Discomforts, Lifestyle & Oral Health 2011

1. Discomforts, Lifestyle & Oral Health2011

2. Discomforts • Nausea and vomiting • Heartburn • Lifestyle concerns with nutritional implications: • alcohol • caffeine • smoking • Illicit drugs • Non-nutritive sweeteners • physical activity • oral health

3. Nausea & Vomiting:Cochrane Intervention Review, 2010 Quinlan et al, Am Fam Phys, 2003

4. Background • 70-85% of women experience nausea with pregnancy • ~ ½ experience vomiting • 35% of women with employment lose time from work due to nausea – an average of 62 hours • Almost 50% of women report that their work efficiency is reduced by n&v

5. Stress Associated with N&V • Lack of understanding and support from others • • Inability to take vitamins or eat healthy • • Taking medications perceived as risky • • Missing out on the “fun” of being pregnant • • Loss of a “normal” pregnancy • • Lost work days or quitting work • • Putting life “on hold” • • Longing to eat and drink normally • • Money expended on care and support • • Lack of energy, fatigue • • Irritability and lack of enjoyment of life • • Memory loss or inability to think clearly • • Burden of care and time on others • • Lack of socialization, isolation cont…

6. • Inability to prepare for birth and arrival of baby • • Inability to care for family and home • Wanting pregnancy over or to end the misery • • Others’ perception that hyperemesis is only in her mind • • Reluctance of doctors to treat because of cost or liability • • Weight loss or inadequate weight gain for gestational age of baby • • Sense of inadequacy and failure at being unable to cope or function • • Difficulty bonding with infant • • Lack of energy and socialization with other children • • Lack of excitement about infant’s arrival

7. Etiology • Unknown – appears to have some association with rising levels of human chorionic gonadotropin (hCG) or estrogens • Nausea less common in those who subsequently experience miscarriage • More common in twin pregnancies

8. Hyperemesis Gravidarum • Severe nausea and vomiting • Affects one in 200 pregnancies • Most common reason for hospitalization in early pregnancy • Clinical features: Persistent vomiting, dehydration, ketonuria, electrolyte disturbances, weight loss • 159 per million pregnant women died in England between 1931-1940 (before IV fluid replacement therapy was available) • (Charlotte Bronte died of hyperemesis in her fourth month of pregnancy)

9. Use of non-pharmacological treatments • Commonly recommended by health professionals without evidence of effectiveness • Safety unknown and unregulated • “women and professionals are more likely to underestimate their possible risks”

10. Cochrane 2010 • Interventions for nausea and vomiting in early pregnancy • 27 studies with 4041 women included • 22 studies excluded

11. Acupressure

12. Acupuncture • Acupuncture versus placebo (sham acupuncture and no treatment) • two studies with 648 women • No sig difference or data not interpretable

13. Ginger

14. Vitamin B6 versus placebo • 2 studies, 416 women • Results favored vitamin B6 for reduction in nausea after three days • Comparing the number of patients vomiting post-treatment, there was no strong evidence that vitamin B6 reduced vomiting

15. Anti-emetic medication versus placebo • 6 studies, 803 women • Hydroxyzine, Debendox (Bendectin) Thiethylperazine,Fluphenazine-Pyridoxine • Review found substantial methodological problems with most studies and could not reach meaningful conclusion

16. Adverse Outcomes • Acupressure: reports of pain, numbness, soreness and hand-swelling • Ginger: few studies reported adverse impacts, one statement about heartburn • Antiemetic drugs: primary complaint was drowsiness.

17. Summary Statements • No acceptable studies of dietary or other lifestyle interventions • Limited evidence regarding acupressure – acupuncture not effective • “The use of ginger products may be helpful to women, but the evidence of effectiveness was limited and not consistent.” • “There was only limited evidence from trials to support the use of pharmacological agents including vitamin B6, and anti-emetic drugs to relieve mild or moderate nausea and vomiting.”

18. Cochrane Conclusions: “Given the high prevalence of nausea and vomiting in early pregnancy, health professionals need to provide clear guidance to women, based on systematically reviewed evidence. There is a lack of high-quality evidence to support that advice. The difficulties in interpreting the results of the studies included in this review highlight the need for specific, consistent and clearly justified outcomes and approaches to measurement in research studies.”

