47 minute read
CPD: INFANT NUTRITION
Continuing Professional Development CPD CPD
60 Second Summary
Infancy is a time of rapid growth. Breastmilk provides all the nutrition an infant requires as well as having many nonnutritional functions. Support for breastfeeding can be sought from midwives, IBCLCs, public health nurses, doctors, mychild. ie and voluntary agencies. Most medications are safe for use when breastfeeding and specialist breastfeeding resources should be used for information.
If families choose to use a breastmilk substitute or formula milk, this should be one suitable for use from birth. There is no evidence that formulas designed for special indications such as colic or reflux are beneficial. Regurgitation or reflux is a normal phenomenon in infancy. Treatment is usually only required if infants have failure to thrive and are under medical supervision. ‘Hungry baby’ formulas are not recommended. First infant milk is suitable for use until the age of one and thereafter breastmilk or regular cows’ milk is recommended.
Colic is described as recurrent and prolonged periods of infant crying, fussing or irritability starting and ending before five months with no obvious cause, which cannot be prevented or resolved by caregivers, with no evidence of failure to thrive, fever or illness (Rome IV). The mainstay of treatment for colic is reassurance and support. Excessive infant crying is a risk factor for non-accidental injury. Dietary modification of breastfeeding mothers has not been found to be of benefit. Use of hydrolysed formula has not been shown to reduce crying in any clinically meaningful way. Use of the probiotics have been shown to reduce daily crying times by approximately 30 minutes per day, the most commonly studied agent is lactobacillus reuteri. There is insufficient evidence to recommend their use for formula feeding infants.
AUTHOR: Dr Anne Doolan, Paediatrician/Neonatologist, Coombe Women & Infants University Hospital Dublin
1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice? 2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area. 3. PLAN - If I have identified a knowledge gap - will this article satisfy those needs - or will more reading be required? 4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result?Have I identified further learning needs? 5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings. Published by IPN. Copies can be downloaded from www.irishpharmacytraining.ie Disclaimer: All material published is copyright, no part of this can be used in any other publication without permission of the publishers and author.
Infant Nutrition
The importance of nutritional support in infants and coping with colic in babies
Introduction:
Infancy is a time of rapid growth. Babies double their birth weight by about 5 months and triple it by their first birthday. A healthy baby born at full term (37-42 weeks), requires about 100kcal per kilogram per day to grow normally. This would equate to 7000kcal per day for a 70 kg person! Babies who were born prematurely (born <37 weeks), were low birth weight (<2.5kg at birth) or have medical conditions such as congenital heart disease may have even higher energy requirements and need careful growth monitoring. Babies lose up to 10% of their birth weight in first few days of life. It is expected that they would regain their birth weight by two weeks of life, thereafter, weight gain is 150-210g per week for the first three months of life.
Supporting breastfeeding:
The WHO recommends that infants should be breastfed until 6 months with continued breastfeeding alongside the introduction of complementary foods until two years and beyond. Breastmilk contains all the nourishment a baby needs for the first six months, however food is only one of its functions. It contains essential amino acids for muscle and brain development, fats which are important components of the immune, cardiovascular and nervous systems and enzymes to encourage chemical reactions in the body. Human milk oligosaccharides are present to feed healthy bacteria in the gut. Breast milk contains live cells to fight infection and hormones which help regulate appetite and feelings of well-being. Nucleotides are contained in breastmilk which are the building blocks of genetic proteins and help send messages between cells. Growth factors and inflammatory mediators are present to help protect the growing bowel. Breastmilk composition varies from person to person and changes from feed to feed. While the calorific content of breast milk remains fairly constant over time at approximately 67 kcal/100ml, the protein content decreases as the baby gets older. In the first few days of life, protein content of breast milk is as high as 1.8g/100ml (Gidrewicz & Fenton (2014) BMC Pediatrics), falling to 1.2g/100ml by the end of the first month and below 1g/100ml by the end of the third month. This reflects the rapid initial growth of the baby which slows by around 3 months of age. Breast milk composition is tailored to the age of the baby.
When babies are breastfeeding, it is not possible to determine the volumes of milk that the baby is receiving. If babies are gaining weight appropriately 150-210g per week, are having 5-7 wet nappies and are passing 2-3 yellow, seedy stools a day, these are all reassuring signs that breastfeeding is going well. Some babies will pass stools more or less frequently and this can be very normal. Volumes of milk produced when expressing can be different to what the baby receives when directly feeding from the breast. It is not usually useful to ask mothers to express milk simply to measure the volumes that the baby is ingesting. In warm weather, breastfeeding babies may feed more often, however they do not need additional fluids such as water. If breastfeeding babies have vomiting or diarrhoea, they should continue to breastfeed, but should seek medical attention as young babies may get dehydrated quickly if not tolerating milk. HSE guidelines recommend 5 micrograms of Vitamin D daily for babies who are breastfeeding or receiving less than 300ml per day of formula milk from birth to 12 months. Routine iron or other multivitamin supplementation is not recommended unless prescribed. If a breastfeeding woman requires either prescribed or over the counter medication, it is important she receives accurate information about safety of use in breastfeeding. Most medications are safe for use when breastfeeding, however occasionally a more suitable medication is advised. Please see table for resources for healthcare professionals about medications in breastfeeding. Parents can access support for breastfeeding from the public health nurse, midwife, maternity unit, International Board Certified Lactation Consultant (IBCLC), GP or voluntary/peer support groups.
