pregnancy and is recommended (at a dose of 400mcg per day) for all women trying to conceive and from the day pregnancy is confirmed through to 12 weeks’ gestation. Also known as vitamin B9, folic acid is an essential nutrient required for DNA replication, which acts as fuel for essential cellular reactions in the body such as amino acid synthesis and vitamin metabolism.
Demand for folic acid increases substantially during pregnancy to support the growth and development of the foetus, notably its nervous system. The neural tube, which is the embryonic precursor to the central nervous system, starts to form as early as two weeks after conception and goes on to become the baby’s brain and spinal cord. Dietary supplementation with folic acid around the time of conception has long been known to reduce the risk of neural tube defects (NTDs) such as spina bifida in the offspring.1
In cases where there is an increased risk of NTDs, ultra high doses of folic acid – up to 5mg per day – may be recommended. Women should be advised to consult their GP if any of the following risk features apply:
In addition to folic acid, the Department of Health and Social Care also recommends that women consider taking supplements containing 10mcg vitamin D during pregnancy. This advice is particularly pertinent for women with darker skin and/or those who typically keep their skin covered while outside. Vitamin A is contraindicated during pregnancy, so customers should be advised to avoid general, non-pregnancy multivitamins and check the labelled ingredients carefully.
All pregnant women who qualify for the Healthy Start scheme are entitled to receive free vitamins containing folic acid and vitamins C and D and should be signposted accordingly. Women on restricted diets (e.g. vegans and coeliacs) are likely to require further targeted advice on nutrition and supplementation, potentially from a specialist dietician, so they should be referred to their midwife or GP.
In an ideal world, it would be preferable to avoid all medications during pregnancy – particularly during the critical window of the first three months. However, in reality, there will still be times when treatment is needed – both for the relief of acute pregnancy-related ailments and for the management of chronic long-term conditions.
Pharmacy teams therefore have a key role to play in advising women on the most suitable drug options for use during pregnancy and reassuring them on the safety of any required medications. As a general rule of thumb, any drug used to treat an acute condition during pregnancy should be used at the lowest effective dose for the shortest possible time.
The UK Teratology Information Service (UKTIS), which provides comprehensive alphabetised lists of medications together with full summaries of their safety during pregnancy, is a useful resource. Customers can also be signposted to the UKTIS public-facing website – BUMPS ‘Best Use of Medicines in Pregnancy’ for further information.
The first step in managing nausea and vomiting in pregnancy should centre on self-care strategies such as eating small, regular meals, avoiding fatty or odorous foods and ensuring sufficient fluid intake. Foods containing ginger and the use of acupressure can also be recommended for mild cases. Based on the severity of symptoms, some women (particularly those with hyperemesis gravidarum) may require treatment with antiemetics.
First-line options recommended by the Royal College of Obstetricians and Gynaecologists (RCOG) include antihistamines (cyclizine or promethazine), phenothiazines (prochlorperazine or chlorpromazine) and combination products comprising doxylamine/pyridoxine. Metoclopramide, domperidone and ondansetron should be reserved for second-line use.2
For pain relief in pregnancy, paracetamol is generally viewed as the preferred choice given its routine use over decades at all stages of pregnancy, coupled with the lack of clear evidence for any harmful effects on the developing foetus.
NSAIDs such as ibuprofen should ideally be avoided during pregnancy given potential links to a range of adverse outcomes including miscarriage – although these associations have yet to be conclusively confirmed. What is known for certain is that all NSAIDs are contraindicated after 30 weeks due to their proven link with the premature closure of the ductus arteriosus and reduction in amniotic fluid levels (oligohydramnios), mediated
via effects on prostaglandin production.3
The UKTIS notes that: “There are no specific guidelines for the management of pain in pregnancy. Choice of analgesic should largely be guided by treatment recommendations for the same type/severity of pain [as] in non-pregnant patients, but will also need to take into account possible risks to the foetus.”
The UKTIS also stresses that “severe or chronic pain, if left inadequately treated or untreated, can potentially have adverse effects on the mother and therefore the foetus”. This highlights the importance of ensuring pregnant women are provided with adequate analgesia when required.3
With the peak of the flu season now upon us, it remains vitally important that all pregnant customers take up the annual flu vaccination. Contracting flu during pregnancy can carry serious consequences including premature birth, low birthweight or even stillbirth. Flu, particularly during the latter stages of pregnancy, also increases the risk of complications in the mother including bronchitis and pneumonia.