19. Nausea and vomiting of pregnancy: an evidence-based review(Davis,J Perinat Neonatal Nurs. 2004) • First step is dietary & lifestyle changes

22. American Gastroenterological Association Institute Medial Position Statement on the Use of Gastrointestinal Medication in Pregnancy (2006) • Metoclopramide, prochlorperazine, promethazine, trimethobenzamide and ondansetron* are considered low-risk drugs based on studies in pregnant women and can be used for nausea and vomiting and for hyperemesis gravidarum. Granisetron and dolasetron have not been studied in human pregnancies.” *Reglan, Compazine , Phenergan , Tebamide, Zofran

23. Interventions for Heartburn in PregnancyCochrane, 2008 • Up to 80% of women in third trimester • Not well understood – pregnancy hormones influence • Lower esophageal sphincter • Gastric clearance • 3 studies, 286 women • “little information to draw conclusions about the overall effectiveness of interventions to relieve heartburn in pregnancy.”

24. Staged approach: Lifestyle modification: Smaller meals, no late night eating, elevate head of bed, avoiding foods/mediations causing heartburn Discuss risk/benefits of drug TX (RCTs not done) The management of heartburn in pregnancy (Richter, 2005. Alimentary Pharmacology & Therapeutics)

25. The management of heartburn in pregnancy (Richter, 2005. Alimentary Pharmacology & Therapeutics)

26. Adverse effects of substance use determined by: • Timing • Dosage • Duration • Number of substances • Environment (nutrition, health status) • Individual susceptibility

27. Effects of substance abuse include: • Increased health problems, including risk of AIDS • Compromised nutritional status/weight gain • Higher rates of OB complications • Psychosocial/economic/legal problems • Parenting difficulties • Higher rates of child abuse/neglect

28. Alcohol: Background • Per capita alcohol consumption has risen through the second half of this century in the US • 70% of individuals between the ages of 20 and 34 consume alcohol • Alcohol consumption peaks in the 20-40 year old group

29. Percentage of women aged 18--44 years who reported any alcohol use or binge drinking, by pregnancy status --- Behavioral Risk Factor Surveillance System (BRFSS) surveys, United States MMWR: May 22, 2009 / 58(19);529-532

30. Alcohol: Background, cont. • Women are at disadvantage because less gastric first pass metabolism due to lower levels of alcohol dehydrogenate in intestinal mucosa • Fetus has no alcohol dehydrogenase activity • Alcohol crosses placenta easily by passive diffusion – fetal levels mimic maternal levels • The amniotic fluid acts as a reservoir for alcohol.

31. FAS Diagnostic Criteria- Fetal Alcohol Study Group of the Research Society on Alcoholism • Prenatal and/or postnatal growth retardation (<10th % ca) • Central nervous system involvement (neurologic abnormality, developmental delay or intellectual impairment) • Characteristic facial dysmorphology with at least 2 of these 3 signs: • Microcephally ( OFC < 3rd %ile) • Micoopthalmia and/or short palpevral fissures • Poorly developed philtrum, thin upper lip, and or flattening of the maxillary area

32. FAS, cont. Other organ systems often involved. Some with nutritional implications: • Cleft palate • Eustachian tube dysfunction • Array of cardiac, renal, and skeletal defects that may require surgical repair

33. FAE – Fetal Alcohol Effects or PFAE • Exhibit some components of FAE, but not all • Most common sign is retarded growth both pre and postnatal • Can have significant developmental and behavioral components

34. Fetal Alcohol Spectrum Disorders (FASD) • Surgeon General’s Advisory (2005) • “FASD is the full spectrum of birth defects caused by prenatal alcohol exposure.” • “The spectrum may include mild and subtle changes, such as a slight learning disability and/or physical abnormality, through full-blown Fetal Alcohol Syndrome, which can include severe learning disabilities, growth deficiencies, abnormal facial features, and central nervous system disorders.”

35. FAS/FAE Incidence • FAS – 1.9 per 1000 births, 25 per 1000 among women who drink heavily • FAE – 3 to 5 per 1000 births, 90 per 1000 among women who drink heavily • FASD is leading cause of mental retardation in the western world

36. Pathophysiology • Combination of • Toxic effects of ethanol and its derivatives • Nutritional factors • Genetic predisposition

37. Toxic effects • Both alcohol and derivative acetaldehyde directly damage developing and mature nervous systems • Impair nucleic acid synthesis • Disrupts protein synthesis • Cell membrane narcosis • High maternal alcohol levels associated with dehydration, fetal hypoxia and acidosis, placental pathology and dysfunction, and endocrine disturbances.