Support for families who are formula feeding:
Some families will choose to use formula only from birth and some will use formula alongside breast milk for many different reasons. It is important for HCPs to adhere to the WHO Code of Marketing of Breast Milk Substitutes (WHO Code) and to share factual advice with families. Infant formula contains adequate nutrition for babies but it confers none of the other health benefits of breast milk. Breast milk continues to be of benefit, even in small amounts. Babies who receive formula milk typically drink approximately 150ml/kg day and gain 150210g per week. Formula should be made up according to manufacturer’s instructions. The Food Safety Authority of Ireland does not recommend the use of formula preparation machines because of hygiene concerns. Impartial advice about preparation of formula milk is available on mychild.ie. Many types of formula are available to buy and this can be confusing for parents who are selecting an appropriate formula for their baby. First infant milk suitable for use from birth can be used as a breast milk substitute from birth to 12 months, at which point regular cows’ milk can be used. Switching to ‘follow-on’ or ‘stage 2’ milk has no benefits for a baby. The existence of these products is because in Ireland, the WHO Code has been interpreted to allow marketing of breast milk substitutes from 6 months and beyond. There is no biological need to switch milks at 6 months of age. Many formulas claim they have added ingredients to make their product more like breast milk. However many of these additions are derived from cows’ milk and have not been shown to have benefits for human babies. First Steps Nutrition is an excellent resource for HCPs and parents. This website reviews all the formula products available on the UK market and fact checks their claims of benefit. There is large variation in the price of different formulas, with no demonstrable benefit of the more expensive formula over a less expensive product. The HSE recommends that families should consult a healthcare professional before changing their baby’s formula. Many specialist-type formulas are available to buy over the counter. Goats milk is a suitable alternative to a cows’ milk based formula, once it is nutritionally complete and suitable for infants from birth. There is no evidence that goats’ milk is less allergenic than cows’ milk. ‘Hungry baby milk’ is a product which contains more casein than whey protein which makes the milk harder to digest. There is no evidence to suggest that babies settle better or drink less milk when fed this type of formula. Also, because it is harder to digest, it can cause constipation. Reflux or regurgitation is a normal physiological event in infancy. NICE guidelines do not recommend treatment of simple reflux in infants. For babies who are being formula fed, conservative management of reflux involves reducing feed volumes and increasing feed frequency. Where there is significant, frequent
regurgitation anti-reflux formula may be recommended and used under medical supervision. These milks are thickened with potato starch, carob or locust bean gum. These milks do not seem to reduce regurgitation but may reduce overt vomiting. Because of the thickening agents present in these milks, they are recommended to be reconstituted with cool water rather than at a temperature of 70°C as per HSE guidelines. This increases the risk of bacterial contamination and infection.
‘Hypoallergenic formula’ is 100% whey protein and is partially hydrolysed. It is marketed as reducing the risk of atopic dermatitis, however this claim has not been supported by the European Food Safety Authority (EFSA). This milk is not suitable for babies who have diagnosed food allergy. Only breastmilk has been shown to reduce the risk of allergy and atopy. Diagnosis and treatment of proven cows’ milk protein allergy is outside the scope of this article. Soya protein-based formula should only be used if prescribed by a doctor for specific conditions such as galactosaemia. Some families wish to use them because of a history or suspected cows’ milk protein allergy, but these milks have not been shown to prevent allergy and many children who have cows’ milk protein allergy will also react to soya protein. Because of the presence of phyto-oestrogens and the potential to have a negative effect on future reproductive health, they are not recommended for infants under 6 months (unless prescribed). The primary source of carbohydrate is maltodextrin rather than lactose which can have a negative effect on the baby’s dental health.
The primary source of carbohydrate in breast milk is lactose, so ‘lactose intolerance’ in infants is an extremely rare cause of unsettled behaviour and failure to thrive. Lactose free formulas use glucose as a carbohydrate source and thus are not kind to teeth. They are not recommended in the treatment of infant colic (see below). Comfort milk is marketed as a type of formula that reduces symptoms of colic and/or constipation, however these claims are unsubstantiated. They contain partially hydrolysed whey protein. They are manufactured with reduced amounts of lactose and this is replaced by glucose, corn syrup or maltodextrin depending on the product. There is insufficient evidence to say they reduce symptoms of colic.
Coping with colic in babies: What is colic?
Since the 1950’s, colic has been described as unexplained paroxysmal crying for longer than three hours per day, for three days per week, for at least three weeks. More recently the Rome IV diagnostic criteria include infants who are less than five months when symptoms start and stop, who have recurrent and prolonged periods of infant crying, fussing or irritability with no obvious cause, that cannot be prevented or resolved by caregivers, with no evidence of failure to thrive, fever or illness. The condition is most frequent within the first six weeks of life and effects up to a quarter of infants. It is equally common in breastfeeding and formula feeding babies. Excessive infant crying is a frequent reason for parents to support from healthcare professionals and is a risk factor for non-accidental injury.
Normal infant behaviour:
Some would argue that the term colic is outdated, and that infant crying is part of normal newborn behaviour. It would be expected that a newborn infant would cry or be unsettled for 2-3 hours a day, with peak incidence of crying occurring at about six weeks of age. Babies have come from a very warm, secure environment and the outside world can be loud and scary. It is normal for a baby to want to be held and kept close to their parents. Physical closeness is important for establishing breastfeeding and the parental response to crying is what keeps babies safe. Parents often perceive a baby’s cry as pain, however this is only means they have to communicate any discomfort to their caregiver. Infant crying can lead to parental distress and parents should be encouraged to seek support and also be aware of the risk of postnatal depression.
What red flags should we be aware of?
If parents are concerned about their baby’s crying, they should be encouraged to speak to a healthcare professional and have a clinical exam and weight measurement. Reassurance can be beneficial. Fever (>38°C), bilious vomiting, projectile vomiting, poor weight gain, blood in the stool or any signs of injury are all reasons to seek medical
attention. Similarly, if parents are struggling to cope, they may also need to speak with their doctor. Typically, the ‘colicky’ baby gains weight well and is keen to feed. They frequently appear quite happy and content when they visit the doctor!
What causes colic?
