St. John’s Wort In Pregnancy And Lactation

St. John’s wort (hypericum perforatum) is one of the five best-selling herbs in the United States. It is used by many to treat the symptoms of depression, and many prefer it to prescription medications such as Paxil® and Zoloft. However, the herb has been the subject of growing concern about its interaction with birth control pills, the blood thinner warfarin, and cyclosporin, a medication used with those who have received organ transplants. A new study examining its effect on pregnant women and those who are breastfeeding contributes to the evidence that the product should be used with caution.

A New Study

The new study, entitled “St. John’s Wort (hypericum perforatum): Is It Safe During Pregnancy, Breastfeeding and With Prescription Medications? A Systematic Review,” will soon be published in the Canadian Journal of Clinical Pharmacology. It is one in a series that systematically reviews the evidence relating to the safety of herbs commonly used during pregnancy and lactation.

The study was conducted by a team of Canadian researchers consisting of the principal investigator Jean Jacques Dugoua, ND, MSc (Cand.), University of Toronto, Sick Kids Hospital, Toronto Western Hospital, Truestar Health and Wellness Clinic, and the Canadian College of Naturopathic Medicine, Toronto, CN; and co-investigators Edward Mills, DPH, MSc., PhD (Cand.), Department of Epidemiology and Biostatistics, McMaster University, Ontario, CN; Dan Perri, MD, BscPharm, FRCP(C), Department of Clinical Pharmacology and Toxicology, University of Toronto, Toronto, CN; and Gideon Koren, MD, The Motherisk Program, Hospital for Sick Children, University of Toronto, Toronto, CN.

Dr. Dugoua is presenting the team’s findings at the 21st Annual Meeting of the American Association of Naturopathic Physicians (http://www.Naturopathic.org), being held August 9-12, 2006 at the Oregon Convention Center, Portland, OR.

Methodology

The aim of the study was to systematically review the literature for evidence on the use, safety, and pharmacology of St. John’s wort focusing on issues pertaining to pregnancy and lactation. The investigators searched seven databases for reports relating to the herb. The databases included AMED, CINAHL, Cochrane CENTRAL, Cochrane Library, MedLine, Natural Database, and Natural Standard. Each database was examined in duplicate for data from its inception. Unpublished research and bibliographies were also included. Data were compiled according to the grade of evidence found.

Results

The researchers found varying levels of scientific evidence on the efficacy of use for different conditions; low-level evidence of harm during pregnancy; and strong evidence of side effects during lactation. As St. John’s wort interacts with a number of medications due to its effect on cytochrome P450 enzymes, this may account for some of the findings.

Conclusions

The researchers concluded:

– Caution is warranted when using St. John’s wort during pregnancy and lactation.

– St. John’s wort may interact with medications prescribed during pregnancy.

– During pregnancy, a case study and some animal studies reported lower birth weights with use of St. John’s wort.

– Strong scientific evidence showed that St. John’s wort consumption during lactation did not affect maternal milk production nor affect infant weight, but may cause colic, drowsiness or lethargy.

– St. John’s wort showed strong scientific evidence of being an effective aid in combating mild to moderate depression and low-level evidence for other conditions.

Recommendations

The authors urge women not to assume that because herbs are labeled “natural” that they are safe. They recommend all pregnant and lactating women consult a licensed, health care professional before consuming any herb or medicine in general, and St. John’s wort in particular. Finally, they recommend that any woman experiencing depression let their physician know immediately.

Babies’ cries linked to their neurological and medical status

Leading researchers in colic and infant development say that a simple analysis of babies’ cries can provide a window into their neurological and medical status.

In a research review in the current issue of Mental Retardation and Developmental Disabilities, Linda LaGasse, PhD, and Barry Lester, PhD, with the Bradley Hasbro Children’s Research Center (BHCRC) and Brown Medical School looked at previous studies that analyzed the acoustics of a baby’s cry. The authors cite the characteristics of a cry that can indicate problems in a baby’s nervous system, as well as sudden infant death syndrome (SIDS). In addition, they cite the importance of how parents react to their squalling offspring.

“The cry signal has enormous potential diagnostic value; for example, very high pitched cries can tell us that something may be wrong with the infant, so the cry signal can be an early warning that leads to further neurological testing,” says LaGasse.

