Healthy Baby Update
a publication of the Mississippi Chapter - American Academy of Pediatrics for providers dedicated to improving the care of mothers and babies
APRIL 2002, Vol. 15 No. 5
NAUSEA AND VOMITING IN PREGNANCY
Nausea and vomiting are so common during the first trimester of pregnancy that many obstetric texts list their occurrence as presumptive evidence of pregnancy. These symptoms, commonly called morning sickness, occur in 50% to 80% of pregnancies, with a typical onset around 4 to 6 weeks of gestation and a spontaneous resolution around 16 weeks’ gestation. Despite extensive study, the exact cause remains unclear. Nausea and vomiting are considered by most clinicians a positive sign for a favorable pregnancy outcome.
DEFINITION
Nausea and vomiting of pregnancy (NVP) applies to symptoms seen during the first 16 weeks of pregnancy, characterized by a disturbance in appetite and reaction to food. This includes nausea with or without vomiting or food aversions. Simple nausea and vomiting (i.e. morning sickness) is not associated with any abnormality of nutrition.
Hyperemesis gravidarum, a severe, potentially life-threatening condition occurs in approximately 1% of pregnancies. These patients have intractable nausea and vomiting that may continue through the entire pregnancy and is associated with evidence of deranged nutrition such as weight loss, ketosis or organ damage.
EPIDEMIOLOGY
The collaborative perinatal project, in a study of women in the first trimester, found that NVP was more common among women less than 20 years old, non-smokers, those whose prepregnancy weight was less than 77 kg, women with less than 12 years of formal education, and being primagravid. The frequency of NVP differs among countries with the highest in Japan and the lowest in India. Seven traditional cultures have been identified in which NVP does not occur.
Women who experience these symptoms report a tremendous impact on their daily lives. Most commonly cited problems include an inability to cook or to care for other children, reduction in social activities, and an inability to go outside because symptoms are triggered by smells. Among women who work outside the home, an average of 206 hours were missed from work due to these symptoms.
Symptoms have been noted as early as 3 weeks from the last menstrual period (i.e. one week of pregnancy) with an average onset at 5 weeks. Peak nausea usually occurs between 11 and 13 weeks. Symptoms may occur at any time of day, and may be of variable duration.
On a more positive note studies indicate that women who experience these symptoms have a decreased risk of miscarriage, stillbirth, preterm delivery, and perinatal mortality.
The cause of NVP remains unclear. Human chorionic gonadotropin, progesterone, and estradiol have all been studied as causal candidates. No clear association has been found. A psychological basis of NVP has been suggested, primarily, because a physiologic basis has proven so elusive. A recent theory is that of evolutionary protection by which the symptoms prevented women from eating spoiled foods or abortifacients during the period of organogenesis.
MANAGEMENT
The first line of treatment for mild to moderate NVP is dietary modification. Patients should avoid greasy and spicy foods with strong odors and eat frequent small meals.
A traditional remedy for NVP is ginger. The recommended dose is 250 mg QID. In two randomized studies ginger reduced the frequency of vomiting and reduced the sensation of nausea. Vitamin B6 is an essential water soluble vitamin that aids in the metabolism of amino acids, carbohydrates and lipids. It crosses the placenta by active transport. It has been shown to decrease both nausea and vomiting and is not teratogenic.
Bendectin was a combination of Vitamin B6 and the antihistamine doxylamine. It was removed from the market in 1983 following several lawsuits alleging teratogenesis. Several subsequent studies have been unable to identify any teratogenic effect of either the drug combination or its individual components.
Doxylamine can be found in the over the counter drug Unisom. The combination of 25 mg of vitamin B6 QID and doxylamine 12.5 mg TID/QID has proven both safe and effective in the treatment of NVP.
Compazine (prochlorperazine) is a phenothiazine, and phenergan (promethazine) is a phenothiazine antihistamine. They are both commonly used to treat nausea and vomiting. Like all phenothiazines, the most common side effect is sedation. Dystonic reactions may occur with either, but seem to be more common with Compazine. Usually relatively high doses of phenergan are needed to cause a dystonic reaction; however, a single dose of compazine may create the effect. The usual dose of compazine is 5-10 mg IM/PO q 4hrs or 25 mg PR q4. The Phenergan dose is 12.5-25 mg IM/PO/PR q4.
Reglan (Metoclopramide) was first used in Europe to treat NVP. The drug works by stimulating upper gastrointestinal tract motility without increasing gastric, pancreatic, or biliary secretions. The usual dose for NVP is 5-10 mg PO q8hrs. Side effects are sedation and rarely, extrapyramidal symptoms.
Dramamine and Meclizine (antivert) are over the counter antihistamimes traditionally used in nausea and vomiting from causes other than pregnancy. Prospective trials with each have shown relief of symptoms. Sedation and dry mouth are the most common side effects. A possible association has been found between inguinal hernia and cardiovascular defects with first trimester Dramamine use.
The Pericardium 6 (P6) accupressure point, also called the Neiguan point has been used to treat nausea and vomiting due to motion sickness. The point is located on the volar surface of the forearm approximately 3 finger widths above the wrist crease. In three randomized controlled studies, the data on the efficacy of pressure applied to the P6 point is questionable. It may provide some relief from nausea but does not appear to decrease the frequency of vomiting.
