Supporting pregnant women and parents of young babies can be the beginning of an enduring relationship between pharmacy and customer

Pharmacy teams can build a rapport with expectant parents as they support them during and after pregnancy, providing an avenue of immediate care or referring on to their GP when necessary, says Nick Thayer, pharmacist at Well Pharmacy.

“Pregnancy can be both an exciting and scary time for parents, leading to many questions or concerns – and this is where local pharmacy teams can really help,” he says.

Medicines safety advice

A big concern for women is what medication they can safely take while they are pregnant.

Many pregnant mothers suffer from heartburn or acid reflux, which can be caused by hormonal changes and the growing baby pressing against the stomach. Pregnant women can safely take antacids and alginates to ease symptoms.

They should also be advised to eat small meals often, rather than larger meals three times a day, and to not eat within three hours of going to bed at night. Cutting down on drinks containing caffeine, and foods that are rich, spicy or fatty, may also help.

Pregnant women should be advised to be careful about taking any herbal and homeopathic remedies, or using aromatherapy products, as not all “natural” or complementary therapies are safe. They should also be cautious about using some hayfever medicines but a corticosteroid or sodium cromoglicate nasal spray and antihistamine or sodium cromoglicate eye drops can be used.

Media reports in recent years have linked paracetamol in pregnancy to childhood asthma, autism spectrum symptoms in boys, attention-related and hyperactivity symptoms in both sexes, reduced female fertility, and reduced testosterone in unborn boys.

NHS advice is that paracetamol has been used routinely during all stages of pregnancy to reduce a high temperature and for pain relief. There is no clear evidence that it has any harmful effects on an unborn baby, the advice says.¹

However, tablets that combine paracetamol and caffeine are not recommended as high levels of caffeine can result in babies having a low birth weight, which can increase the risk of health problems in later life. Too much caffeine can also cause miscarriage.

Pregnant women are generally advised to avoid taking ibuprofen, particularly when they are 30 or more weeks pregnant, unless advised by a doctor. Ibuprofen at this stage of pregnancy is associated with an increased risk of complications, including heart problems in babies and a reduced amount of amniotic fluid.

“It is best to minimise medication where possible,” says Nick Thayer. “Most medicines are not tested in pregnancy and should therefore be taken at the lowest possible dose for the shortest possible length of time.

"When getting close to the due date, it is important to note down exactly what medication has been taken and when, because the timings of recent medication doses may influence analgesia in hospital.”

Dietary supplements

Another possible dilemma during pregnancy concerns what to eat and what supplements to take. Marcella Fiuza, registered dietician and spokesperson for the British Dietetic Association, says pregnant women should eat a healthy diet including food from all the main food groups. This should ensure they get all the vitamins and minerals they need.

Key foods to avoid during pregnancy are soft cheeses, liver, raw or undercooked meat, and raw shellfish. Many of these foods have a small risk of serious infectious diseases, such as listeria or toxoplasma gondii, which can sometimes result in miscarriage.

The only dietary supplements pregnant women need to take are vitamin D and folic acid before and up to at least 12 weeks during pregnancy, to help prevent neural tube birth defects in the foetus.

Some women who struggle during pregnancy with morning sickness and heartburn may feel their diet is not as balanced as it should be, and may want to take a vitamin supplement. “

If women want to take a multivitamin, they should take one targeted at pregnant women and make sure that it doesn’t contain vitamin A as this may cause birth defects,” Marcella Fiuza says.

Many nutritional supplements containing vitamins, minerals and other micronutrients are heavily marketed to women for all stages of pregnancy, but research published in the Drug and Therapeutics Bulletin found no evidence that these products boosted the health of mothers and babies, and concluded that they were an unnecessary expense.²

Breastfeeding

Public Health England (PHE) recommends exclusive breastfeeding for the first six months of a baby’s life. Thereafter, breastfeeding should continue alongside complementary foods for up to two years.