Overall, studies have repeatedly shown that infants at medical risk (like premature babies), and infants who have been exposed to lead or drugs, cry at a higher and more variable frequency than normal, but at lower amplitude, and with short utterances. These types of cry signals point toward a capacity problem in the respiratory system as well as an increased tension and instability of neural control of the vocal tract.

“Given the results of earlier studies relating cry characteristics to known neurological compromise, these findings suggest that at-risk infants have undetected neurological damage and that cry analysis may be able to identify these infants when no other symptoms are present,” says Lester.

In looking at cry analyses on sudden infant death syndrome, researchers found that high resonance and changes in the cry mode were consistent markers associated with SIDS. Resonance is the characteristic of a sound’s richness and depth that help humans distinguish a C note on a piano versus a guitar, and mode changes are noisy, broken-sounding cries that indicate poor neural control of the vocal track.

While someone might be able to point out a noisy cry, there is little evidence that a high resonance is distinguishable from a low resonance by an untrained listener.

“Instead, resonance is identified by a computerized analysis of the cry signal in the studies cited in the paper — this is why a detailed analysis of the cry signal is an important part of understanding the ‘full message’ of the cry,” says LaGasse.

The authors also note that parents tend to understand the nature of their babies’ cries well, and stress the importance of parental reaction to cries.

“Parents can usually tell the difference between pain and non-pain cries which guides the urgency of their care taking, and helps parents deal with infants with colic,” says LaGasse.

But parent perception of their infant’s cry may be affected by conditions such as depression or age of parent which can lead to action or nonaction which may be out of sync with the infant’s needs. The most extreme case is “shaken baby syndrome” where the cry triggers aggression rather than concern in the caretaker.

Lester and LaGasse say that clinicians should be aware of how parents respond (or don’t respond) to their baby’s crying, especially in light of the high prevalence of depression in young mothers.

“Helping parents to correctly interpret their infants’ cries can optimize development particularly in high risk infants who may have atypical signals or high risk parents who may misperceive a normal cry,” they write.

Heat Halts Pain Inside The Body

The old wives’ tale that heat relieves abdominal pain, such as colic or menstrual pain, has been scientifically proven by a UCL (University College London) scientist, who presented the findings at the Physiological Society’s annual conference hosted by UCL.

Dr Brian King, of the UCL Department of Physiology, led the research that found the molecular basis for the long-standing theory that heat, such as that from a hot-water bottle applied to the skin, provides relief from internal pains, such as stomach aches, for up to an hour.

Dr King said: “The pain of colic, cystitis and period pain is caused by a temporary reduction in blood flow to or over-distension of hollow organs such as the bowel or uterus, causing local tissue damage and activating pain receptors.

“The heat doesn’t just provide comfort and have a placebo effect - it actually deactivates the pain at a molecular level in much the same way as pharmaceutical painkillers work. We have discovered how this molecular process works.”

If heat over 40 degrees Celsius is applied to the skin near to where internal pain is felt, it switches on heat receptors located at the site of injury. These heat receptors in turn block the effect of chemical messengers that cause pain to be detected by the body.

The team found that the heat receptor, known as TRPV1, can block P2X3 pain receptors. These pain receptors are activated by ATP, the body’s source of energy, when it is released from damaged and dying cells. By blocking the pain receptors, TRPV1 is able to stop the pain being sensed by the body.

Dr King added: “The problem with heat is that it can only provide temporary relief. The focus of future research will continue to be the discovery and development of pain relief drugs that will block P2X3 pain receptors. Our research adds to a body of work showing that P2X3 receptors are key to the development of drugs that will alleviate debilitating internal pain.”

Scientists made this discovery using recombinant DNA technology to make both heat and pain receptor proteins in the same host cell and watching the molecular interactions between the TRPV1 protein and the P2X3 protein, switched on by capsaicin, the active ingredient in chilli, and ATP, respectively.

Certain herbs and supplements can help tummy aches

As more parents choose home remedies for their children’s gastrointestinal complaints, the question arises, which ones really work?

