Medication Management in Lactation-A Pharmacist Education Pilot Project: Part one survey.

BACKGROUND: Pharmacists as the most accessible health professionals can serve as an important resource on medication safety for breastfeeding women. Previous research suggests that a barrier to pharmacists providing optimal pharmaceutical care for this population is a lack of knowledge. OBJECTIVE: To evaluate pharmacist perceptions and barriers related to medication management of patients who are breastfeeding. METHODS: A 25-question electronic survey was distributed via e-mail list servers to members of state pharmacy organizations. Pharmacists were queried on the importance of breastfeeding, barriers to pharmaceutical care, comfort level in making pharmacotherapy recommendations, adequacy of pharmacy school's curriculum, breastfeeding resources used, and need for continuing pharmacy education regarding medication use during breastfeeding. RESULTS: Pharmacists from all geographic regions of the United States and diverse practice settings agreed to participate in the survey (N = 197). Most pharmacists reported feeling somewhat or extremely comfortable making recommendations and counseling breastfeeding patients on over-the-counter (102 of 187, 55%) and prescription medications (110 of 187, 59%). In contrast, 66% (123 of 187) reported feeling somewhat or extremely uncomfortable making recommendations and counseling on the use of herbal supplements in breastfeeding. Notably, 95% of pharmacists (171 of 180) responded that there is an unmet need for continuing pharmacy education on medication use in lactation. CONCLUSION: Pharmacists are generally uncomfortable when making recommendations and counseling breastfeeding patients on herbal and other supplements. Most pharmacists agree that there is a lack of available continuing pharmacy education on breastfeeding.

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.

Opioid use disorder: Calling pharmacists to action for better preconception and pregnancy care.

Opioid use disorder (OUD) in women of child-bearing potential is problematic in the United States. This has resulted in increasing risk for adverse maternal outcomes, neonatal abstinence syndrome, fetal and neonatal harm, prolonged hospitalizations, and increased health care costs. Pharmacists in all practice settings have opportunities to provide preconception and pregnancy care to prevent and manage OUD. Given pharmacists' scope of practice and expertise, key roles include assessing patients for OUD; mitigating exposure; educating patients regarding potential infant effects; recommending contraceptive methods and counseling on proper use; ensuring safe breastfeeding with concurrent medications; and linking patients to needed services. Through patient counseling, medication management, and harm reduction interventions, pharmacists can work to combat this public health crisis. To encourage increased uptake of pharmacists into these roles, more needs to be done to reimburse pharmacists for these important services and quantify their impact on patient and population health outcomes.

Reduction in Newborn Screening False Positive Results Following a New Collection Protocol: a Quality Improvement Project.

OBJECTIVE: Premature infants are known to have a higher rate of false positive newborn screening (NBS) results, with TPN as a contributing factor. The purpose of this quality improvement (QI) project is to reduce false positive NBS results via a TPN interruption protocol. METHODS: A multidisciplinary team reviewed the literature and developed a new NBS collection protocol, which was implemented in 2 periods. In period 1, TPN was interrupted for 4 hours before NBS sample collection and initiation of carnitine supplements was avoided. In period 2, TPN was interrupted for 6 hours for infants birth weight (BW) < 1000 g, carnitine supplementation continued to be avoided. The rates of false positives NBS results were compared pre- and post-interventions in periods 1 and 2. RESULTS: Four hundred twelve neonates were evaluated prior to implementation of this QI project (July 2013-June 2014) and 414 during period 1 intervention (July 2014-June 2016). False positive results decreased from 20.6% to 11.4% (p < 0.001) among all BW categories following the 4-hour TPN interruption. The rate of false positives was further reduced among infants < 1000 g (p = 0.035) in period 2 (n = 112), including a significant reduction in false positive results with elevated amino acid profiles (p = 0.005). CONCLUSIONS: The implementation of a strict NBS collection protocol reduced false positive NBS results, which potentially can improve patient care by reducing unnecessary laboratory draws, pain, and parental anxiety. Interruption of TPN for 6 hours was significant in reducing NBS false positive results in neonates < 1000 g.

Neonatal Abstinence Syndrome Practices in the United States.