The aetiology of colic is undefined and is likely multifactorial – behavioural and biological components, gut microflora and dysmotility factors are the focus of research. Lactose intolerance and presence of allergens in formula or Educational resources for Healthcare Professionals breast milk have been investigated as causes. The intestinal microbiome has been found to be HSEland – Infant Growth and Nutrition, Breastfeeding elearning modules different in infants with and without colic. Immature gut motility has Hale’s Medication and Mother’s Milk also been investigated. Breastfeeding Network medication factsheets What is the treatment of colic?(breastfeedingnetwork.org.uk) First Steps Nutrition (firststepsnutrition.org) Once no red flags are present, the mainstay of treatment is Association of Lactation Consultants of Ireland (alcireland.ie) support and parental reassurance. Babies are unable to self-soothe. Responding to them quickly Resources for families reduces the crying time. Parents should be reassured that they will not ‘spoil’ their baby by holding them. Local Health Centre/Public Health Nurse The most recent Cochrane Review HSE – mychild.ie on Dietary Modifications for First Steps Nutrition (firststepsnutrition.org) Infantile Colic was published in 2018. 15 studies of 1121 infants La Leche League were included. Modification of the maternal diet to reduce Ciudiu intake of potential allergens was Friends of Breastfeeding not found to be beneficial. If the breastfeeding mother decides to exclude allergens from her diet, baby’s symptoms should be monitored with reintroduction of normal eating as soon as possible if there is no effect. Longer term dietary modification should be Colic - recurrent and prolonged periods of infant crying, fussing or irritability starting and ending before five months with no obvious cause, which cannot be prevented or resolved by caregivers, with no evidence of failure to thrive, fever or illness (Rome IV) Red flags - parental concern, fever, bilious vomiting, projectile vomiting, poor weight gain, blood in the stool or any signs of injury Treatment – parental reassurance and support - Probiotics (lactobacillus reuteri) may have a role for breastfeeding infants - No/insufficient evidence to recommend maternal dietary medication, specialist formulas, medications or manipulation therapies
supported by a dietitian in order to support a healthy balanced diet for the mother.
Use of hydrolysed formula has not been shown to reduce crying times in any meaningful way. Similarly reduced lactase intake or use of lactase drops showed no difference in crying times. There is no evidence to say that changing formula type will influence colic or crying times. The different types of formula have been discussed above.
Probiotics have been studied for use in infantile colic (Cochrane 2019). 6 studies of 1886 infants compared probiotics with placebo. There was no evidence to suggest that probiotic use prevented colic. A meta-analysis of three studies showed a reduction in crying time of approximately 30 minutes per day with use of probiotic when compared with placebo, the most studied agent was Lactobacillus reuteri. A meta-analysis (Paediatrics 2018) of probiotics concluded that there was insufficient data to recommend use in formula fed infants.
Simethicone is an anti-flatulent medication, however it is no better than placebo at treating colic. Gripe water typically contains sodium hydrogen carbonate and some other agents such as fennel which are thought to reduce wind. Gripe water has not been shown to reduce infant colic.
Studies of manipulative therapies (chiropractic, osteopathy or craniosacral therapy) to date have been poorly designed with high levels of bias because of study design and a lack of blinding. While some reduction of crying time has been shown, there is insufficient evidence to recommend these treatments. Infant massage by parents has not been shown to be of benefit in reducing crying, however it is soothing for both parent and child and encourages positive interactions. For crying infants, once red flag signs and symptoms have been out ruled, no treatments have been found to reduce infant crying by any clinically meaningful amount. Parents need support and reassurance. It should be acknowledged that caring for a crying baby is frustrating and tiring and they should be encouraged to ask for help. New parents are vulnerable and tired. Many breastmilk substitutes and medications that are sold as colic remedies are expensive. We have a responsibility to provide evidence based advice.
Questions:
Q1. Which of the following statements are true?
A. Babies triple their birth weight by 1 year of age B. Babies need approximately 100kcal/kg per day to grow normally C. Babies with congenital heart disease often need less than 100kcal/kg per day D. Babies should regain their birth weight by 4 weeks of age
A. Breastmilk continues to have nutritional and immunological benefits for children for the first 2 years of life and beyond B. Breastfeeding is only beneficial if it is done exclusively for six months C. The protein content of breastmilk continues to increase in the first year of life to encourage babies to grow D. In warm weather breastfed babies do not require extra water, however they may feed more frequently than usual
A. Formula feeding babies will typically drink 100ml/kg/day of milk B. The Food Safety Authority of Ireland does not recommend use of formula preparation machines C. It is recommended that babies move on to Stage 2 formula at 6 months because first infant milk is no longer nutritionally suitable at this age D. If a baby is allergic to cows’ milk, goats’ milk is recommended in the first instance
Q4. A parent is concerned that their formula feeding baby vomits after every feed. What is the best advice to give her?
A. You ask about red flags and suggest that they see their GP as soon as possible but you recommend starting anti-reflux formula today without delay B. You ask about red flags and suggest that they see their GP as soon as possible but you recommend starting a different brand of formula C. You ask about red flags and suggest that they see their GP as soon as possible but you recommend more frequent, smaller feeds D. You ask about red flags and suggest that they see their GP as soon as possible but you say that the baby will probably be prescribed anti-reflux medication
A. Colic most frequently starts when a baby is over 5 months of age B. Parents should be discouraged from picking their baby up when they are crying because this will ‘spoil’ them C. Maternal dietary medication is unlikely to help treat infant colic D. It may be useful to recommend a probiotic containing lactobacillus reuteri to breastfeeding infants
Visit www.pharmacynewsireland.com for the full article, questions and answers.
HSEland – Infant Growth and Nutrition, Breastfeeding elearning modules Hale’s Medication and Mother’s Milk Breastfeeding Network medication factsheets (breastfeedingnetwork.org.uk) First Steps Nutrition (firststepsnutrition.org) Association of Lactation Consultants of Ireland (alcireland.ie)
Resources for families
Local Health Centre/Public Health Nurse HSE – mychild.ie First Steps Nutrition (firststepsnutrition.org) La Leche League Ciudiu Friends of Breastfeeding
Category Focus: Eyes & Ears
Category Focus on Eyes and Ears
Eye and ear care may be considered as smaller categories within the scope of pharmacy care; however, eye and ear problems can be unpleasant, and this therefore represents an opportunity where pharmacists can make a big difference when treated properly.
