Extent of medication use in breastfeeding women

Equitable Representation of Pregnant and Lactating Women in Clinical Research: A Historical Review and Critical Analysis of Proposed Legislation

A long history of policymaking and regulation constructed for the purpose of ensuring adequate fetal and infant protections has inadvertently sanctioned the widespread exclusion of pregnant and lactating patients from biomedical research, leaving a paucity of high quality data necessary for clinical decision-making. Although well-intended, the regulatory classification of pregnant women as "vulnerable," in conjunction with burdensome enrollment criteria and other factors weighing against broad inclusion, have ultimately placed the health and safety of these women and their babies in jeopardy. Robust measures are urgently needed to overcome patient and physician reluctance, address substantial evidence gaps, and rectify long-standing disparities which precipitate disproportionately poor health outcomes among this population. In February 2023, the Advancing Safe Medications for Moms and Babies Act of 2023 (the Act) was introduced in the United States House of Representatives with the overarching goal of enabling pregnant and lactating women to achieve equitable participation in clinical research and contribute to developing important biomedical knowledge to guide and improve health care delivered to these patients. This review discusses the historical influence of federal human subject protection regulations on the health and clinical treatment of pregnant and lactating women, outlines and critically analyzes the provisions incorporated into the Act, and reflects on the potential long-term impact the Act would have should it be successful in becoming law. KEY POINTS: · Pregnant and lactating patients are widely excluded from clinical research.. · Evidence guiding the treatment of these patients is limited and of unacceptably low quality.. · Proposed legislation seeks to rectify disparities and empower these patients through improved representation in research..

Characterization of the US Food and Drug Administration Post-Marketing Commitments and Requirements for Pregnancy and Lactation

Enactment of the US Food and Drug Administration Amendments Act (FDAAA) in 2007 and the Pregnancy and Lactation Labeling Rule (PLLR) in 2015 are important milestones giving the FDA the authority to request studies in pregnant and lactating women. Our objective was to characterize trends of pregnancy and lactation-related postmarketing commitments (PMCs) and postmarketing requirements (PMRs) for new molecular entities approved by the FDA between 2000 and 2022. Approval letters of original New Drug Applications (NDAs, N = 488) for new molecular entities were obtained from the FDA website. NDAs with pregnancy and lactation-based PMCs/PMRs were identified, and data extracted. Data included: PMC/PMR timelines and attributes of requested study(ies) (type, design elements, and outcomes) when available. Fifty-nine NDAs included 92 PMCs/PMRs related to pregnancy and lactation. Forty-one NDAs had pregnancy-related PMRs/PMCs, 4 had lactation-related PMRs, and 14 had both. Most PMRs/PMCs were for nervous system medications (N = 33). Forty-seven NDAs specified safety data collection in infants in at least the first year of life. All pregnancy-related PMRs were issued after 2008, most PMCs (N = 8) were issued before 2008. Only one PMC requested a pharmacokinetic study in pregnant women. All lactation-related PMRs (N = 18) requested measurement of drug concentrations in breast milk with one also requiring measurement of maternal blood concentrations. Eighty-nine percent of lactation-related PMRs were requested after 2015. There was a steady increase in pregnancy and lactation-related PMRs following enactment of FDAAA and PLLR. Additions involved information collection pertaining to safety of the medication in pregnant and lactating women and children exposed to medications during pregnancy and breastfeeding.

Comparison between pollutants found in breast milk and infant formula in the last decade: A review

Since ancient times, breastfeeding has been the fundamental way of nurturing the newborn. The benefits of breast milk are widely known, as it is a source of essential nutrients and provides immunological protection, as well as developmental benefits, among others. However, when breastfeeding is not possible, infant formula is the most appropriate alternative. Its composition meets the nutritional requirements of the infant, and its quality is subject to strict control by the authorities. Nonetheless, the presence of different pollutants has been detected in both matrices. Thus, the aim of the present review is to make a comparison between the findings in both breast milk and infant formula in terms of contaminants in the last decade, in order to choose the most convenient option depending on the environmental conditions. For that, the emerging pollutants including metals, chemical compounds derived from heat treatment, pharmaceutical drugs, mycotoxins, pesticides, packaging materials, and other contaminants were described. While in breast milk the most concerning contaminants found were metals and pesticides, in infant formula pollutants such as metals, mycotoxins, and packaging materials were the most outstanding. In conclusion, the convenience of using a feeding diet based on breast milk or either infant formula depends on the maternal environmental circumstances. However, it is important to take into account the immunological benefits of the breast milk compared to the infant formula, and the possibility of using breast milk in combination with infant formula when the nutritional requirements are not fulfilled only with the intake of breast milk. Therefore, more attention should be paid in terms of analyzing these conditions in each case to be able to make a proper decision, as it will vary depending on the maternal and newborn environment.

The Prevalence of Nonserious Events in a Cohort of Breastfed Infants

Introduction: Data on baseline rates of nonserious events in breastfed infants in the general population are sparse. This results in difficulty determining if there is an increase in infant nonserious events potentially due to prescription medication exposure through human milk. In this study, we determined the prevalence of nonserious events in infants consuming human milk whose mothers reported no exposure to any prescription medications, tobacco, or recreational drugs in the previous 14 days. Materials and Methods: Between August 2014 and December 2019, 487 breastfeeding mothers without any recent exposure to prescription medications, tobacco, or recreational drugs enrolled in the Human Milk Research Biorepository at the University of California, San Diego. Participants completed a semistructured telephone interview with trained research staff and provided information on maternal and child health, breastfeeding habits, recent medication, and lifestyle exposures, and completed a standard checklist of infant adverse reactions. Results: We found 131 (44.1%) participants reported one or more infant nonserious adverse events in the past 14 days at the time of their study interview. The most commonly reported nonserious events were rash (12.1%), irritability (9.4%), constipation (7.8%), poor sleep (7.1%), and fever (6.3%). Conclusions: These baseline frequencies provide a benchmark for rates of recent nonserious events in breastfed infants in the general population. These data can be used as a reference point for studies that examine adverse events in breastfed infants following maternal use of prescription medications or exposures due to other lifestyle habits such as tobacco or other substances. Clinical Trial Registration Number: NCT05553743.