OBJECTIVE: To survey current practices for the treatment of neonatal abstinence syndrome (NAS) among institutions in the United States to identify changes in national practice over time. METHODS: Previous NAS management reports were referenced in the development of our 26-question electronic survey, which was distributed in the fall of 2019 to pediatric practitioners of 2 national clinical pharmacy organizations via email list servers. Not all questions required a response and responses from incomplete surveys were included. Institution demographics and NAS management strategies, including location of care, observation period, and inpatient and outpatient pharmacotherapy, were queried. RESULTS: Seventy respondents representing institutions from all US geographic regions participated in the survey The most commonly reported inpatient observation durations were 3 (18 of 61, 29%) and 5 (22 of 61, 36%) days. Respondents indicated that neonates were typically transferred to the NICU if pharmacologic management was required (38 of 56, 68%). According to participants, first-line agents used for NAS management were morphine (45 of 56, 80%), methadone (5 of 56, 9%), clonidine (2 of 56, 4%), and buprenorphine (2 of 56, 4%). Among respondents, only 20% (11 of 56) reported that infants may be discharged home on pharmacotherapy, including morphine (n = 6), phenobarbital (n = 3), clonidine (n = 1), and methadone (n = 1). CONCLUSIONS: Opioids are the most commonly used first-line agents for NAS management in the United States. The primary site of NAS management is the inpatient setting, as only 20% of institutions report discharging patients on pharmacotherapy.

Micronutrient Monitoring and Management in Parenteral Nutrition-Dependent Premature Neonates: A Case Series.

We present a prospective case series of 3 premature neonates with abnormal vitamin A, vitamin E, and selenium levels after being managed on prolonged parenteral nutrition (PN). All 3 patients experienced gastrointestinal complications including spontaneous intestinal perforation, necrotizing enterocolitis, and/or short bowel syndrome. Additionally, all 3 patients developed PN-associated liver disease, which required the use of a mixed lipid emulsion and a fish oil-based lipid emulsion for a short period of time. We evaluated the micronutrient levels of these patients after they had been receiving PN for 1 to 2 months. After the early identification of these abnormalities, we promptly attempted to correct the levels through supplementation and restriction, as appropriate. One barrier we experienced in the treatment of these patients was the conflicting guidance of daily micronutrient dosing in PN and when to evaluate levels in premature infants from the European and American pediatric nutrition organizations, the European Society for Paediatric Gastroenterology Hepatology and Nutrition and the American Society for Parenteral and Enteral Nutrition. Additionally, after we assessed micronutrient levels, we experienced a lack of guidance on how to adjust dosing and when to monitor subsequent levels.

Neonatal hyperglycemia in a preterm infant managed with a subcutaneous insulin pump.

PURPOSE: Successful use of a subcutaneous insulin pump to administer regular insulin to a preterm infant with neonatal hyperglycemia is described. SUMMARY: A 520-g female infant born at 23 weeks' gestational age via caesarian section was noted to have elevated blood glucose concentrations ranging up to 180 mg/dL (in SI units, 10 mmol/L) on day of life (DOL) 3 and peaking on DOL 9 at 250 mg/dL (13.9 mmol/L) despite conservative glucose infusion rates. Continuous infusion of regular insulin was begun on DOL 8 and continued through DOL 44, with an average insulin infusion rate of 0.08 units/kg/h. The patient experienced blood glucose concentration lability due to multiple factors, resulting in the need for frequent and routine blood glucose concentration monitoring to minimize hypoglycemia events. On DOL 44, a subcutaneous insulin pump was placed and used to provide diluted regular insulin (25 units/mL). After 1 week, the patient's blood glucose concentration normalized, which led to a reduction in the frequency of glucose monitoring. After 3 weeks, insulin pump use was discontinued. The patient remained euglycemic thereafter. CONCLUSION: The use of an insulin pump resulted in decreased blood glucose checks, discontinuation of central line access, and overall better patient care.

What do patients feel they can do following lumbar microdiscectomy? A qualitative study.

PURPOSE: Lumbar microdiscectomy is becoming increasingly popular in the management of prolapsed intervertebral disc. The early stage of rehabilitation has been under-researched, with little documented about optimal activity levels during the initial six weeks. This study aimed to gain insight into patients' experiences of physiotherapy and activity choices during this period. METHOD: Eight participants were chosen purposively. All had undergone an uncomplicated lumbar microdiscectomy in the preceding six weeks in an acute neurosurgical unit in the Northeast of England. One-to-one semi-structured interviews were conducted in the participants' homes and transcribed. Data were thematically analysed within a constructionist framework. Mechanisms to ensure analytical rigour were implemented. RESULTS: Three major themes were derived inductively from the data. The first, 'wish for precise movement boundaries,' described participants reduced levels of activity postoperatively as being related to high levels of anxiety about the surgery and fear of re-injury. The second theme suggested that physiotherapy failed to help participants explore their potential for activity. The final theme described post-operative fatigue. CONCLUSIONS: High levels of postoperative anxiety about movement and activity were not addressed postoperatively. This has significant clinical implications and highlights the need for further research.