Building Loyalty
In the last year, with the Covid-19 outbreak, I have found that customers are relying more and more on the pharmacy when it comes to minor ailments as it was almost impossible to get a doctor’s appointment. As a result of this, patients will have gained a lot of trust in the pharmacy profession and should in future know to turn to their local pharmacist for advice before going to the doctor. Pharmacists and pharmacy staff need to keep on top of training in these areas so they can be confident in their ability to recommend certain products and know when to refer on to a GP. This is essential for building up a good rapport with patients, ensuring they will return for your advice in future.
It is important that staff have the confidence to ask appropriate questions to establish the level of discomfort a patient is feeling, how long this issue has been occurring, other medications etc. This will help the staff to know whether they can recommend a product for this issue or whether they need to refer this customer to the pharmacist or the GP to ensure they get appropriate treatment. Any educational information available from the product manufacturers should be taken advantage of. While these companies offer training in order to promote their own products, they should be taken with an open mind and staff can use the knowledge they will gain across a range of different products. These training opportunities help staff to build confidence to be able to offer the best help to patients who will recognise and appreciate the staff knowledge. The company may also provide leaflets or samples, which can help the pharmacy to provide a more knowledgeable and professional service. These training sessions can generally be requested through the sales representative of the company in your area, via phone call or email.
Effective Merchandising
Eye and Ear care categories should be merchandised appropriately and should be displayed in a way to help boost sales. Eye care should have a place out on the shop floor as well as behind the counter. This enables patients to have a browse allowing for selfselection and consideration while also having the ability to ask for products at the counter when they have brought their other items to the till. Pharmacies should dual site eyecare with allergy treatments as there is some crossover with dry eyes, itchy, watering eyes etc. In order to maximise on sales, pharmacies should be looking at marketing hay fever medications from mid-March, as the end of March to early September tend to be the months with the highest pollen count. Having staff put out displays for hay fever medication early, allows them ample opportunity to go through patient information leaflets, guidelines and ask the pharmacist if they have any questions about the products. It also means that you will have customers prepared early and can give them advice on methods of preventing hay fever and the importance of prophylactic use if they tend to have very severe symptoms. It is worth noting the different options available within this category. There are eye drops containing antihistamines to help prevent the allergic reaction, blocking histamines in the body and quickly reducing symptoms like itchy, watery eyes. Examples of antihistamine eye drops include Opticrom and Otrivine. Other eye-drops on the market can help alleviate the symptoms associated with hay fever including eye drops for itchy, watery eyes, however, these do not contain antihistamines. If patients tend to have overly sensitive eyes, pharmacy staff should suggest the single dose eye drops (Opticrom Allergy, Optase Allergy Drops, Fusion Allergy eye drops) as these products do not contain any preservatives which can cause irritation in patients with sensitive eyes.
Age-Related Macular Degeneration
Age-related macular degeneration (AMD) is one of the leading causes of visual impairment in older adults. It causes gradual loss of sight and blurred vision. A lot of the time, patients get a diagnosis for this condition when the damage is already done. There are certain factors which make patients more susceptible to getting this condition, including smoking, high blood pressure, obesity or a
Written by Emer Scullion, Pharmacist, Inish Pharmacy Buncrana
diet high in unsaturated fat and lack of exercise.
Supplements containing all three macula carotenoids Lutein, Zeaxanthin and meso-zeaxanthin like MacuShield, MacuShield Gold, MacuSave MacuPrime and MacuPrime PLUS help to reduce the risk and/or slow the progression of AMD. Lutein Omega-3, MacuPrime PLUS also contain zinc to help maintain normal vision, copper, vitamin C and vitamin E, which contributes to the protection of cells from oxidative stress. MacuPrime and MacuSave are gluten free so they are safe for coeliac customers. Most of these supplements are a once daily tablet which tends to be well tolerated by customers. Pharmacy staff should be well versed in the benefits of these treatments as they should be confident in discussing the benefits of these supplements with patients whom they recognise to be in an ‘at risk’ category. Pharmacies can also take advantage of the cosmetic side of eyecare, including anti-redness eye drops, eye creams and eye brighteners. Dry skin around eyes can often lead to discomfort for patients and pharmacy staff should be well versed on which eye ointments and moisturisers are safe to be used on and near the eyes. In recent years, there has been an increased demand for cosmetic procedures involving the eyes, including lash lifts and tints, semipermanent eyelash extensions and eyebrow tints. As a result of this, more people are suffering with allergic reactions or skin irritation to some of the products being used. Products like Xailin Eye Gel or Hylo-Night can be recommended in these instances as they contain white soft paraffin (Hylo-night also contains liquid paraffin) which will hydrate the skin on the eyelid, locking in moisture, helping to heal the irritation and discomfort for the patient. Hylo-Night also contains retinol palmitate (vitamin A) which helps improve skin tone and prevent collagen breakdown. These products are licensed for use in the eye and so offer a safe option to treat dry/ irritated skin on the eyelid as it doesn't matter if the patient were to accidentally get it in their eye. Pharmacy staff should proactively offer this advice if a customer is discussing getting these treatments done soon. Pharmacists should also actively offer ear and eye health promotion services. This can include suggesting products for uses which may not come to mind straight away, for example, Blephaclean wipes can be used to remove make-up while also gently cleansing the eyelids and lashes. These wipes are free from parabens, perfumes and preservatives and so are a fantastic alternative to eye-make up removal for patients with extremely sensitive eyes. This will also help prevent eye infections and blepharitis in patients who may be prone to these conditions. For ear health, using products like ‘Audispray’ to clean ear wax, rather than the traditional but unsafe way of using cotton buds. These are common areas where staff would get asked questions on a regular basis so having staff well versed in these areas with helpful hints and tips for patients is essential. This will add value to pharmacy services and should encourage loyalty among customers. It is important to educate patients on the need for proper eye and ear care and the importance of not ignoring problems as these could be signs of a more serious condition. Eyesight and hearing are so precious and so it is vital that we would treat these with care and do everything possible to maintain their health.