Adverse Drug Reactions in Breastfed Infants: A Cross-Sectional Study of Lactating Mothers

Background: Breastfeeding-related adverse drug reactions (ADRs) are thought to be uncommon as reported cases are globally low. The nonspecific nature of these reactions and a lack of awareness and difficulty in identification of ADRs by mothers and clinicians may result in these ADRs being underreported. Aims: This study hypothesized that breastfeeding-related infant ADRs are more frequent than reported. As a first-hand account of breastfeeding mothers, this study aimed to evaluate the impact of the perceived ADRs on the continuation of breastfeeding and maternal treatment. Methods: Women currently breastfeeding or having breastfed in the last 12 months were invited to complete an online survey. The survey comprised 42 questions in 5 sections to obtain data from breastfeeding mothers, including their use of medicines during lactation, perceptions of infant adverse reactions attributable to maternal medication use and its potential impact on breastfeeding. Results: This online survey was completed by 339 women, 42% of whom reported taking at least one medication during breastfeeding. ADRs were reported in 23 infants where a possible or probable causal relationship indicated by a Naranjo score of 1-8 was established in 16 (11.3%). Antibiotics (n = 12) and opioids (n = 2), including tramadol and oxycodone were identified as the most common adverse reaction-causing drugs. The average age of infants at the time of the perceived ADR was 25.6 days (95% confidence interval; 4-85 days; median age 17.5 days). Conclusion: Suspected ADR reporting in this study was significantly greater than those reported to the regulatory body, the Australian Therapeutics Goods Administration, which shows that common breastfeeding-related infant ADRs are underreported.

Prevalence, patterns, and attitude regarding dietary supplement use in Saudi Arabia: Data from 2019

Dietary supplements are products containing dietary elements including vitamins, minerals, amino acids, herbs, or botanicals. They can aid consumers with low dietary intake and quality, as well as those with high demands, by boosting nutritious value. A cross-sectional study was conducted among adults living in Saudi Arabia aged between 18–60 years old using online self-administered questionnaire. Information regarding sociodemographic characteristics, use and type of dietary supplements, and attitude toward and patterns of dietary supplement use was collected. The chi-square test, Pearson correlations, and the independent t-test were used. In total, 531 participants (115 men and 416 women) were included. Approximately half of the participants (51.8%, n = 275) used dietary supplements. Participants who were using dietary supplements were significantly younger (29.16 ± 9.32 years), more highly educated (85.5%, n = 235), and worked in the health sector (63.7%, n = 100). Herbal supplement use was associated with older age and female sex. Single mineral supplements were used more frequently by married, female, pregnant, or breastfeeding participants and those not working in the health sector. Fatty supplements were used more frequently by participants with a higher level of education. Regarding the attitude toward dietary supplement use, women, single participants, and health care workers showed a significant positive attitude. In-depth investigation into the amount of and reasons for dietary supplement use in the health sector is required. Additionally, educating pregnant and breastfeeding women on the importance of dietary supplements is necessary.

Use of Nonprescription and Prescription Drugs and Drug Information Sources among Breastfeeding Women in Japan: A Cross-Sectional Study

Breastfeeding women may experience various health issues that require medication. This survey aimed to gain insights into the use of nonprescription and prescription drugs by breastfeeding women in Japan. A cross-sectional study involving women with children aged under two years was conducted in Fukuoka, Japan. Nonprescription drugs were used by 26% of participants in the breastfed-only group, 41% in the breastfed more than half the time group, 55% in the formula-fed more than half the time group, and 82% in the formula-fed-only group. We found that when breastfeeding rates decreased, the use of nonprescription drugs increased (p < 0.05, Cochran-Armitage test for trend). There were significant differences in the use of nonprescription cold medicines and oral analgesics between the formula-fed and breastfed groups, but a nonsignificant difference in prescription drugs use between the groups. These results indicated breastfeeding had a significant influence on use of nonprescription drugs, which was not observed with prescription drugs. Breastfeeding women commonly used the Internet to obtain information on both nonprescription and prescription drugs; however, this did not influence medication use.

Development of a Generic Physiologically-Based Pharmacokinetic Model for Lactation and Prediction of Maternal and Infant Exposure to Ondansetron via Breast Milk

Ondansetron is commonly used in breastfeeding mothers to treat nausea and vomiting. There is limited information in humans regarding safety of ondansetron exposure to nursing infants and no adequate study looking at ondansetron pharmacokinetics during lactation. We developed a generic physiologically-based pharmacokinetic lactation model for small molecule drugs and applied this model to predict ondansetron transfer into breast milk and characterize infant exposure. Drug-specific model inputs were parameterized using data from the literature. Population-specific inputs were derived from a previously conducted systematic literature review of anatomic and physiologic changes in postpartum women. Model predictions were evaluated using ondansetron plasma and breast milk concentration data collected prospectively from 78 women in the Commonly Used Drugs During Lactation and infant Exposure (CUDDLE) study. The final model predicted breast milk and plasma exposures following a single 4 mg dose of intravenous ondansetron in 1,000 simulated women who were 2 days postpartum. Model predictions showed good agreement with observed data. Breast milk median prediction error (MPE) was 18.4% and median absolute prediction error (MAPE) was 53.0%. Plasma MPE was 32.5% and MAPE was 43.2%. The model-predicted daily and relative infant doses were 0.005 mg/kg/day and 3.0%, respectively. This model adequately predicted ondansetron passage into breast milk. The calculated low relative infant dose indicates that mothers receiving ondansetron can safely breastfeed. The model building blocks and population database are open-source and can be adapted to other drugs.

The prevalence of self-medication in breastfeeding mothers during the COVID-19 pandemic

BACKGROUND

Self-medication is an important health and social issue, especially for women due to critical periods such as pregnancy and lactation. Accordingly, this study aimed to investigate the use of nonprescribed medications by lactating mothers visiting health centers affiliated to Kerman University of Medical Sciences during the COVID-19 pandemic.

MATERIAL AND METHODS

This descriptive-analytical cross-sectional study was conducted in Kerman from October to December 2020. The research population included all lactating women who visited health centers affiliated to Kerman University of Medical Sciences to receive health services. The data in this study were collected using a checklist.

RESULTS

A total of 228 mothers who met the inclusion criteria participated in the study. A total of 221 mothers (97.0%) received nonprescribed medications (377 drugs in total). Among 377 nonprescribed medications, 279 drugs (74.0%) could be used while breastfeeding. The three most commonly used nonprescribed medications were acetaminophen tablets (84 [22.3%]), gelofen compound (51 [13.5%]), and adult cold medications. The majority of the mothers, 153 (40.6%), chose nonprescribed medications based on pharmacy staff recommendations. The COVID-19 outbreak was the most common reason for using 246 (65.3%) nonprescribed drugs. There was a statistically significant relationship between the mothers' education and the accuracy of their information about the side effects of nonprescribed medications use.