Authored by Lisa E. Moore, MD, Fellow in the Division of Maternal Fetal Medicine, Dept. of Obstetrics and Gynecology at the University Medical Center in Jackson, MS.
References available upon request.
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(Note: This article may be photocopied and distributed to interested families).
The sun is the main cause of skin cancer, the most common form of cancer in the United States. There will be a million new cases of skin cancer this year.
Most of our sun exposure - between 60 percent to 80 percent - happens before we turn 18 years of age. That’s because children spend more time outdoors than most adults, especially in the summer. Sun exposure in early childhood and adolescence contributes to skin cancer. Research has shown that two or more blistering sunburns as a child or teen increase the risk of developing skin cancer later in life. Babies and children should be protected from sunburn. Sun protection should be a regular family event.
Babies under 6 months of age need extra protection from the sun. Young children are more vulnerable to the sun. Recommendations for children younger than 1 year old:
For children older than 1 year old and all family members, recommendations to protect your family from sunburns now and from skin cancer later in life are:
Additional sun safety tips that apply to all members of a family:
Excerpted
from the AAP brochure “Protecting Your Child from the Sun”.
MISSISSIPPI CHILDREN’S MEDICAL PROGRAM
(Note: This article may be photocopied and distributed to interested families).
The Children’s Medical Program (CMP) is a federally and state funded program providing financial and medical assistance for Mississippi children and adolescents with special health care needs. CMP is a vital part of the Mississippi State Department of Health (MSDH). This program, formerly known as the MS Crippled Children’s Services, coordinates pediatric multi-specialty services through hospitals and specialists statewide with community-based follow-up available through local health departments.
The Blake Clinic for Children, located in Jackson, is the principal CMP multi-specialty facility. Statewide specialty clinics are conducted throughout the state in health departments, private physicians’ offices, and hospitals, including but not limited to the University of Mississippi Medical Center or Methodist/Lebonheur in Memphis, depending on availability of needed services. Out of state services are limited and require special approval.
Services available through CMP include outpatient/inpatient pediatric specialty care, braces and other durable medical equipment, limited drugs (such as seizure medication), evaluation by pediatric health professionals, dental corrections for certain conditions, referral for genetic screening and follow-up, evaluation and referral to other community resources, and a special program for children and adolescents with cystic fibrosis, hemophilia, and sickle cell disease.
Eligibility for Children’s Medical Program is based upon factors of family service and income and patient diagnosis. The extent of CMP coverage may depend on the estimated cost of treatment. Mississippi residents from birth through 20 years of age may qualify. Eligible medical conditions include, but are not limited to, Spina Bifida, Hydrocephalus, Cerebral Palsy, Orthopedic problems (non-traumatic), Congenital heart problem requiring surgical correction, Head and Neck deformity, Cleft Lip and Palate, Seizure disorders, and Urinary or Intestinal system defects requiring surgical corrections. If a child’s diagnosis does not fit into any of these categories, contact your local/regional health department or the central Children’s Medical Program office for further information.
It is difficult to describe the “typical” CMP-covered child. A cystic fibrosis patient may receive medication through CMP in collaboration with the MSDH pharmacy. A myelomeningocele patient might benefit from CMP payment of hospital per diem and multi-disciplinary follow-up through Blake Clinic. That follow-up may include fitting the patient to a customized wheelchair or related Physical and Speech therapies.
Children’s Medical Program coverage is considered to be a payer of last resorts. Patients can have CMP Coverage in addition to Medicaid and private insurance. It may be advantageous for families who qualify to maintain CMP eligibility as CMP may cover some services not covered by private insurance or Medicaid.
Families may apply for Children’s Medical Program services by contacting their local Health Department and requesting help in applying for CMP. They will need a statement with specific diagnosis, requested services, and referral from a physician, if available; complete and accurate financial information; names, relation, and ages of all household members; private insurance or Medicaid card or information, if applicable; and signature of parent or legal guardian. Copies of pertinent medical reports about the children’s problem will be needed at time of application or will be sent for as a part of the eligibility consideration process. The CMP application form contains a release of information consent statement.
For further information, please contact the Children’s Medical Program, Mississippi State Department of Health, Post office Box 1700, Jackson, MS, 39215-1700. We can be reached by telephone at 601-987-3965 or toll-free at 1-800-844-0898. The Children’s Medical Program administrative offices and Blake Clinic for Children are located in Jackson at the Jackson Medical Mall.
Authored by Mike Gallarno, Director of the Children’s Medical Program at the MS State Department of Health in Jackson, MS
June 24, 2002
Basic Life Support (BLS) Health Care Provider Course
UMC Campus
Jackson, MS
For information, call 601-984-1300 or visit UMC Continuing Education online.
Pediatric Advanced Life Support (PALS) Provider Course
UMC Campus
Jackson, MS
For information, call 601-984-1300 or visit UMC Continuing Education online..
July 21-25, 2002
MS Academy of Family Physicians 2002 Annual Meeting
Sandestin Beach Hilton, Destin, Fl.
For information, call 601-957-7722.
October 21-23, 2002
Tobacco Update 2002: Scientific Advances, Clinical Perspectives
Crowne Plaza Hotel, Jackson, MS
For information, call
601-984-1300 or visit UMC Continuing Education online.