Women can be reassured that the flu vaccine is proven safe when administered at any stage during pregnancy and enables vital immune protection to pass to the baby for the first few months of its life. Other vaccinations currently recommended during pregnancy are whooping cough and hepatitis B (in high-risk women only).
Both antacids and alginates can be recommended for the specific relief of pain due to heartburn. However, it is important to caution women suffering with anaemia during pregnancy not to take antacids at the same time as iron tablets as reduced acidity in the GI tract can inhibit the mineral’s absorption. If first-line heartburn therapy proves unsuccessful, the acid-blocking drugs ranitidine and omeprazole have both been used during pregnancy and are not known to be harmful to the developing foetus.4
Pharmacy teams can also dispense general self-care advice on managing heartburn and indigestion, such as changing eating/drinking habits, avoiding trigger foods, keeping upright, stopping smoking and avoiding alcohol – all of which apply equally during pregnancy. Women should be advised to consult their midwife if they experience difficulty eating, vomiting after eating, weight loss or abdominal pains.
Pregnancy involves a raft of screening tests including ultrasound scans and blood tests for inherited haemoglobin disorders (sickle cell anaemia and thalassaemia), genetic diseases (Down’s syndrome, Edwards’ syndrome and Patau’s syndrome), physical conditions (11 of which are assessed at the 20-week scan), as well as infections like HIV, hepatitis B and syphilis. However, not all conditions that can affect newborns are currently covered by the nationwide screening schedule.
Estimates suggest that around a quarter of women in the UK carry Group B Streptococcus (GBS) bacteria in their vagina. If detected during the current pregnancy or if a previous baby was affected by GBS, women should be offered prophylactic intravenous antibiotics during labour to reduce the risk of the infection passing to the baby.
The potential for serious infections caused by undetected GBS in newborns – which include sepsis, pneumonia and meningitis – has been well documented in media reports over recent years, yet screening for GBS is still not routinely offered to all pregnant women in the UK.
For women who are worried they may be GBS carriers, home tests are available costing around £35. The charity Group B Strep Support (GBSS) provides a comprehensive list of tests on its website, all of which adhere to the enriched culture medium international gold standard for detecting GBS carriage.5 GBSS advises that testing is carried out between 35-37 weeks’ gestation as results in this time window are most highly predictive of whether a woman will be carrying GBS when labour commences.5
However, it should be noted that there is no clear evidence that routine screening would do more good than harm. Many women carry the bacteria and, in the majority of cases, their babies are born safely and without developing an infection. Screening all women late in pregnancy cannot necessarily predict which babies will develop GBS infection.
Any pregnant female customer with concerns or questions about GBS should be signposted to her midwife or GBSS for further advice and support. Women can be reassured that only one in every 1,750 newborn babies in the UK and Ireland will be diagnosed with early-onset GBS, making the risk relatively low.6
GBS in newborns is also readily treatable with antibiotics and most babies will make a full recovery, although infection does carry a small but not insignificant risk of death (5.2 per cent) or long-term disability (7.4 per cent).6
Women should also be aware that the risk of GBS infection increases if the mother experiences fever during labour, her waters break prior to labour onset or the baby is born prematurely.
After helping women safely navigate their pregnancy, pharmacy teams then have a key role to play in providing parents with advice on managing common ailments in babies. Some of the common conditions encountered during the early months of a child’s life include:
Teething is one of the major causes of discomfort and distress in young babies and toddlers, with the first tooth typically cut at six to seven months. Infant analgesics can be recommended to help ease the pain of teething in children over three months.
Self-care measures such as gently rubbing the gum with a clean figure or allowing the infant to bite on a clean and cool object (e.g. a chilled teething ring) can also help.
A number of teething gels and other preparations are available OTC which typically contain local anaesthetics such as lidocaine to help numb painful gums. These products are not recommended by NICE Clinical Knowledge Summaries but if parents do decide to use them, pharmacy staff should advise on the importance of following the correct dosing recommendations to avoid adverse events due to excess consumption.