CONCLUSION

The prevalence of self-medication by lactating women during the COVID-19 pandemic was very high. A significant percentage of the mothers did not have correct information about the adverse effect of arbitrary use of nonprescribed drugs on their babies.

Breastfeeding and the Pharmacist's Role in Maternal Medication Management: Identifying Barriers and the Need for Continuing Education

Breastfeeding offers a multitude of benefits for infants, mothers, and society. Exclusive breastfeeding of infants is recommended for at least the first 6 months of life. Although transfer of drug into breastmilk can occur, most medications are safe to use during breastfeeding. Pharmacists, regarded as the most accessible health care professionals, recognize their role as medication specialists for breastfeeding women. Unfortunately, a lack of formal and continuing education on medication use during lactation often results in pharmacists providing the unnecessary recommendation to disrupt breastfeeding during medication use. In addition to lack of education, other barriers pharmacists experience in providing optimal patient care during lactation include difficulty identifying breastfeeding status and inconsistency in recommendations between scientific resources. Pharmacists must voice their need for additional continuing education and take action to close the knowledge gap and address barriers to providing care.

Trends and influencing factors of plasma folate levels in Chinese women at mid-pregnancy, late pregnancy and lactation periods

Folate status for women during early pregnancy has been investigated, but data for women during mid-pregnancy, late pregnancy or lactation are sparse or lacking. Between May and July 2014, we conducted a cross-sectional study in 1211 pregnant and lactating women from three representative regions in China. Approximately 135 women were enrolled in each stratum by physiological periods (mid-pregnancy, late pregnancy or lactation) and regions (south, central or north). Plasma folate concentrations were measured by microbiological assay. The adjusted medians of folate concentration decreased from 28·8 (interquartile range (IQR) 19·9, 38·2) nmol/l in mid-pregnancy to 18·6 (IQR 13·2, 26·4) nmol/l in late pregnancy, and to 17·0 (IQR 12·3, 22·5) nmol/l in lactation (Pfor trend < 0·001). Overall, lower folate concentrations were more likely to be observed in women residing in the northern region, with younger age, higher pre-pregnancy BMI, lower education or multiparity, and in lactating women who had undergone a Caesarean delivery or who were breastfeeding exclusively. In total, 380 (31·4 %) women had a suboptimal folate status (folate concentration <13·5 nmol/l). Women in late pregnancy and lactating, residing in the northern region, having multiparity and low education level had a higher risk of suboptimal folate status, while those with older age had a lower risk. In conclusion, maternal plasma folate concentrations decreased as pregnancy progressed, and were influenced by geographic region and maternal socio-demographic characteristics. Future studies are warranted to assess the necessity of folic acid supplementation during later pregnancy and lactation especially for women at a higher risk of folate depletion.

The Use of Herbal Remedies Among Breastfeeding Mothers: A Cross-Sectional Study Among Women Visiting Public Health Facilities in Kingston and St. Andrew, Jamaica

BACKGROUND

The use of herbal remedies is increasing among Jamaican women especially during pregnancy and breastfeeding even though there is no sufficient evidence on the safety of herbal remedies used during breastfeeding. The aim of this study was to determine the prevalence, commonly used herbal remedies and factors contributing to the use of herbal remedies among breastfeeding women. This research was guided by the Health Belief Model.

METHODS

A quantitative cross-sectional study was conducted using a structured and validated questionnaire. A consecutive sampling was used to achieve a sample size of 240 breastfeeding mothers across three Health Centers. Ethical considerations were followed. Data was analyzed using SPSS version 22.0.

RESULTS

There was a 100% response rate with 56% of respondents who used herbal remedies while breastfeeding. Additionally, 43% chose garlic as their preferred herbal remedy while 16% used fever grass and 18% preferred ginger as their commonly used herb. The analysis revealed that 58% of the respondents used herbal remedies as supplements. It was also found that 13% used herbs to increase their breast milk supply while 12.9% used herbal remedies to treat illnesses. In addition, 10% used herbal remedies to prevent illness and 7% used herbal remedies for other reasons.

CONCLUSION

The use of herbal remedies is prevalent among breastfeeding women in public health facilities in Jamaica. Although few respondents use herbal remedies to promote lactation, most women use herbs for various reasons other than to increase their breast milk supply.

Infant drug exposure via breast milk

More than half of women take medications during breastfeeding, predisposing their infants to medication exposure via breast milk. As a result, adverse drug reactions may emerge in the infant, although they are rarely reported. Disposition of maternal drugs in breast milk is described with several key parameters, which include relative infant dose (RID): infant drug intake via milk (weight- and time-adjusted) expressed as a percentage of the similarly adjusted mother's dose. Most drugs show RID values of <10%, indicating that drug concentrations in infant serum do not reach a level known to be therapeutic in adults unless drug clearance is markedly lower than the adult level on a weight basis. RID is a function of milk-to-(maternal) plasma drug concentration ratio (MP ratio) and maternal drug clearance. Therefore, MP ratio between drugs must be interpreted not by itself but with maternal drug clearance of each drug. This is why some drugs such as phenobarbital show an MP ratio of <1 but an RID as high as 50-70%, while morphine shows an MP ratio of 2 but an RID in the range of 5%. Using RID, we interpreted case reports of infant adverse outcomes, and we observed cases with relatively low infant serum concentrations of drug, consistent with low RID, as well as those with near- or above-adult therapeutic serum concentrations, with or without increased drug intake (i.e. high RID). It is important to consider both pharmacokinetic and pharmacodynamic factors in interpreting adverse outcomes in infants breastfed by a mother taking medications.

Calls to a Major Teratogen Information Service Regarding Exposures During Breastfeeding

Background: MotherSafe is a free telephone-based counseling service for Australian consumers and health care providers concerned about drug exposures during pregnancy and breastfeeding. Calls relating to breastfeeding are relatively common and a source of significant distress to the breastfeeding mother, particularly if there is a lack of clarity regarding possible adverse effects of drug exposure on the infant. This study seeks to identify the medication exposures of concern for breastfeeding mothers and the information available to address these concerns. Aims: To review calls to MotherSafe about breastfeeding drug exposures during the 19-year period from 2000 to 2018 and to highlight drugs of concern and counseling issues. Materials and Methods: A retrospective descriptive assessment of a prospectively collected Access database was undertaken. Phone counseling records identified the medication (and other) exposures of concern regarding breastfeeding. The information about medication exposures via breastfeeding provided in consumer and product information (PI) was also reviewed. Results: Of a total of 315,158 calls received at MotherSafe between 2000 and 2018, 116,876 (37.1%) were regarding drug exposure via breastfeeding; 30% of these calls related to nonsteroidal anti-inflammatory drugs, antihistamines, antidepressants, simple analgesics, and antibiotics, and 5% were regarding an exposure specifically contraindicated when breastfeeding. Conclusions: Queries about medication exposures via breastfeeding represent a significant proportion of all the counseling calls to MotherSafe. This study demonstrates the inconsistent and often misleading information about breastfeeding exposures found in consumer and PI sheets and online and highlights the important role of Teratogen Information Services like MotherSafe in providing evidence-based information to both consumers and health care providers.