Product Innovation
Continuing product innovation within eye care is providing customers with new options. The latest option in this category is the increasing availability of eye mists/ sprays. This allows for absorption of active ingredients through the eyelids and removes the need for the accuracy of instilling drops. There are currently eye mists/ sprays available for dry and tired eyes, itchy and watery eyes. A lot of patients tend to mention not liking instilling eye drops and so this overcomes that issue as the patient can close their eyes and self-administer. This is also a helpful method to administer eye drops for a patient who has any motor impairment caused by Parkinson’s, Multiple Sclerosis, Motor neuron Disease etc.
These patients can maintain their independence by administering a spray as it is easier to use and requires less dexterity and accuracy than drops. In patients with extremely poor motor function, it may also be easier for a carer or family member to administer the spray to the patient rather than the drops. These are things which pharmacies are in a unique position to be able to give advice on as they can see the patient’s medication history when they are purchasing items in store. Ear care is often overlooked as a section in pharmacy, however, with the availability of ear wax treatments over the counter, it prevents customers from having to wait on doctors’ appointments to solve such an easily fixed issue. This also allows for patients to rule out the cause of the problem being a small ear wax build up, which is helpful for the doctors as they can look at other potential causes and treatments which are more appropriate. Patients will often present to the pharmacy looking for treatment to relieve the symptoms of pain, swelling and itchiness in the ear. This is often called ‘Otitis Externa’ or swimmer’s ear. There are drops available to help ease this, including Cl-ear which work by coating the outer ear canal with a protective film which helps to soothe irritation and swollen tissue resulting from burning, itching, swelling and pain. They work to reduce swelling in the ear and alleviate pain. Children will also often present with what is known as glue ear, this is a condition where the empty middle part of the ear canal fills up with fluid. This can cause pain in the ear, temporary hearing loss or a ringing in the ear (tinnitus). This condition normally clears up on its own and it is important to reassure parents of this, but they can use the Otovent nasal device to reduce symptoms. Pharmacy staff should provide all customers with advice pertaining to what to look out for in cases of infections and if such symptoms should appear, that they would stop self-treating and go to see their doctor.
Both categories can provide an excellent service to patients when merchandised properly and when staff are trained to know the different products and feel confident to sell the products and offer advice to customers.
Category Focus: CBD
Growth of CBD Pharmacy Market
The CBD market is one of the fastest growing within the OTC sector.
The global CBD oil and CBD consumer health market size is expected to reach USD 123.2 billion by 2027, expanding at a CAGR of 25.6% over the forecast period according to the latest market report in this field. However recent legislation changes have provided some confusion within community pharmacies. It was announced last year that CBD companies would have until 31 March 2021 to have a validated novel foods application for each of their products or else risk being removed from shelves. Pharmacies were able to sell CBD products currently on the market until the end of March this year, as long as these were “labelled correctly” and are not “unsafe to eat [or] contain substances that fall under drugs legislation”. The criteria for products which can remain on sale from 1 April 2021 has been updated. Previously, only products which were on sale at the time of the FSA’s announcement (13 February 2020) and were linked to an application which had been validated by 31 March 2021 were to be included. To maximise the opportunity to pass validation, this now includes all products on sale on 13 February 2020 and linked to an application submitted before 31 March 2021 that is subsequently validated. Irish rules on CBD stand in line with the European Union’s Novel Food Regulation. This regulation classifies CBD as a novel food, which doesn’t have a significant history of consumption in Europe before May 15, 1997. Besides the “history of consumption” rule, the Irish authorities included an additional standard for CBD products — the type of the extraction process. According to Irish laws, CBD extracted with solvents or supercritical CO2 extraction requires a novel food permit from the European Commission (EC). Otherwise, it can’t be marketed as a food product or health supplement. However, the Food Safety Authority of Ireland (FSAI) stated that if the CBD oil is extracted by cold pressing it is legal for sale. One brand that uses this process is Emerald Farm – which is cold press and 100% compliant.
Medicinal Cannabis Access Programme
At the start of this year, Minister for Health, Stephen Donnelly TD, announced provision for the delivery and funding of the Medicinal Cannabis Access Programme. “The Budget in October 2020 saw an extra ¤4billion added to the Health Budget. This increase is indicative of how determined we in Government are to fund an expansion of, and improvements in, our health and social care services,” he said. “One of the improvements in our Health Services that will benefit from this extra funding is the Medicinal Cannabis Access Programme which has been added to the HSE Service Plan for 2021.
“The purpose of this Programme is to facilitate compassionate access to cannabis for medical reasons, where conventional treatment has failed. It follows the clear pathway laid out by the Health Products Regulatory Authority in their expert report ‘Cannabis for Medical Use – A Scientific Review’. “Ultimately it will be the decision of the medical consultant, in consultation with their patient, to prescribe a particular treatment, including a cannabis-based treatment, for a patient under their care. It is important to state that there are no plans to legalise cannabis in this country.” Once suitable medical cannabis products are made available by suppliers, the Access Programme will make it possible for a medical consultant to prescribe a listed cannabis-based treatment for a patient under his or her care for the following medical conditions, where the patient has failed to respond to standard treatments: • spasticity associated with multiple sclerosis • intractable nausea and vomiting associated with chemotherapy • severe, refractory (treatmentresistant) epilepsy.