Kathi J. Kemper, M.D., M.P.H., a pediatrics professor at Wake Forest University Baptist Medical Center, and the author of “The Holistic Pediatrician,” has written the cover article for Contemporary Pediatrics magazine on which herbs and dietary supplements can help children with nausea, constipation and similar gastrointestinal (GI) problems.

“What we did was look at the original research, the studies, what people were out there doing, and came up with a guide for pediatricians,” Kemper said. “Historically, 50 years ago, people used home remedies. Then they began relying on prescriptions, and now there is a swing back toward using more natural health products.”

The article in the current issue cites chamomile as one of the most widely used and safest herbs for children with abdominal discomfort. It can be given in small amounts to treat colic in infants and can be combined with peppermint, star anise or fennel for stomach aches, gas, indigestion and bloating for school-age children, according to the article.

Ginger has been well documented as a remedy for nausea and dyspepsia. Probiotics, such as yogurt, have been used to prevent antibiotic-associated diarrhea, newborn colic, ulcerative colitis, and a variety of forms of diarrhea. On the other hand, the article says that star anise should be avoided for colicky infants.

Fussy Baby Network answers cries for help in community

Erikson Institute’s Fussy Baby Network is meeting a real need in the Chicago community. Already, more than 200 families have received help from this first-of-its-kind program in Illinois that responds to parent concerns about their infant’s inconsolable crying.

Twenty percent of infants struggle with excessive crying–about 37,000 babies in Illinois alone, regardless of their birth order, gender, feeding style, race, parents’ education or income. It also could occur despite excellent care.

Excessive crying usually occurs during the first three months of life. Many of these infants have colic–crying for more than three hours a day at least three days a week for three weeks. Their parents often are frustrated and feel helpless trying to soothe their infant. The Fussy Baby Network is designed to assess the infant, support parents and reduce family stress.

“Parents are desperate by the time they call us,” said Linda Gilkerson, PhD, network director and professor of infant studies at Erikson. “We help the parents find answers to their questions about their baby’s crying and gain confidence in their ability to calm their baby.

The relatively new network offers resources, support and consultation for families concerned about their baby’s crying, sleeping, feeding or temperament during the first year of life. Phone counseling, home visits and parent groups are just a few ways the program brings calm to chaos.

“Persistent, inconsolable crying is a trigger for child abuse in the first year of life,” Gilkerson said. “So we take every call seriously.”

A recent study published in Archives of Disease in Childhood found that excessive crying that continues more than three months of age was linked to behavioral and intellectual development problems by age 5. Difficulty in regulating crying can occur with other early challenges such as having a hard time sleeping or feeding. Also, these infants can have hypersensitivities to touch or movement, problems calming down and paying attention, and behavior issues. The Fussy Baby team of specialists works with families to get a needed evaluation and an appropriate intervention.

A partnership with University of Chicago pediatricians and LaRabida Children’s Hospital connects parents to behavioral and developmental specialist Larry Gray, MD, who serves as the Fussy Baby Network’s medical director. Gray can examine a child more closely, and if necessary, make referrals to other specialists.

“In some cases, these parents have been told that nothing is wrong, but mom instinctively feels there is,” Gilkerson said. “We don’t brush off their concerns.”

Excessive crying can be part of a cycle of mother/infant distress. Crying is both a trigger and a response. “If the mother is feeling overwhelmed or exhausted, or suffering from post-partum depression, this can increase the baby’s crying and irritability or the baby can begin to withdraw,” Gilkerson explained. “The relationship is just that–a relationship. Each person brings something to that relationship and responds to each other’s cues.”

The goal of the Fussy Baby Network is to prevent and interrupt that distressful cycle. Gilkerson believes early troubles in the family relationship can turn around. “This is a very open time psychologically for the mother,” she said. “Information, support, empathy and coaching can really help.”

Most parents get connected to the network through the Fussy Baby Warmline–a telephone call-in service that hooks up parents to a team of child development specialists. “Over the phone I hear high levels of anxiety,” explained Susan Connor, program coordinator of the Fussy Baby Network. “Anxiety not only about what’s happening now, but what the future is going to be like.” Parents often are surprised by the loneliness and isolation that accompany an uncontrollably crying infant, she added.