Opioids in Breast Milk: Pharmacokinetic Principles and Clinical Implications

Safety of maternal drug therapy during breastfeeding may be assessed from estimated levels of drug exposure of the infant through milk. Pharmacokinetic (PK) principles predict that the lower the clearance is, the higher the infant dose via milk will be. Drugs with low clearance (<1 mL/[kg·min]) are likely to cause an infant exposure level greater than 10% of the weight-adjusted maternal dose even if the milk-to-plasma concentration ratio is 1. Most drugs cause relatively low-level exposure below 10% of the weight-adjusted maternal dose, but opioids require caution because of their potential for severe adverse effects. Furthermore, substantial individual variations of drug clearance exist in both mother and infant, potentially causing drug accumulation over time in some infants even if an estimated dose of the drug through milk is small. Such PK differences among individuals are known not only for codeine and tramadol through pharmacogenetic variants of CYP2D6 but also for non-CYP2D6 substrate opioids including oxycodone, indicating difficulties of eliminating PK uncertainty by simply replacing an opioid with another. Overall, opioid use for pain management during labor and delivery and subsequent short-term use for 2-3 days are compatible with breastfeeding. In contrast, newly initiated and prolonged maternal opioid therapy must follow a close monitoring program of the opioid-naive infants. Until more safety data become available, treatment duration of newly initiated opioids in the postpartum period should be limited to 2-3 days in unsupervised outpatient settings. Opioid addiction treatment with methadone and buprenorphine during pregnancy may continue into breastfeeding, but infant conditions must be monitored.

Pharmacogenomic Testing In Pediatrics: Navigating The Ethical, Social, And Legal Challenges

For the past several years, the implementation of pharmacogenetic (PGx) testing has become widespread in several centers and clinical practice settings. PGx testing may be ordered at the point-of-care when treatment is needed or in advance of treatment for future use. The potential benefits of PGx testing are not limited to adult patients, as children are increasingly using medications more often and at earlier ages. This review provides some background on the use of PGx testing in children as well as mothers (prenatally and post-natally) and discusses the challenges, benefits, and the ethical, legal, and social implications of providing PGx testing to children.

Emerging Research Paradigm for Infant Drug Exposure Through Breast Milk

Background:

Information on drug secretion into milk is insufficient due to the exclusion of lactating women from clinical trials and drug development processes. As a result, non-adherence to the necessary drug therapy and discontinuation of breastfeeding occur, even if the predicted level of infant exposure is low. In contrast, inadvertent infant exposure to drugs in breast milk continues to happen due to lack of rational risk assessment, resulting in serious toxicity cases including death. This problem is multifactorial, but one of the key elements is the lack of pharmacokinetic information on drug secretion into milk and resultant infant exposure levels, the first line of evidence for risk assessment.

Methods:

Basic PK principles in drug excretion into milk were explained. The literature was scanned to identify approaches for PK data acquisition in this challenging field.

Results:

This review describes the feasibility to develop such approaches, and the knowledge gaps that still exist. A combination of population pharmacokinetics approach (to estimate averages and variations of drug concentration profiles in milk) and physiologically-based pharmacokinetics modeling of infants (to predict the population profiles of infant drug exposure levels) appears useful.

Conclusions:

In order to facilitate participant enrollment and PK data acquisition in a timely manner, networks of investigators become crucial.

Drugs in lactation

Although most medications can be taken safely during breastfeeding, potential risks of infant toxicity do exist because all medications will be excreted into the breast milk to some extent. The amount of medication excreted in the milk depends mainly on (i) within-drug variation, such as dosing; (ii) between-drug variation including chemical characteristics of the medication; and (iii) host factors, such as maternal pharmacokinetics (PK), including variations of pregnancy-associated changes and their post-partum recovery. Neonatal drug exposure is usually assessed by calculating an expected total infant daily dose through breast milk and comparing it to the normal therapeutic dose. However, clinical PK studies in this population are challenging to conduct. Recently, research methods using population PK analyses and physiologically-based PK modeling and simulation techniques have been recognized as a complementary approach to the conventional PK studies in this field. These efforts are important for rational risk assessment balancing the toxicity risk against the benefits of human milk. Health benefits of lactation for both mother and child are significant and a decision to withhold from this should not be taken lightly. In case limited information is present, additional expertise from pharmacists or clinical pharmacologist with expertise in this area should be sought.

Uso de medicamentos antidepressivos na amamentação: avaliação da conformidade das bulas com fontes bibliográficas baseadas em evidências científicas

O objetivo deste artigo foi avaliar a conformidade entre as recomendações de uso de medicamentos antidepressivos durante a amamentação, presentes em bulas, e as recomendações de fontes bibliográficas baseadas em evidências científicas. Foram avaliadas as bulas padrão de 23 antidepressivos com registro ativo no Brasil. A presença de contraindicação do uso do antidepressivo durante a amamentação foi comparada com as informações presentes no manual técnico do Ministério da Saúde, no livro Medications and Mothers’ Milk e nas bases de dados LactMed, Micromedex e UpToDate. Na maioria das bulas (62,5%), o antidepressivo é contraindicado na amamentação. Entre as fontes bibliográficas, esse percentual variou de 0% a 25%. O estudo aponta para baixa conformidade entre bulas e fontes bibliográficas, alertando sobre a necessidade de revisão do conteúdo e forma de apresentação das informações presentes nas bulas dos antidepressivos no Brasil.

Lactating Canadian Women Consuming 1000 µg Folic Acid Daily Have High Circulating Serum Folic Acid Above a Threshold Concentration of Serum Total Folate

Background

Consumption of high-dose folic acid supplements is common throughout pregnancy and lactation in several countries, including Canada, Brazil, and the United States, and may lead to high levels of circulating unmetabolized folic acid.

Objective

The objective of the study was to characterize serum and whole-blood folate forms in Canadian lactating women regularly consuming a daily high-dose folic acid supplement.

