After reading this feature you should be able to:
The pharmacy team can support any soon-to-be parents from early pregnancy – or even from the family planning stage – by dispelling any common myths well-meaning friends or relatives may have passed on. This ability to offer accurate and essential information will not only help them enjoy a healthy pregnancy, but will build a relationship of trust that extends long past delivery and well into the childhood years.
“With people finding it increasingly difficult to see their GP, any additional support that pharmacy teams can offer, in terms of signposting the importance of vaccines, say, or offering advice on the use of OTC products during pregnancy or breastfeeding, is hugely important,” says Jane Bass, spokeswoman on behalf of the Neonatal and Paediatric Pharmacists Group (NPPG).
According to NICE guidelines1 healthcare professionals should focus on the following during any first contact with a woman in the early stages of pregnancy:
• Folic acid supplementation
• Food hygiene, including how to reduce the risk of food-acquired infection
• Lifestyle advice, including smoking cessation, and the implications of recreational drug use and alcohol consumption in pregnancy.
“Smoking cessation is a topic we always bring up,” says Jane Bass, “along with alcohol and possibly even recreational drugs, as part of a general conversation geared towards promoting pregnancy health rather than simply asking an outright question.”
Maintaining a healthy diet is a key area of advice so expectant mothers can ensure their unborn baby is getting optimum levels of the vitamins and nutrients required for healthy growth and development, as well as helping them manage the usual pregnancy bugbear of constipation.
Contrary to popular belief, pregnant women do not require any extra calories until the last trimester, when an additional 200 calories per day is advocated. As a guide, women should be looking for a weight gain of between 11-16kg, with no dieting recommended during this period.
Unfortunately, 50 per cent of pregnant women are already overweight or obese, which has a severe impact on the health and weight of the developing foetus, says Professor Neena Modi, president of the Royal College of Paediatrics and Child Health. Obese parents are far more likely to have obese children, with many born into lifestyle habits that are hard to shift, she says.
With gestational diabetes a risk during pregnancy, good eating practices are essential. Focusing on iron, folic acid and calcium constitutes an excellent starting point, supported by a balance of starch, protein, dairy and fibre, while avoiding too much fat.
Offering advice on which foods women should avoid can help reduce the risk of any pregnancy-related illness, as well as potential birth defects in the unborn baby. This includes highlighting the elevated risk of listeria and toxoplasmosis associated with certain cured or undercooked meats, as well as those that could contain higher levels of vitamin A or mercury.
Food is often a source of immense confusion for pregnant women – so having a good understanding of the issues will help you steer them through these tricky waters.
The current recommendation for folic acid, which reduces the risk of spinal chord problems like neural tube defects (NTD), is 400mcg per day – although higher doses may be prescribed by a GP for women considered to be in a high-risk category. These include:
• Women who have had a previous pregnancy affected by a NTD
• Where a woman or her partner have such a defect or one is in the family
• Medication is being taken for epilepsy
• Women who are clinically obese
• Women suffering from coeliac disease, insulin-dependent diabetes, sickle cell anaemia or thalassaemia, or those who abuse alcohol.2
There is huge scope for community pharmacies to support breastfeeding mothers, “so I would love to see ‘breastfeeding support’ listed as one of the services on offer from pharmacies”, says Dr Deirdre D’Arcy, assistant professor in pharmaceutics and pharmaceutical technology at Trinity College, Dublin.
Having a chair available suitable for breastfeeding is a good start, she says, and will help encourage related conversations. Any new mother can experience challenges and difficulties while breastfeeding with sometimes conflicting advice, so it is important that everyone in the pharmacy is on the same page, regardless of whether they have direct breastfeeding experience or not.
“Ideally, the pharmacy team would focus on developing an understanding of breastfeeding behaviours – such as cluster feeding, for example, as well as common issues such as cracked nipples and expressing and storing milk, alongside giving appropriate advice on medication use while breastfeeding.”
While extra vitamins are not deemed necessary for those following a healthy eating plan, additional levels of vitamin D are advised for pregnant women or those breastfeeding. The current recommendation is 10mcg daily to ensure bone health. Babies from birth to one year of age who are being breastfed should be given a daily supplement containing 8.5 to 10mcg.
In recent years, studies have been published specifically linking iodine to intelligence.3 NHS guidelines recognise the role of iodine but recommend striking a balance via food sources such as milk, eggs, yoghurt and fish. Additional levels of vitamin A are not recommended during pregnancy, however, with liver or related products such as pate, and cod liver oil supplements, to be avoided.
While some women appear to sail through pregnancy with few if any issues, most will not be so lucky and can experience any number of health gripes – sometimes as soon as conception occurs.
One of the biggest hurdles to overcome is morning sickness which, contrary to its name, can actually occur at any time of day or simply be ongoing. Vomiting or a constant feeling of nausea are both common, affecting an estimated 80 per cent of women. For many women, this will begin to ease by the 12th to 14th week, although its severity and duration can vary enormously.4
Provided sufferers are able to ingest sufficient levels of food and fluids, there should be no risk to the baby itself. However, in cases of constant vomiting or where dehydration is perceived to be a risk, women should seek urgent medical advice from a GP or midwife.