Ground-breaking Projects
CÚRAM, the SFI Research Centre for Medical Devices based at NUI Galway, has announced a new research partnership with B. Braun, one of the world's leading providers and manufacturers of healthcare solutions. The partnership will see the development of a novel drug delivery system for cannabinoids for more effective treatment of wound pain and improved wound healing, and the development of a device for the management of wound odour. Chronic wounds affect up to 4% of people over 65 years, with venous leg ulcers being the most prevalent of these, accounting for approximately 70% of all ulcers of the lower limbs. Chronic wounds are associated with reduced quality of life and affect the individual in physical, psychological and psychosocial domains. This in turn can impact family members and the individual’s ability to contribute to society fully. Among the many symptoms associated with chronic wounds, pain is cited as one of the worst aspects. While multiple forms of pain relief exist, these do not provide relief for all patients, and people with chronic wounds regularly state they do not wish to take more medication and have a fear of addiction.
Professor Georgina Gethin, CÚRAM Investigator, project colead, and Director of the Alliance for Research and Innovation in Wounds, explains, “Members of our patient panel in Alliance for Research and Innovation in Wounds have recounted using a trial and error process to alleviate pain and often take to resting until the pain goes away. They have identified that research to develop interventions to relieve pain is a priority for them. The endogenous cannabinoid (endocannabinoid) system plays a key role in pain modulation and also regulates wound healing. It represents a novel target for more effective dual management of both pain and wound healing.” Professor David Finn, an Investigator in CÚRAM, Head of Pharmacology, and Co-Director of NUI Galway’s Centre for Pain Research is a co-lead on the project. He brings over 20 years of expertise in cannabinoids, the endocannabinoid system and pain to the project. His group will play a key role in advancing understanding of the endocannabinoid system in wound pain and healing, and in preclinical testing of the novel cannabinoideluting delivery system for more effective treatment of wound pain and improved wound healing.
Category Focus: Digestive Health
A Closer Look at the Digestive Market
In addition to allowing nutrients and vitamins to reach your body, the digestive system also helps remove waste from your body. However, People may experience discomfort when something goes wrong with their digestive system. In fact, four out of every ten adults in the world experience digestive problems at any one time.
Many digestive complaints such as constipation, diarrhoea, heartburn, bloating, and irritable bowel syndrome can be alleviated with lifestyle changes. Eliminating high sugar, fat, refined carbohydrates, and low fibre typical in many of our diets should be considered first. However, given many of our cravings for such foods, and the ever increasing fastfood options that tempt us, it is unlikely that there will be any mass population changes in eating habits overnight. As such, community pharmacists can help patients with effective products that alleviate while also educating them. Referral to a doctor will be recommended if something more serious is suspected.
Drop in Footfall
Despite remaining open during the pandemic, our pharmacies experienced a considerable drop off in footfall. However, in addition to prescription medications, one over the counter category that was notable was the digestive ailment category. The demand and sales of products in this sector increased throughout the pandemic. However, as people stayed at home much more, there was a definite shift in sales to online and we noticed this with our own on-line channel.
To show the increase in online sales in this sector I am sharing a comparison on sales from January and February 2020 with sales from January and February 2021. I have broken this sector down into six sections – constipation, haemorrhoids and piles, acid indigestion and reflux, diarrhoea, bloating and gas and cramping, and IBS. Each section saw a substantial increase with the largest increase in the acid indigestion & reflux section, which rose by 609%. All the increases are as follows:
Constipation 239.5% increase
Haemorrhoids & Piles 334% increase
Acid Indigestion & Reflux 609% increase Bloating & Gas 263% increase Cramping & IBS 256% increase. The period shown in 2021 was during level 5 restrictions. With these restrictions, people were required to stay at home except for travel for work (only if essential), education, or other essential purposes. With a lot of people having to work from home and home-school and nonessential services closed it may have been a stressful period. In addition to causing you to lose your appetite and slow down your digestion, stress can also provoke issues such as constipation, diarrhoea, indigestion, or upset stomachs. This may explain part of the increase.
Other factors which may have skewed the figures are product availability (shortages), limited access to GPs. No doubt most customers would have traditionally gone to their local pharmacist rather than purchasing on-line in the past. So there is no surprise that on-line sales increased in trend with a general shift to online shopping during the pandemic.
Increased Demand
So what’s your take away from our figures? Well I’d suggest that as the pandemic is not over then there is likely to still be an increased demand for products in this category. People are still experiencing changes to lifestyle and work and increased levels of stress. Access to GPs is still limited. As such, it is certainly an area that we as community pharmacists can help with. With restrictions easing and footfall in shopping areas returning we anticipate the on-line demand to reduce and a return to in-store demand.
Within our pharmacies, we do not actively advertise specific brands. However, I would advise that you make your customers more aware that you have products available that could help their symptoms. Make these categories more visible by choosing noticeable shelf locations and category specific marketing.
Written by Stephen Cuffe, Pharmacist, Inish Pharmacy, Carndonagh Shopping Centre, Carndonagh
United Drug – Irelands Leading Provider of Ostomy and Urology Products and Services
Providing best in class sourcing and customer service for Ostomy and Urology
The foundation of the United Drug business is exceeding expectations in sourcing and supply chain excellence. With a continuous focus on the latest products, innovations and processes United Drug strives for best-in-class customer service every time.
As a part of the retail solutions offering within United Drug Wholesale, the ostomy and urology care team are the market leaders and endeavour to provide service excellence, enabling retail pharmacists to improve the quality of life for ostomy patients across Ireland.
Why Choose United Drug for Your Ostomy Requirements?
The focus on the customer and the ostomy patient drives everything, including: • Continually expanding their extensive product range- Over 3000 products • Partner with all leading manufacturers of Ostomy products • Complimentary bag cutting service-cutting in excess of 8000 bags weekly • Best in class supply chain ensuring reliable and timely delivery to Pharmacy daily • Supply complimentary bags and wipes for your clients use.