Methods

One-hundred and seventeen Canadian lactating women aged between 18 and 42 y, with a geometric mean ± SD prepregnancy body mass index (kg/m2) of 23.1 ± 1.2, were enrolled in a vitamin D supplementation trial between 13 and 22 wk of gestation. As part of the trial, the women received a daily multivitamin containing 1000 µg folic acid throughout pregnancy and lactation until 8 wk postpartum. At 8 wk postpartum, serum folate forms, including folic acid and RBC total folate, were determined from nonfasted blood samples. Differences in median folate vitamer concentrations among quintiles of serum total folate status were assessed by the Wald test and quantile regression methods. A breakpoint in the relation between serum folic acid and serum total folate was modeled with the use of the segmented package in R.

Results

Median serum total folate concentration among participants was 79.3 nmol/L (5th-95th percentile 30.7-186 nmol/L) and median RBC folate concentration was 2790 nmol/L (5th-95th percentile 1330-4850 nmol/L). There was a breakpoint in the relation between serum total folate and serum folic acid at 78.5 nmol/L (95% CI: 67.9, 89.1 nmol/L), below which serum folic acid was not associated with serum total folate, and above which serum folic acid increased 0.78 nmol/L (95% CI: 0.70, 0.86 nmol/L; P < 0.001) for each 1 nmol/L increase in serum total folate.

Conclusions

These data demonstrate the potential for high serum folic acid concentrations proportional to overall folate concentrations in lactating women with serum total folate >80 nmol/L taking high-dose supplemental folic acid. This study was registered at clinicaltrials.gov as NCT01112891.

Human Milk Nutrient Composition in the United States: Current Knowledge, Challenges, and Research Needs

Human milk is considered to be the ideal food for infants. Accurate, representative, and up-to-date nutrient composition data of human milk are crucial for the management of infant feeding, assessment of infant and maternal nutritional needs, and as a guide for developing infant formula. Currently in the United States, the nutrient profiles of human milk can be found in the USDA National Nutrient Database for Standard Reference, and in books or review articles. Nonetheless, these resources all suffer major drawbacks, such as being outdated, incomplete profiles, limited sources of data, and uncertain data quality. Furthermore, no nutrient profile was developed specifically for the US population. The purposes of this review were to summarize the current knowledge of human milk nutrient composition from studies conducted in the United States and Canada, and to identify the knowledge gaps and research needs. The literature review was conducted to cover the years 1980-2017, and 28 research papers were found containing original data on macronutrients and micronutrients. Most of these 28 studies were published before 1990 and mainly examined samples from small groups of generally healthy lactating women. The experimental designs, including sampling, storage, and analytic methods, varied substantially between the different studies. Data of several components from these 28 studies showed some consistency for 1-6 mo postpartum, especially for protein, fat, lactose, energy, and certain minerals (e.g., calcium). The data for 7-12 mo postpartum and for other nutrients are very scarce. Comprehensive studies are required to provide current and complete nutrient information on human milk in the United States.

Gestation-Specific Changes in the Anatomy and Physiology of Healthy Pregnant Women: An Extended Repository of Model Parameters for Physiologically Based Pharmacokinetic Modeling in Pregnancy

BACKGROUND

In the past years, several repositories for anatomical and physiological parameters required for physiologically based pharmacokinetic modeling in pregnant women have been published. While providing a good basis, some important aspects can be further detailed. For example, they did not account for the variability associated with parameters or were lacking key parameters necessary for developing more detailed mechanistic pregnancy physiologically based pharmacokinetic models, such as the composition of pregnancy-specific tissues.

OBJECTIVES

The aim of this meta-analysis was to provide an updated and extended database of anatomical and physiological parameters in healthy pregnant women that also accounts for changes in the variability of a parameter throughout gestation and for the composition of pregnancy-specific tissues.

METHODS

A systematic literature search was carried out to collect study data on pregnancy-related changes of anatomical and physiological parameters. For each parameter, a set of mathematical functions was fitted to the data and to the standard deviation observed among the data. The best performing functions were selected based on numerical and visual diagnostics as well as based on physiological plausibility.

RESULTS

The literature search yielded 473 studies, 302 of which met the criteria to be further analyzed and compiled in a database. In total, the database encompassed 7729 data. Although the availability of quantitative data for some parameters remained limited, mathematical functions could be generated for many important parameters. Gaps were filled based on qualitative knowledge and based on physiologically plausible assumptions.

CONCLUSION

The presented results facilitate the integration of pregnancy-dependent changes in anatomy and physiology into mechanistic population physiologically based pharmacokinetic models. Such models can ultimately provide a valuable tool to investigate the pharmacokinetics during pregnancy in silico and support informed decision making regarding optimal dosing regimens in this vulnerable special population.

Use of Psychotropic Medications in Breastfeeding Women

BACKGROUND

Breastfeeding women who are prescribed with psychotropic medications on a regular basis are often concerned, regarding the possible implications of such treatment on the breastfed infant. A mother's well-being has a direct influence on the well-being of the baby. However, the notorious reputation of psychotropic medications may lead to suboptimal prescribing by the physician and poor adherence by the mother.

METHODS

A PubMed search (from 1976 through February 2017) was conducted for commonly used psychotropic drug classes, as well as individual medications commonly prescribed in these classes, along with the MeSH terms "breastfeeding"/"lactation". In each case, we chose studies that describe the pharmacokinetics of passage into breast milk and/or adverse effects in breastfed infants.

RESULTS

No large-scale controlled studies regarding the safety of psychotropic medications in breastfeeding mothers were reported. Based on case reports and small studies, most psychotropic medications produce low milk levels and low plasma levels in the infant, while serious adverse effects in the breastfed infant are rarely reported. Safety data for some psychotropic medications are still unavailable.

CONCLUSION

According to the data available in the literature to date, most psychotropic medications are expected to produce low levels in breast milk with no clinical importance. Nevertheless, an individual risk-benefit assessment of a proposed treatment should always be performed, as inter-individual differences may have a substantial effect on the breastfeeding infant's response to the treatment. Further studies and additional objective data are needed to consolidate and improve our current knowledge of psychopharmacotherapy in breastfeeding women. Birth Defects Research 109:957-997, 2017. © 2017 Wiley Periodicals, Inc.

Improving Safe and Effective Use of Drugs in Pregnancy and Lactation: Workshop Summary

In February 2015, given high rates of use of medications by pregnant women and the relative lack of data on safety and efficacy of many drugs utilized in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the Society for Maternal-Fetal Medicine (SMFM), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Pediatrics (AAP) convened a group of experts to review the "current" state of the clinical care and science regarding medication use during the perinatal period. The expert panel chose select medications to demonstrate what existing safety and efficacy data may be available for clinicians and patients when making decisions about use in pregnancy or lactation. Furthermore, these example medications also provided opportunities to highlight where data are lacking, thus forming a list of research gaps. Last, after reviewing the existing vaccine safety surveillance system as well as the legislative history surrounding the use of drugs for pediatric diseases, the expert panel made specific recommendations concerning policy efforts to stimulate more research and regulatory attention on drugs for pregnant and lactating women.