38. Nutrition Related Effects of Alcohol • Poor nutritional status of mother • Reduced placental transfer of zinc and folic acid associated in animal models • Alcohol impairs absorption, utilization, and metabolism of nutrients • Poor zinc status has been associated with adverse effects of alcohol in many studies

39. Surgeon General’s Advisory (2005) • Science: • Alcohol consumed during pregnancy increases the risk of alcohol related birth defects, including growth deficiencies, facial abnormalities, central nervous system impairment, behavioral disorders, and impaired intellectual development. • No amount of alcohol consumption can be considered safe during pregnancy. • Alcohol can damage a fetus at any stage of pregnancy. Damage can occur in the earliest weeks of pregnancy, even before a woman knows that she is pregnant. • The cognitive deficits and behavioral problems resulting from prenatal alcohol exposure are lifelong. • Alcohol-related birth defects are completely preventable

40. Surgeon General’s Advisory (2005) Recommendations: • A pregnant woman should not drink alcohol during pregnancy. • A pregnant woman who has already consumed alcohol during her pregnancy should stop in order to minimize further risk. • A woman who is considering becoming pregnant should abstain from alcohol. • Recognizing that nearly half of all births in the United States are unplanned, women of child-bearing age should consult their physician and take steps to reduce the possibility of prenatal alcohol exposure. • Health professionals should inquire routinely about alcohol consumption by women of childbearing age, inform them of the risks of alcohol consumption during pregnancy, and advise them not to drink alcoholic beverages during pregnancy.

41. Caffeine • History: • Rat based studies with high levels of caffeine found adverse pregnancy outcomes • Early 1980s US FDA issued advisory about adverse effects of caffeine in pregnancy • Further research found little association, FDA concludes that no strong evidence, urges moderation • 1996 IOM review for WIC advised removing excessive caffeine intake from WIC risk criteria • 1998 - USDA removed as WIC risk criteria

42. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Consumption: • In US 70-95% of pregnant women consume caffeine - average intake is 99-185 mg/day • 5-30% of pregnant women consume >300 mg/day • Heavy caffeine intake more likely in women who smoke and those with lower education levels

43. The Effects of Caffeine on Pregnancy Outcome Variables (Hinds et al. Nutrition Review, 1996) • Metabolism • methylxantines cross the placenta to the fetus where an equilibrium is achieved between maternal and fetal plasma • half-life of caffeine in pregnancy changes from 5.2 to 18.1 hours in T2 and T3 and returns to non-pg levels a few weeks pp

44. Caffeine Metabolism, Genetics and Perinatal Outcomes(Ann Epidemiol 2005) • Wide individual variation in caffeine metabolism • Due to variation in CYP1A2 enzyme activity • “Measuring maternal, fetal and neonatal caffeine metabolites may allow for a more precise measure of fetal caffeine exposure.”

45. Coffee and Health: A Review of Recent Human Research (Higdon and Frei; Crit Rev Food Sci and Nutrition, 2006)

46. Conception • Many studies find > 300 mg/d associated with delay in time to conception (some do not find this effect) • Author’s conclusions: “it may be prudent for women who are having difficulty conceiving to limit caffeine consumption to less than 300 mg/d in addition to eliminating tobacco use and decreasing alcohol consumption.”

47. Spontaneous Abortion • Conflicting studies • Women who decrease Caffeine due to N&V, more likely to have viable pregnancies. • “Most studies that observed significant associations between self-reported coffee or caffeine consumption and the risk of spontaneous abortion did so at intake levels of at least 300 mg/d of caffeine.”

48. Fetal Growth • “Several studies found that maternal caffeine intakes ranging from 200-400 mg/d were associated with decreases in mean birth weight of about 100 g.” • “A meta-analysis that combined the results of eight epidemiological studies found that maternal caffeine consumption greater than 150 mg/d increased the risk of low birth weight by approximately 50%.”

49. Preterm Delivery • “Most epidemiological studies have not found coffee or caffeine consumption to be associated with the risk of preterm delivery.”

50. Birth Defects • “At present, there is no convincing evidence from epidemiological studies that maternal caffeine consumption ranging from 300-1000 mg/d increases the risk of congenital malformations in humans.”