Continuously Investing to Enhance Customer Service:
United Drug continues to invest in state of the art cutting technology, cutting over 8,000 ostomy bags every week. United Drug’s ostomy bag cutting service provides the best possible fit and guarantees increased precision for every single cut. This complimentary service affords patients optimum comfort and peace of mind, giving them the highest level of security.
The additional products that can make the difference to quality of life:
From the 3,000 products available from United Drug Wholesale there are a range of additional solutions for the patients who may be struggling with some issues. • Leakage Solutions: elastic tape, pouch belts, mouldable rings • Odour Solutions such as lubricating deodorant • Skin irritation solutions: adhesive remover sprays and wipes,
skin barrier spray, wipes and cream, ostomy powder and skin protection sheets. • Discomfort & Discretion
Solutions: ladies and men’s briefs and vests, specialist swimwear, hernia belts and support waist bands.
Dedicated, highly experienced customer care team to support Pharmacy teams:
It’s not required to start out as an expert in order to offer additional support for your ostomy customers. United Drug provides support for over 20,000 customer care queries annually with 5 dedicated members on the Ostomy Care Team. • The customer care team upskills their product knowledge every 6 weeks, this high level of training allow them to deal sensitively and efficiently with your queries. • They are highly trained to deal sensitively and efficiently with your queries. Their depth of knowledge of stoma-care solutions enables them to offer best in class support to you and your customer.
How Pharmacy Teams Can Enhance the Quality of Life for Stoma Patients:
The Gastrointestinal Nursing journal published an article in March 2017 titled “Assessing Ostomates’ Quality of Life in the Republic of Ireland”, where it was revealed that ostomy and urostomy patients in Ireland have a lower quality of life than the international average. In the event of stoma prolapse, blockage, high output or dehydration you should advise your patient to consult their GP. As a pharmacist, you are a part of your ostomy clients’ patient care team. For many patients you’ll be their only regular medical engagement and their first line of support. Therefore, it can be critical to their well-being to be able to have a conversation in a private consultation room at their local pharmacy with someone who cares. Once discharged from their hospital’s specialist nurse, this is more care than many ostomates currently receive with many suffering in silence with symptoms that pharmacy products may help them manage or alleviate. Tips when talking to your Ostomy patients, there are some signs to watch out for.
• Increased bag usage. • Increased usage of powders or creams.
• Problems with odour control.
Get In Touch:
If at any stage United Drug’s Ostomy Pharmacy clients can reach out to the company’s dedicated customer care team on 01 4632347 to get up to the minute advice on how to best serve their ostomy customers. For more information about the UD Ostomy and Urology product range contact the UD BDM for your area or visit www.udw.ie
Generations of Family Pharmacy Success
McCabes Pharmacy Group are celebrating 40 years in business this year. Managing Director Sharen McCabe recently took to social media to share this image alongside her father who started the business, Roy McCabe.
“It’s simply one of the greatest privileges of life to get to work with a parent at some point in a career, never mind celebrate 40 years in pharmacy and healthcare,” she reflected.
Mum-to-be Síle Seoige was on hand to meet the newest addition to McCabes, as the family-owned pharmacy unveiled its Digital Prescription Service, Easy Script. The “new arrival” is the first web based digital prescription service in Ireland, and it comes as McCabes Pharmacy celebrates 40 years in business this year.
At the launch in McCabes Pharmacy, Gorey, Co. Wexford, Síle Seoige was joined by store pharmacist Colin Ryan for a demo of the new service. With Easy Script, customers can order their prescription instantly and collect from their nearest pharmacy in 3 simple steps: • Complete the order form on the McCabes website www. mccabespharmacy.com (alternatively via the McCabes app available on Apple and
Android) • Take a photo of your prescription and upload it • Select the McCabes pharmacy you want to collect from Customers receive a text when their prescription is ready for collection (within 3 working hours). To make it even easier, there is no need to register online, and customers do not have to be a pre-existing patient at McCabes. The service is open to everyone! McCabes Managing Director, Sharen McCabe, explains, “McCabes Easy Script gives customers a new way to manage their medication needs from home. We know from talking to busy parents and timepressed family carers, that they want certainty about when their prescription will be ready to collect. We see so many customers who have limited time in their day to run errands while juggling other commitments at home. With no need to wait in store, we hope that Easy Script will meet a real need in a very innovative way.”
Easy Script marks 40 years of firsts
McCabes has led the way on innovation since the family-run business first opened its doors in 1981. For the past four decades, the brand has continued to adapt as customer needs evolved. Easy Script is the latest in a growing list of market firsts for the innovative Irish family brand. In the past year, McCabes has also been first to introduce the Morning After Pill using a pay online, click and collect-in store service.
Other milestone firsts over the years include the introduction of health checks into a pharmacy setting, the setting up of health education seminars with consultants, the use of open plan dispensaries so that the pharmacist is always visible to the customer, and the introduction of Sunday openings and late-night dispensing.
Digital first for 20 years
McCabes has always been an early adopter of new technologies, with an e-commerce website dating back to 2000. Investment in digital continues today, with more services available online than ever before, including Video Consultation, Live Online Pharmacist Chat for answers to health and medication queries, and an Online Doctor Service, enabling customers to see a GP from the comfort of home with services starting from just ¤25 and appointments available 7 days a week for new or repeat prescriptions, referral letters, sick notes and general medical advice.
Covid-19 & Consumer Trends
While the impact of Covid-19 has accelerated innovation in At the launch in McCabes Pharmacy, Gorey, Co. Wexford, Síle Seoige was joined by store pharmacist Colin Ryan for a demo of the new service
services, on the retail side it has also seen people keen to continue supporting their local McCabes Pharmacy online. An analysis by McCabes of customer shopping habits on www. mccabespharmacy.com reveals some interesting trends about customers’ health and beauty priorities in recent months.