Consumption of dietary supplements by Chinese women during pregnancy and postpartum: A prospective cohort study

The objectives of this study were to investigate usage patterns and factors associated with maternal dietary supplementation by Chinese women. A prospective cohort study of 695 mothers, who gave birth to a singleton baby, was conducted in Jiangyou, Sichuan Province of China. Information on dietary supplement use was collected from participants by personal interview at hospital discharge and followed up by telephone at 1, 3, and 6 months postpartum. Logistic regression analysis and generalised linear-mixed modelling were performed to determine factors affecting dietary supplementation during pregnancy and the first 6 months postpartum, respectively. A total of 81.8 and 32.1% of women consumed dietary supplements during pregnancy and postpartum, respectively. Calcium was the most popular supplement (pregnancy 63.9%; postpartum 28.1%), whereas folic acid was only taken during pregnancy (62.3%) with an average usage duration of 2.5 (standard deviation 1.3) months among users. High school and above education, adjusted odds ratio (OR) = 2.67, 95% confidence interval (CI) [1.63, 4.38], and attendance at prenatal classes (adjusted OR = 1.99, 95% CI [1.05, 3.76]) were associated with dietary supplementation during pregnancy. Mothers with a higher level of education (adjusted OR = 3.10, 95% CI [1.81, 5.30]) were also more likely to use dietary supplements in the postpartum period. Although dietary supplementation appeared to be common among Chinese mothers, maternal intake of folic acid was well below the guidelines. There is a need for further nutrition education on maternal use of micronutrient supplements, especially targeting mothers who are less educated.

Medication Use in Breastfeeding Women: A National Study

INTRODUCTION

A wealth of evidence reveals the benefits of breastfeeding. During the breastfeeding period, nursing mothers may face many medical conditions that require medical management. The medication use among breastfeeding women in Jordan is largely unknown.

OBJECTIVE

This study assessed the beliefs and attitudes of breastfeeding women in Jordan toward medication use.

METHODS

The data were collected from breastfeeding women in hospitals and maternal and children care centers from north, middle, and south Jordan by semistructured interviews using a self-administered questionnaire from February 2015 to November 2015.

RESULTS

Of the 903 participants (96% response rate), 17% used over-the-counter medications and 33% took prescribed medications. Of these, 7% (n = 64) used both over-the-counter and prescribed medications. Analgesics followed by antibiotics were the most commonly used medications among breastfeeding women in Jordan. The majority of breastfeeding women consulted with their physician or pharmacist before initiating or changing any medication. Product Information was the most commonly used drug information resource utilized by breastfeeding women to inquire about safety of medication use during breastfeeding.

CONCLUSION

Breastfeeding women should be educated about the reliable sources of medication information and the importance of physician consultation before initiation or modification of medication therapy. Physicians and pharmacists should be encouraged to be actively involved in detailed discussion with breastfeeding women regarding medication use.

Postpartum women's use of medicines and breastfeeding practices: a systematic review

The objectives of this article are to systematically review i) the extent of medicine use in postpartum women, and ii) the impact of maternal medicine use (excluding contraceptives and galactogogues) on breastfeeding outcomes (initiation and/or duration). PubMed, Medline (Ovid), Scopus (Elsevier), Cinahl (EBSCO), PsycINFO (Ovid), Embase (Ovid) and Web of Science (ISI) databases were searched to find original studies on medicine use in women after the birth. Additional studies were identified by searching Google Scholar, Wiley Online Library, Springer Link, selected journals and from the reference list of retrieved articles. Observational studies with information about postpartum women's use of any type of medicine either for chronic or acute illnesses with or without breastfeeding information were included. The majority of relevant studies suggest that more than 50 % of postpartum women (breastfeeding or not) required at least one medicine. Due to the lack of uniform medication use reporting system and differences in study designs, settings and samples, the proportion of medicine use by postpartum women varies widely, from 34 to 100 %. Regarding the impact of postpartum women's medicine use on breastfeeding, a few studies suggest that women's use of certain medicines (e.g. antiepileptics, propylthiouracil, antibiotics) during lactation can reduce initiation and/ or duration of breastfeeding. These studies are limited by small sample size, and with one exception, all were conducted in Canada more than a decade ago. Large scale studies are required to establish the relationship between maternal medicine use and breastfeeding, considering type of illness, period of use and total duration of medicine use.

Population PK modelling and simulation based on fluoxetine and norfluoxetine concentrations in milk: a milk concentration-based prediction model

AIMS

Population pharmacokinetic (pop PK) modelling can be used for PK assessment of drugs in breast milk. However, complex mechanistic modelling of a parent and an active metabolite using both blood and milk samples is challenging. We aimed to develop a simple predictive pop PK model for milk concentration-time profiles of a parent and a metabolite, using data on fluoxetine (FX) and its active metabolite, norfluoxetine (NFX), in milk.

METHODS

Using a previously published data set of drug concentrations in milk from 25 women treated with FX, a pop PK model predictive of milk concentration-time profiles of FX and NFX was developed. Simulation was performed with the model to generate FX and NFX concentration-time profiles in milk of 1000 mothers. This milk concentration-based pop PK model was compared with the previously validated plasma/milk concentration-based pop PK model of FX.

RESULTS

Milk FX and NFX concentration-time profiles were described reasonably well by a one compartment model with a FX-to-NFX conversion coefficient. Median values of the simulated relative infant dose on a weight basis (sRID: weight-adjusted daily doses of FX and NFX through breastmilk to the infant, expressed as a fraction of therapeutic FX daily dose per body weight) were 0.028 for FX and 0.029 for NFX. The FX sRID estimates were consistent with those of the plasma/milk-based pop PK model.

CONCLUSIONS

A predictive pop PK model based on only milk concentrations can be developed for simultaneous estimation of milk concentration-time profiles of a parent (FX) and an active metabolite (NFX).