Helping customers to manage the symptoms may be a matter of offering some simple dietary tips – such as preparing plainer, or even cold, food to avoid any aroma-based triggers, as well as the use of calming ingredients such as ginger. Acupressure, in the form of a wristband, for example, is also thought to bring some relief. The use of anti-sickness medication is not generally recommended, although in certain cases a GP may prescribe an antihistamine for a short time.
A by-product of hormonal changes is the slowing down of food travelling through the gut. Constipation can strike early and be ongoing – often leading to bloating or stomach pain. Most cases can be addressed by increasing fibre intake, drinking plenty of water and gentle exercise.
If these measures prove ineffective, the use of a laxative is seen as an appropriate next step. A wide number of products are deemed safe for use during pregnancy – particularly osmotic agents that are not absorbed by the digestive system. However, a GP may prescribe senna (as a stimulant) or bisacodyl (as a stool softener), but their partial systemic absorption means they are rarely used during the third trimester.5
Pelvic girdle pain (PGP)
During the second semester of pregnancy, women may begin to experience pain in their pelvic region, although in some cases it can appear earlier. Pelvic girdle pain (also known as symphysis pubis dysfunction) can range from mild discomfort to acute pain and is due to the release of relaxin, a hormone that loosens the ligaments to enable the baby to pass through the body more easily during birth.
PGP can often make it difficult to turn in bed, for example, or exit a car. Although the symptoms may be managed with the use of analgesics or assisted devices such as pelvic supports or crutches, pregnant women are advised to seek guidance from their GP or midwife without delay.
Heartburn, bladder weakness, back pain and swollen ankles are all common in later pregnancy, when the rapidly growing baby begins to put more pressure on the body.
Women can help offset heartburn and indigestion by eating smaller, more regular meals, although an OTC alginate rafting agent such as Gaviscon can be recommended because it forms a barrier over the stomach contents rather than entering the bloodstream. Antacids may also be used, with the exception of those containing sodium bicarbonate.6
Pregnancy can also lead to the onset of urinary incontinence, so pelvic floor exercises are recommended, with panty liners and pads available to offer additional support and peace of mind.
Due to the inappropriateness of testing drugs on pregnant women, most information regarding medication in pregnancy is anecdotal or based on an increased number of birth defects that can be linked to use of a specific drug. To avoid any contraindications, expectant mothers are advised to limit their use of any medication as much as possible.
Although paracetamol is widely considered safe and may be taken for mild/moderate pain or fever, it is still recommended that it is taken at the lowest effective dose for the shortest period. This also applies to hayfever or allergic conditions, with reduced OTC and prescription options available for use during pregnancy (e.g. antihistamines).
Pharmacists should be ready to assist anyone managing a long-term condition such as diabetes, asthma or epilepsy that requires continuous medication. “The risks associated with taking sodium valproate7 [for epilepsy] in pregnancy have been known for many years,” says Jane Bass. “I would ask that all pharmacists ensure that girls and women taking valproate are aware of the MHRA guidance.”
A medicines use review should be conducted as early as the family planning stage, with anyone taking prescription or regular medication advised to visit their GP as soon as possible.
Pharmacy teams can dispel common myths
Annual flu jabs are recommended for all pregnant women and are free on the NHS. A booster vaccination for whooping cough (pertussis) should also be given – ideally between weeks 16 and 32 – to ensure there is cover for the baby during the neonatal period before the formal immunisation schedule commences.
A build-up of mucus is common in babies but can be difficult for them to clear. This is unrelated to the cold virus, so can be cleared with a nasal aspirator. In the case of actual colds, liquid paracetamol or ibuprofen may be administered, as well as plenty of fluids.
This presents as an itchy rash featuring spots that resemble blisters. Treatment involves infant paracetamol in the case of fever, as well as the use of cooling gels/sprays to reduce itching and limit any potential scarring.
Colic is characterised by prolonged bouts of crying in the evenings. Babies with colic also tend to draw their knees up, clench their fists or arch their back. The problem tends to disappear at around four months, but some digestion aids and dietary advice and support may be given.
A common virus, croup causes swelling in the larynx and trachea. Known for its barking cough as well as fever and stridor (raspy breathing), steam can relieve symptoms, although parents noticing any breathing difficulties should seek urgent medical advice.
A type of seborrhoeic dermatitis common in babies, cradle cap is characterised by yellow, greasy scales. Baby wash and oils may be used to soften the area, although any flakes should be left to fall off naturally.
Often associated with colds, ear infections typically cause babies to pull or rub at the ear, become irritable and lose their appetite. Cases should clear up within 72 hours, although infant liquid paracetamol or ibuprofen can be used to relieve the pain.
Often seen as red spots or patches around the nappy region, this type of rash is the result of skin irritation from contact with urine and faeces. Customers should initially change nappies more often and instigate frequent cleansing and the use of barrier or medicated creams.
Noticeable as white patches in the mouth or on the tongue that do not rub away, oral thrush can also result in a reluctance to feed and nappy rash. Antifungal miconazole gel is the commonest treatment.
Common in newborn babies and young children while their tear ducts are developing, sticky eye normally resolves by itself but the eyes should be kept clean at all times.
Typically commencing at around four months of age, cutting teeth can cause hot red cheeks, drooling, loss of appetite, irritation and an urge to chew. Herbal and medicated gels are available for infants, but parents can also try associated aids such as teething rings.