Trending in Lockdown
• Treats – people invested more to treat themselves to luxury items including premium skincare products, larger sized and more expensive bottles of fragrance. • Natural Look – fewer opportunities to socialise combined with mask-wearing saw a huge move to more natural make-up, and a much bigger focus on skincare overall.
• Maskne – customers, including more male shoppers, bought skin care products to help treat skin conditions such as acne exacerbated by face masks. • Vitamin Boost – demand grew for vitamins to support immunity, notably Vitamin D. • Lockdown Locks – with hair salons closed, hair dyes and root touch-up products were a popular purchase for customers keen to cover the grey. • Menopause supports – with more open discussion re the impact of menopause, demand increased for vitamin and supplement supports to help to manage symptoms.
Biosimilars – Increasing Access to Medicines
The 2021 Virtual Summit on Biosimilar Medicines was held recently, a series of live webinars which looked at the current challenges and opportunities within this field.
The 2021 Biosimilar Medicines Virtual Summit explored the latest developments in biosimilar medicines policies. In a novel online format, each live session was complemented by resources such as recorded interviews and presentations, infographics and reports. Fifteen years after the first global approval, biosimilar medicines systemically increase access to medicines for patients who need them, while contributing to the sustainability of our healthcare systems. Medicines for Europe commented, “We are at a unique moment for pharmaceutical policy, given the ongoing pressure from Covid-19 and the upcoming opportunities to build healthcare efficiency presented by the European Commission Pharmaceutical Strategy. “Biosimilar medicines have always been a strong asset to offer equitable access to treatment for chronic disease patients including those with cancer. Smart policies that expand biosimilar medicines use have led to efficient outcomes for patients, healthcare professionals and healthcare systems.” To deliver their full potential, biosimilar medicines need:
• The right market conditions and incentives
• A fit-for-purpose regulatory environment, tailored to their specificities • To be part of standard patient care.
Isabell Remus, Chair of the Biosimilar Medicines sector group, commented “Covid-19 will have a lasting impact on national health systems in Europe and their recovery will be absolutely crucial for all patients. For 15 years, biosimilar medicines provide an effective solution to balance patient access and healthcare sustainability. There are many more opportunities ahead for biosimilar medicines. Their smart use must be facilitated in practice but also in policies, like recognised in the EU Pharmaceutical Strategy and the EU Beating Cancer Plan.” The Biosimilar Medicines Group is a sector group of Medicines for Europe representing the leading companies developing, manufacturing and/or marketing biosimilar medicines across Europe. With more than 10 years of positive patient treatment experience and 20 products successfully launched, biosimilar medicines provide today a huge opportunity to deliver significantly improved access to modern therapies for millions of European patients in both chronic and acute care.
Medicines for Europe members bring competition to the biological medicines market, thereby increasing access to highly innovative treatments to patients, in Europe and around the world, and supporting the sustainability of the European healthcare systems.
The Resilient Pharmacist Podcast
The Irish Institute of Pharmacy (IIOP) has launched a new podcast, The Resilient Pharmacist (The Resilient Pharmacist Podcast) hosted by Dr Catriona Bradley.
Dr Catriona Bradley, IIOP
Each fortnight, through 10 episodes, guests speak candidly about their experiences in pharmacy. The series includes fascinating stories about pharmacy hold-ups, burnouts, breakthroughs, and everything in between. Guests share their stories so that others may learn from their experiences and so that we can start new conversations about pharmacy.
Podcast Host, Dr. Catriona Bradley says, “This is a wonderful collection of human stories that may shock and surprise you, but there are heart-warming moments too, all of which speak to the resilience at the heart of the pharmacy profession in Ireland.” The first episode: “Ailbhe Harnedy. Frightening Experiences” is available to download on podcast platforms. A new episode will be released fortnightly.
The Resilient Pharmacist podcast has been developed in collaboration with the IIOP Mental Health and Wellbeing working group and the IIOP Mental Health Ambassador Network.
The Irish Institute of Pharmacy (IIOP) manages the Continuing Professional Development (CPD) system for pharmacists in Ireland. This includes supporting pharmacists engaging with CPD, managing the CPD quality assurance systems and commissioning and delivering education and training programmes. RCSI is the managing body for the Irish Institute of Pharmacy (IIOP) on behalf of the Pharmaceutical Society of Ireland (PSI).
Visit www.iiop.ie for further details.
New Ways to Treat Superbug
Research led by scientists in NUI Galway has identified a new way to make MRSA vulnerable to antibiotic treatment. The MRSA superbug is resistant to penicillin-type antibiotics making infections difficult to treat. The microbiology research team, discovered that when a gene called sucC in MRSA is mutated, it leads to the build-up of a molecule called succinylCoA. This increase in succinylCoA can change numerous proteins in MRSA, which makes the bacteria more sensitive to antibiotics again.
The study has been published in the flagship journal of the American Society for Microbiology, mBio, and was funded by the Health Research Board and the Irish Research Council.
The research was carried out by the Discipline of Microbiology at NUI Galway in collaboration with the Pacific Northwest National Laboratory and the University of Nebraska Medical Centre in the US, and the University of Umeå in Sweden.
Summarising the discovery Dr Chris Campbell, co-first author and NUI Galway microbiology PhD graduate, said, “A mutation that affected the way in which MRSA uses glucose to fuel growth unexpectedly switched off antibiotic resistance.”
Co-first author and NUI Galway microbiology PhD student Claire Fingleton explains, “If we can find other ways to increase succinyl-CoA in MRSA, for example by developing drugs that have the same effect, it opens up the possibility that MRSA infections can be more easily treated with antibiotics. It would mean that penicillin-type antibiotics, which are currently ineffective for MRSA infections, could become successful once more in treating this superbug.”
“Penicillin-type antibiotics remain among the safest and most effective treatment options for bacterial infections, but unfortunately many bacteria including MRSA are now resistant to these drugs.” according to study co-author and NUI Galway microbiology postdoctoral fellow Dr Merve Zeden.