Medicine use and safety while breastfeeding: investigating the perspectives of community pharmacists in Australia

Consumers and health professionals rely on community pharmacists for accurate information about the safety of medicines. Many breastfeeding women require medications, yet we know little about the advice provided to them by pharmacists in Australia. The aim of this study therefore was to investigate the perspectives of community pharmacists in Australia on medication use and safety in breastfeeding using a postal survey of a national random sample of 1166 community pharmacies in 2011. One hundred and seventy-six pharmacists responded (51% female). Of the 52% of participants with children, many (70%) had a total breastfeeding duration (self or partner) of 27 weeks or more. The majority (92%) were confident about supplying or counselling on medication during breastfeeding. The most commonly used resources were drug company information, Australian Medicines Handbook and the Royal Women's Pregnancy and Breastfeeding Medicine Guide. Most (80%) believed the available information to be adequate and 86% thought it accessible. Over one-third were unaware that ibuprofen and metronidazole are compatible with breastfeeding. Most (80%) were able to name at least one medicine that may decrease milk supply. We found that community pharmacists discuss medicine use in lactation and are confident of their ability to do so; however, their knowledge may be variable.

Maternal medication, drug use, and breastfeeding

This article reviews the necessary skills required for clinicians to make informed decisions about the use of medications in breastfeeding women. Even without specific data on certain medications, this review of kinetic principles, mechanisms of medication entry into breast milk, and important infant factors can aid in clinical decision making. In addition, the article reviews common medical conditions (eg, depression, hypertension, infections) in breastfeeding women and their appropriate treatment.

The use of herbal medicines during breastfeeding: a population-based survey in Western Australia

BACKGROUND

Main concerns for lactating women about medications include the safety of their breastfed infants and the potential effects of medication on quantity and quality of breast milk. While medicine treatments include conventional and complementary medicines, most studies to date have focused on evaluating the safety aspect of conventional medicines. Despite increasing popularity of herbal medicines, there are currently limited data available on the pattern of use and safety of these medicines during breastfeeding. This study aimed to identify the pattern of use of herbal medicines during breastfeeding in Perth, Western Australia, and to identify aspects which require further clinical research.

METHODS

This study was conducted using a self-administered questionnaire validated through two pilot studies. Participants were 18 years or older, breastfeeding or had breastfed in the past 12 months. Participants were recruited from various community and health centres, and through advertising in newspapers. Simple descriptive statistics were used to summarise the demographic profile and attitudes of respondents, using the SPSS statistical software.

RESULTS

A total of 304 questionnaires from eligible participants were returned (27.2% response rate) and analysed. Amongst the respondents, 59.9% took at least one herb for medicinal purposes during breastfeeding, whilst 24.3% reported the use of at least one herb to increase breast milk supply. Most commonly used herbs were fenugreek (18.4%), ginger (11.8%), dong quai (7.9%), chamomile (7.2%), garlic (6.6%) and blessed thistle (5.9%). The majority of participants (70.1%) believed that there was a lack of information resources, whilst 43.4% perceived herbal medicines to be safer than conventional medicines. Only 28.6% of users notified their doctor of their decision to use herbal medicine(s) during breastfeeding; 71.6% had previously refused or avoided conventional medicine treatments due to concerns regarding safety of their breastfed infants.

CONCLUSIONS

The use of herbal medicines is common amongst breastfeeding women, while information supporting their safety and efficacy is lacking. This study has demonstrated the need for further research into commonly used herbal medicines. Evidence-based information should be available to breastfeeding women who wish to consider use of all medicines, including complementary medicines, to avoid unnecessary cessation of breastfeeding or compromising of pharmacotherapy.

Comparison of dietary food and nutrient intakes by supplement use in pregnant and lactating women in Seoul

This study was performed to compare the dietary food and nutrient intakes according to supplement use in pregnant and lactating women in Seoul. The subjects were composed of 201 pregnant and 104 lactating women, and their dietary food intake was assessed using the 24-h recall method. General information on demographic and socioeconomic factors, as well as health-related behaviors, including the use of dietary supplements, were collected. About 88% and 60% of the pregnant and lactating women took dietary supplements, respectively. The proportion of dietary supplements used was higher in pregnant women with a higher level of education. After adjusting for potential confounders, among the pregnant women, supplement users were found to consume 45% more vegetables, and those among the lactating women were found to consume 96% more beans and 58% more vegetables. The intakes of dietary fiber and β-carotene among supplement users were higher than those of non-users, by 23% and 39%, respectively. Among pregnant women, the proportion of women with an intake of vitamin C (from diet alone) below the estimated average requirements (EAR) was lower among supplement users [users (44%) vs. non-users (68%)], and the proportion of lactating women with intakes of iron (from diet alone) below the EAR was lower among supplement users [usesr (17%) vs. non-users (38%)]. These results suggest that among pregnant and lactating women, those who do not use dietary supplements tend to have a lower intake of healthy foods, such as beans and vegetables, as well as a lower intake of dietary fiber and β-carotene, which are abundant in these foods, and non-users are more likely than users to have inadequate intake of micro-nutrient such as vitamin C and iron.

Pharmacogenetic testing: Current Evidence of Clinical Utility

Over the last decade, the number of clinical pharmacogenetic tests has steadily increased as understanding of the role of genes in drug response has grown. However, uptake of these tests has been slow, due in large part to the lack of robust evidence demonstrating clinical utility. We review the evidence behind four pharmacogenetic tests and discuss the barriers and facilitators to uptake: 1) warfarin (drug safety and efficacy); 2) clopidogrel (drug efficacy); 3) codeine (drug efficacy); and 4) abacavir (drug safety). Future efforts should be directed toward addressing these issues and considering additional approaches to generating evidence basis to support clinical use of pharmacogenetic tests.

Maternal medication, drug use, and breastfeeding

This article reviews the necessary skills required for clinicians to make informed decisions about the use of medications in women who are breastfeeding. Even without specific data on certain medications, this review of kinetic principles, mechanisms of medication entry into breast milk, and important infant factors can aid in clinical decision making. In addition, common medical conditions and suitable treatments of depression, hypertension, infections and so forth for women who are breastfeeding are also reviewed.

Folate-status response to a controlled folate intake in nonpregnant, pregnant, and lactating women

BACKGROUND

Folate dose-response studies in women of childbearing age who consumed a folic acid (FA)-containing multivitamin in the era of FA fortification are lacking.

OBJECTIVE

We sought to investigate folate-status response to a known folate dose comprising an FA-containing prenatal supplement (750 μg/d) plus natural food folate (400 μg/d) in third-trimester pregnant women, lactating women 5-15 wk postpartum, and nonpregnant women.

DESIGN

Pregnant (n = 26), lactating (n = 28), and nonpregnant (n = 21) women consumed the study folate dose under controlled intake conditions for 10-12 wk. Blood, urine, and breast milk were collected at baseline, study midpoint, and study end.