The word colic can strike fear into the heart of any new parent, raising the spectre of constant crying and chronically disrupted sleep. Various products available OTC for colic relief typically contain ingredients such as simethicone, which acts to break up tiny bubbles of trapped air in the stomach; lactase, which breaks down lactose to aid milk digestion; alkalising agents to neutralise excess stomach acid; or ginger to soothe.
Current guidance from NICE CKS cautions against recommending these products due to insufficient evidence for their effectiveness.7 Instead, it says, advice should centre on strategies for soothing a crying infant such as holding the baby through the crying episode; applying gentle motion/rocking or white noise; warm baths; and the use of optimised winding techniques.
It is also important to signpost parents to other sources of inform-ation and support, and provide strategies for safeguarding their own mental and physical wellbeing. Parents can be reassured by the fact that, while infantile colic is a common problem, it typically resolves by the age of six months.
Almost all babies will develop some degree of nappy rash during the first 18 months of life. Again, self-care tips should form the cornerstone of advice to parents, who should be encouraged to use high absorbency nappies, change the nappy every three to four hours (cleaning the skin with water or fragrance/alcohol-free wipes and drying gently) and allow regular nappy-free periods. A thin layer of barrier cream can also be applied at each nappy change to help protect the skin from further assault.
Excessive bathing is not recommended (once a day is optimal) and soaps, bubble bath, lotions and talcum powder should be avoided due to their potential irritant effect. In most cases, nappy rash is a self-limiting and easily managed condition, but parents should be alert for oozing, pus or fever suggestive of bacterial infections or tiny red spots spreading into a solid red blotch, which could indicate a potential fungal infection.
Although distressing for both infants and parents alike, inner ear infections (otitis media) occur commonly in young children due to their heightened susceptibility to viral infections and their more horizontal eustachian tubes.
Children under the age of two years with an infection in both ears may benefit from antibiotics and should be referred to their GP, as should any child under three months of age with a temperature ≥38oC or three to six months with a temperature ≥39oC.7
For all other cases, pharmacy staff should explain to parents that ear infections typically resolve spontaneously within three days and that antibiotics are not usually warranted.7
Management advice should focus on regular doses of paracetamol and/or ibuprofen for pain using a dosing schedule appropriate to the age and weight of the child.
Applying a warm or cold flannel directly to the ear can also help ease discomfort and any discharge can be removed by wiping with cotton wool. There is no evidence to support the use of decongestants or antihistamines to manage ear infection symptoms.7
Cradle cap is another common complaint in early infancy, which typically manifests as thick, greasy, yellowish scales/crusts on the scalp. The crusts can flake off making the skin appear reddened, and other areas such as the eyebrows, nose and nappy regions can also be affected.
Cradle cap is thought to be caused by hormonal changes that trigger increased oil secretion by glands in the skin. Parents can be reassured that cradle cap does not cause pain or itching to the baby and that most cases clear up within a few months of birth.
To help treat cradle cap, the baby’s head can be rubbed gently with baby oil or olive oil to soften the crusts (potentially leaving on overnight) before washing/sponging to remove. Hair should also be washed regularly with a baby shampoo and brushed with a soft brush to loosen flakes.
A number of special cradle cap creams and shampoos are available OTC that can be recommended alongside these self-care measures.
As with most childhood illnesses, chicken pox is self-limiting and usually resolves within a week without the need for medical attention. Paracetamol is the recommended first-line treatment for chicken pox-related pain and/or fever. Ibuprofen should be avoided as it is associated with an increased risk of severe skin and soft tissue infections.7 Pharmacists can also consider offering chlorphenamine for treating itch associated with chickenpox in children one year of age or older.7
Topical calamine lotion or other cooling creams or gels available OTC can be useful in helping to alleviate itch. Parents should be advised to keep their child well hydrated, cut or cover their nails to avoid scratching, dress them in loose clothes and bathe in cool water before patting the skin dry.
As an accessible source of advice and support for parents, pharmacy teams have a key role to play in reinforcing the importance of childhood vaccinations. This is particularly necessary given the rising anti-vax movement, which has led to increasing concern among new parents about the right course of action. Babies should have their first round of vaccinations at eight weeks, followed by subsequent doses at 12 and 16 weeks.
The NHS currently recommends that paracetamol 120mg/5ml is administered after vaccinations given in the first year of life to reduce the risk of fever. Parents can be reassured that some redness and tenderness at the injection site is normal and should settle within a few days.