Breastfeeding boosts a baby’s ability to fight illness and infection, and lowers a mother’s risk of breast and ovarian cancer, but it is a highly emotive subject because many mothers can find it challenging, which may cause them to give up. Breastfeeding rates in England are among the lowest in the world:³

• Almost three-quarters of women start breastfeeding when their child is born
• By six to eight weeks this drops to just under 43 per cent
• The prevalence of breastfeeding is particularly low among very young mothers and disadvantaged socio-economic groups.

PHE says evidence shows that the right support helps mothers to breastfeed for longer but warns that parents may feel that failing to breastfeed implies that they have not done the best for their child and this embarrassment may close down conversation.

A survey of 1,000 mothers of young children commissioned by PHE revealed that many mothers wished they had been better prepared for breastfeeding.⁴ Post-birth:

• Nearly a quarter (24 per cent) wished they had read about and were more prepared for breastfeeding
• One in four (26 per cent) of those who had given breast milk to their first child wished they had known that asking for help can make a difference
• Almost a third (31 per cent) of mothers felt embarrassed about asking for help regarding breastfeeding from healthcare professionals.

Recent guidance issued by the Royal College of Midwives (RCM) says that “the decision of whether or not to breastfeed is a woman’s choice and must be respected”.⁵

Pharmacy teams should offer breastfeeding mothers and their partners information and support to help them to manage the physical, mental, emotional and societal challenges of breastfeeding.

Mothers who choose to formula feed their babies should be given relevant support and information on the safe preparation of bottles and responsive feeding to enable them to develop a close and loving bond with their baby.

‘‘If, after being given appropriate information, advice and support on breastfeeding, a woman chooses not to do so, or to give formula as well as breastfeeding, her choice must be respected,” says RCM chief executive Gill Walton. “We recognise that some women cannot or do not wish to breastfeed and rely on formula milk.”

Many pharmacy staff will have had experience of feeding their own children or heard stories from friends and will be well placed to give evidence-based information to pregnant women and new mums.

All mothers with babies or toddlers should be asked if they are breastfeeding before selling medication, says Wendy Jones, community pharmacist and trainer with the Breastfeeding Network.

The question asked most often at this time of year by breastfeeding mothers, she says, concerns cough and cold remedies. Breastfeeding mums should not take oral decongestants such as pseudoephedrine but can use nasal sprays and steam inhalations alongside paracetamol and ibuprofen, she points out.

With just moderate increases in breastfeeding, she says, “the NHS could potentially save £40m and tens of thousands of fewer hospital admissions and GP consultations for just five illnesses – breast cancer in mothers and gastroenteritis, respiratory infections, middle ear infections and necrotising enterocolitis in babies”.

Flu vaccinations

It is recommended that all pregnant women have the flu vaccine because they have a weaker immune system during pregnancy and are at higher risk of complications from flu such as pneumonia. Flu in pregnancy can also lead to a baby being born prematurely or with a low birth weight and may lead to stillbirth or death.

Serious complications of flu are very rare, but a confidential enquiry into maternal deaths between 2009-12 showed that one in 11 of the women who died had flu.⁶ Flu can also be serious for newborn babies.

Women can be reassured that it is safe to have the flu vaccine during any stage of pregnancy or while they are breastfeeding. Some of this protection will be passed onto their babies.

References

1. Paracetamol during pregnancy. NHS UK: nhs.uk/common-health-questions/ pregnancy/can-i-take-paracetamol-wheni- am-pregnant
2. Drug and Therapeutics Bulletin 2016. dx.doi.org/10.1136/dtb.2016.7.0414
3. Position statement: breastfeeding in the UK. Royal College of Paediatrics and Child Health. May 2018: rcpch.ac.uk/sites/ default/files/generated-pdf/document/ Position-statement per cent253Abreastfeeding- in-the-UK.pdf
4. Press Release, Public Health England, March 2018: gov.uk/government/news/ new-technology-supports-new-mums-tobreastfeed
5. RCM Position statement Infant Feeding. June 2018: rcm.org.uk/sites/default/files/ Infant per cent20Feeding.pdf
6. Saving Lives, Improving Mothers’ Care. MBRRACE UK 2014: nct.org.uk/sites/default/files/related_documents/Saving per cent20Lives per cent20Improving per cent20Mothers per cent20Care per cent20report per cent202014 per cent20Summary_0.pdf