RESULTS

Study-end serum total folate concentrations averaged ~30 ng/mL and did not differ by physiologic group (P = 0.876). Study-end urinary folate excretion represented ~9-43% of total folate intake and ranged from 100 to 500 μg/d. Third-trimester pregnant women excreted less urinary folate than did lactating (P = 0.075) and nonpregnant (P < 0.001) women. Lactating women excreted less (P < 0.001) urinary FA than did nonpregnant women. Breast-milk total folate concentrations remained constant (P = 0.244; 61.8 ng/mL at study end), whereas breast-milk FA concentrations increased (P = 0.003) to 24.1 ng/mL at study end.

CONCLUSIONS

The consumption of the study folate dose yielded a supranutritional folate status regardless of the physiologic state. Based on urinary folate excretion, folate use was greatest to least: pregnant > lactating > nonpregnant women. Breast-milk folate species were responsive to maternal folate intake, and FA made up ~40% of breast-milk total folate at study end. These findings warrant revisiting prenatal supplement FA formulation in populations exposed to FA-fortification programs.

Psychotropic drug use during breastfeeding: a review of the evidence

OBJECTIVE

The objective of this study was to review the existing literature on the use of various classes of psychotropic medications during breastfeeding to provide information about infant exposure levels and reported adverse events in breastfed infants.

METHODS

A bibliographic search in the Medline (1967 through July 2008), Embase (1975 through July 2008), and PsycINFO (1967 through July 2008) databases was conducted for studies on breastfeeding and psychotropic medications for a total of 96 drugs. References of retrieved articles, reference books, and dedicated Web sites were also checked. The manufacturers were contacted for drugs without published information. Original articles and review articles that provide pharmacokinetic data on drug excretion in breast milk and infant safety data were considered, to estimate the "compatibility level" of each drug with breastfeeding.

RESULTS

A total of 183 original articles were eligible for analysis. Documentation was retrieved for 62 (65%) drugs. In all, 19 (31%) psychotropic drugs can be used during lactation according to an evidence-based approach. For 28 drugs, the available data do not permit an evaluation of the drug's safety profile during breastfeeding and, for an additional 15 drugs, the exposure dose or observed adverse effects make their use unsafe.

CONCLUSIONS

Although most drugs are considered safe during breastfeeding, compatibility with breastfeeding has not been established for all psychotropic drugs. There is a need for additional research and accumulation of experience to guarantee a more rational use of psychotropic drugs during breastfeeding.

The identifying and counseling of breastfeeding women by pharmacists

OBJECTIVE

Concerns about medications influence breastfeeding decisions. Mothers may stop breastfeeding when they take medications. After the distribution of Thomas Hale's Medications and Mother's Milk (MMM) (Hale Publishing, Amarillo, TX, 2006) by the Rhode Island Department of Health (Providence, RI) in November 2006 to Rhode Island pharmacies, we investigated, during the summer of 2007, what strategies and resources pharmacists were using to identify breastfeeding women and guide medication recommendations.

METHODS

Copies of MMM were sent to 47 pharmacies in Rhode Island. Subsequently, one pharmacist at each site completed a confidential, 10-question written survey.

RESULTS

The survey response rate was 92%. More than half (58%) of the pharmacists surveyed never asked women if they were breastfeeding. Most (85%) of pharmacists reported feeling somewhat or very comfortable giving advice to breastfeeding women. All but one pharmacist who had received MMM reported using the reference at least monthly. More than half (52%) of the pharmacists reported using the Physician's Desk Reference (Thomson PDR, Montvale, NJ).

DISCUSSION

Pharmacists need a consistent approach to identify breastfeeding women and access to reliable, continuously updated resources to guide their advice about medication use to breastfeeding women. Physicians and pharmacists should collaborate to prevent medication use from being a barrier to breastfeeding.

Medications in pregnancy and lactation: part 1. Teratology

One of the least-developed areas of clinical pharmacology and drug research is the use of medication during pregnancy and lactation. This article is the first in a two-part series designed to familiarize physicians with many aspects of the drugs they commonly prescribe for pregnant and breast-feeding women. Almost every pregnant woman is exposed to some type of medication during pregnancy. Although the majority of pregnant and breast-feeding women consume clinically indicated or over-the-counter drug preparation regularly, only few medications have specifically been tested for safety and efficacy during pregnancy. There is scant information on the effect of common pregnancy complications on drug clearance and efficacy. Often, the safety of a drug for mothers, their fetuses, and nursing infants cannot be determined until it has been widely used. Absent this crucial information, many women are either refused medically important agents or experience potentially harmful delays in receiving drug treatment. Conversely, many drugs deemed "safe" are prescribed despite evidence of possible teratogenicity. Novel research and diagnostic applications evolving from the opportunities presented by the advances in genomics and proteomics are now beginning to affect clinical diagnosis, vaccine development, drug discovery, and unique therapies in a modern diagnostic-therapeutic framework-part of the new scientific field of theranostics. This review critically explores a number of recently raised issues in regard to the use of several classes of medications during gestation and seeks to provide a general and concise resource on drugs commonly used during pregnancy and lactation. It also seeks to make clinicians more aware of the controversies surrounding some drugs in an effort to encourage safer prescribing practices through consultation with a maternal-fetal medicine specialist and through references and Web sites that list up-to-date information.

Use of dietary supplements by pregnant and lactating women in North America

Nutrient requirements increase during periods of growth and development such as pregnancy and lactation. In response, many clinicians recommend dietary supplements during these important periods of the life cycle. Although there exist some recommendations concerning the need for a limited number of nutrients in supplemental form (eg, iron, folic acid, and iodine), there is a relative paucity of data concerning the use of dietary supplements during pregnancy and lactation. Limited data suggest, however, that usage is dependent on demographic, sociologic, and economic factors. Thus, it is possible that the nation's most at-risk populations may be those who are least likely to comply with these recommendations. As researchers continue to study what is meant by "optimal nutrition" during pregnancy and lactation, it is likely that additional recommendations concerning dietary supplements will emerge. For example, it is possible that increased consumption of some of the long-chain polyunsaturated fatty acids during pregnancy or lactation may impart a benefit to infant health. Understanding better the population dynamics related to supplement use during these periods will be critical in implementation of campaigns designed to encourage appropriate use--and discourage inappropriate use--of dietary supplements during these important phases of human reproduction. The purpose of this article is to briefly review what is known about the use of dietary supplements in North America and, more specifically, in pregnant and lactating women. In addition, information concerning barriers to supplement use is discussed as are current recommendations for dietary supplement consumption during these periods of the life cycle.