How Pharmacists Can Help Lower Infants’ Leading Cause of Death

Birth defects affect approximately 3% of all babies born in the United States each year, affecting roughly 1 baby born every 4 and a half minutes, which makes birth defects the leading cause of infant death in the United States.¹

To raise awareness of this issue, March 3 was recognized as National Birth Defects Awareness Day. Because approximately 1 in 10 birth defects are caused by the use of teratogenic medications, pharmacists have multiple roles in prevention of these birth defects.²

Roughly 6% of pregnancies in the United States are exposed to potentially teratogenic medications because of various reasons, such as 1 in 6 women being prescribed a teratogenic medication each year, approximately half of US pregnancies are unplanned, and there is a lack of pre-pregnancy health counseling.³

Based on these statistics, it is essential that women are informed of these risks anytime they take a potentially teratogenic medication because most birth defects are likely to happen early in pregnancy before women become aware they are pregnant. Pharmacists are in a prime position to meet this education and counseling demand because they are the most accessible health care provider to aid in safe OTC therapy in the community as well in dispensing of medications.

More than 90% of women take at least 1 OTC or prescription medication while pregnant, and in the past 40 years, the number of women using 4 or more medications during pregnancy has more than doubled.⁴ Some examples of common teratogenic OTC medications are aspirin, guaifenesin, and pseudoephedrine.

In contrast, there are also certain vitamins and minerals necessary for appropriate fetal development, and if intake is not adequate, it can lead to birth defects. For example, inadequate folic acid intake during pregnancy increases the risk of neural-tube defects.⁴

With the increasing amount and complexity of medication regimens of the general population, it is also necessary to increase access to preconception and pregnancy care, which pharmacists can do in all practice settings. For example, in the community setting, pharmacists can intervene when pregnant patients are selecting aspirin as a pain reliever when acetaminophen may be a safer option.

A prescription medication of current importance is molnupiravir because of its evolving role in COVID-19 treatment. Molnupiravir has been found to have fetal harm concerns based off findings from animal reproduction studies, including malformation of the eye, kidney, and axial skeleton, as well as rib variations.⁵ This risk is transmitted through both females and males of reproductive age.

Because COVID-19 treatment is constantly changing and management can be complex, pharmacists are in an ideal position to notify providers and patients of this risk and how to avoid potential harm. In an inpatient and ambulatory care setting, pharmacists can serve as essential managers of complex drug regimens directly. Pharmacists can also assist through the development of educational handouts on how to minimize medication-induced birth defects, conducting a periodic review of medications stocked on obstetrician floors, and using the most up-to-date information when developing or modifying order sets to make sure they align with recommended guidelines and pose the lowest risk of fetal harm.

A group of medications associated with birth defects that pharmacists have vast potential to address in the prevention of fetal harm are opioids. In 2019, the National Survey on Drug Use and Health documented that approximately 6.6% of pregnant women reported using a prescription opioid and 21% of them reported opioid misuse.⁶

Furthermore, 31.9% of women reported that they never received information about how the use of opioids could affect a fetus. This gap could be addressed by pharmacists in community settings, office visits, and even discharge counseling from the hospital by providing education on opioids and their potential fetal effects, monitoring for substance misuse, and providing awareness for social support services.⁶

A more unique role that pharmacists can be involved in for the prevention of birth defects is being aware of and informing other health care providers about rarer drug-induced birth defects, such as the association between lithium use early in pregnancy with an increased risk of Ebstein’s anomaly, as well as management of these medications during pregnancy.⁷

For example, if a pharmacist was presented with a situation in which a pregnant patient was picking up a prescription for a psychotropic with minimal potential risk of fetal harm, such as olanzapine, and the patient was concerned about the switch from lithium, this is a prime opportunity to counsel on why it was necessary to switch medications, what other options may be needed in the future, as well as general pregnancy health education.⁸

Lastly, it is important to note that vaccine hesitancy is a significant barrier in pregnant women receiving recommended vaccines, such as the inactivated influenza Tdap vaccines because the passive immunity significantly reduces the risk of influenza and pertussis illness among infants during the first few months.⁹ Pharmacists need to be familiar with these vaccines to appropriately address pregnant women's concerns, recommend necessary vaccines, and provide accurate counseling to help increase vaccination rates in pregnant women to help prevent infectious diseases that result in birth defects.

With nearly 120,000 babies born with birth defects each year in the United States, which has an unusually high infant mortality rate for a developed nation, it is imperative steps be taken to reduce the rate of these events.¹ Although pharmacists have had a major role in counseling on common teratogenic medications and appropriate alternatives, their expertise and diverse positions in the community places them in a key position to fill in the counseling and education gap on potentially teratogenic medication to other health care members and the general population, assist in contraceptive needs, administer recommended vaccinations, and provide preconception and pregnancy care in order to reduce these risks.

References

1. Centers for Disease Control and Prevention. (2021, December 8). Learn more about birth defects. Centers for Disease Control and Prevention. Retrieved December 13, 2021, from https://www.cdc.gov/ncbddd/birthdefects/index.html.
2. Shirole, D. T. (2016, April 22). Drug-induced birth defects - teratogenic drugs - causes - effects - faqs. Medindia. Retrieved December 13, 2021, from https://www.medindia.net/patients/patientinfo/drug-induced-birth-defects.htm.
3. Schwarz, E. B., Parisi, S. M., Handler, S. M., Koren, G., Shevchik, G., & Fischer, G. S. (2013). Counseling about medication-induced birth defects with clinical decision support in primary care. Journal of women's health (2002), 22(10), 817–824. https://doi.org/10.1089/jwh.2013.4262
4. Joseph V. Etzel, P. D. A. D. for S. A. A. C. P. S. J. U. (2021, July 21). Pharmacist's role in prenatal care and safe medication use. U.S. Pharmacist – The Leading Journal in Pharmacy. Retrieved December 13, 2021, from https://www.uspharmacist.com/article/pharmacists-role-in-prenatal-care-and-safe-medication-use.
5. Haupt, R. (2021, December 23). Important Safety Information Regarding Use of Molnupiravir in Pregnancy and Individuals of Childbearing Potential. FDA EAU108. Retrieved February 25, 2022, from https://www.fda.gov/media/155101/download#:~:text=Based%20on%20findings%20from%20animal,adverse%20maternal%20or%20fetal%20outcomes.
6. Williamson, J. D. M., Mager, N. D. P., Bright, D., & Cole, J. W. (2021, August 4). Opioid use disorder: Calling pharmacists to action for better preconception and pregnancy care. Research in Social and Administrative Pharmacy. Retrieved December 14, 2021, from https://www.sciencedirect.com/science/article/pii/S1551741121002904?via%3Dihub.
7. Patorno, E., Huybrechts, K. F., Bateman, B. T., Cohen, J. M., Desai, R. J., Mogun, H., Cohen, L. S., & Hernandez-Diaz, S. (2017, June 8). Lithium use in pregnancy and the risk of cardiac malformations. The New England journal of medicine. Retrieved December 14, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5667676/.
8. Grover, S., & Avasthi, A. (2015, July). Mood stabilizers in pregnancy and lactation. Indian journal of psychiatry. Retrieved January 6, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4539876/#ref44
9. Joint position statement on vaccines from the society for ... (n.d.). Retrieved January 6, 2022, from https://birthdefectsresearch.org/pubs/bdr2_1674.pdf