A survey of emergency room admissions, conducted by Gilkerson and Gray, showed that of families bringing their young babies to the emergency room for crying, one-third of the visits were diagnosed as colic. The other infants had problems that required medical attention.

“The findings underscored the need for more resources to be made available to parents,” said Gilkerson, who was originally inspired to form the Fussy Baby Network by her own experience as a parent of a fussy baby. Even pediatricians and other medical professionals call the Network asking for advice and help for their patients.

Many times the Fussy Baby Warmline phone calls lead to home visits by the network team. “People are surprised and grateful that someone will come and just sit with them, paying attention to their concerns and being patient,” Gilkerson said.

Child development experts talk with parents about their baby’s day, ways they can calm their baby and how they can take care of themselves. “We don’t hold the babies,” Gilkerson said. “We “hold” the parents. That is, we listen, observe with the parent, and at times, gently coach. The best moment is often when the parents calm the baby, and realize they can do this.”

Sometimes it takes only one visit for parents to feel more comfortable and confident with their baby. But the specialists can work with the family for as long as it takes, averaging five visits over a two-month period.

The network, in operation since March 2003, also includes a drop-in time where parents come with their baby to the Erikson Institute to meet informally with other parents and with the Fussy Baby team. Parent groups are held throughout the area, too, that offer discussions on such topics as helping a fussy baby sleep, strategies to refuel parents and life after colic.

All babies have periods of crying that can’t be soothed; but some have many more bouts of this kind of crying. The cause of colic is not known. For a relatively small group, crying may be caused by allergies or digestive problems such as reflux. Most recently, in the October issue of Pediatrics, a study shows smoking during or after pregnancy could be a trigger. Some doctors believe it’s a matter of temperament–some babies take a bit longer to get adjusted to the world. But for most babies, there is no known medical or developmental cause.

Besides the University of Chicago and LaRabida, the Fussy Baby Network works with Northwestern Prentice Hospital, Healthy Families Illinois, Illinois Department of Children and Family Services, and Family Focus.

The Fussy Baby Network is funded primarily through a grant from the Doris Duke Charitable Foundation. The Irving Harris Foundation provided additional support.

The Fussy Baby Warmline is free. Home visits and parent support groups are offered on a sliding-fee basis. Any parent struggling with a fussy baby is encouraged to contact the network at 1-888-431-BABY or http://www.fussybabynetwork.org.

Colicky Babies And Postpartum Depression

A compelling connection exists between colicky babies and postpartum depression, according to a study conducted by a Brown Medical School professor and Rhode Island Department of Health family health experts.

The study is the first to establish a link between colic and depression using a large sample of demographically diverse women. Results will be presented in May at the Pediatric Academic Societies’ 2006 Annual Meeting in San Francisco. The meeting is the largest academic pediatric gathering in the world.

Pamela High, M.D., served as lead. High is a clinical professor of pediatrics at Brown Medical School and director of developmental-behavioral pediatrics at Hasbro Children’s Hospital. She is also head of the Infant Behavior, Cry and Sleep Program run by the Brown Center for the Study of Children at Risk, which is supported by Women & Infants Hospital of Rhode Island.

The research team also included staff from the Rhode Island Department of Health’s Division of Family Health, who provided data and analytical support. They are Hannah Kim, senior epidemiologist; Samara Viner-Brown, chief of data and evaluation and director of the Pregnancy Risk Assessment Monitoring System, or PRAMS; and Rachel Cain, PRAMS coordinator.

High warned that the work does not show a direct cause-and-effect relationship between a fussy baby and a depressed mom. “We can’t say that inconsolability causes depression or that depression causes inconsolability,” High said. “However, we did find a link between the two. And this won’t surprise anyone who knows a mother coping with a fussy baby.”

High directs the Infant Behavior, Cry and Sleep Program - known locally as the Colic Clinic - in Providence. High and other Colic Clinic staff have helped hundreds of families having trouble with their infants’ crying. After conducting an exam and taking a medical history, clinic staffers help new mothers and fathers console their babies, pinpoint the cause of the crying, and take care of their own needs.

A 2005 Brown Medical School study of 93 mothers seen at the Colic Clinic showed that 45 percent reported moderate to severe depressive symptoms. Barry Lester, head of the Brown Center for the Study of Children at Risk, led the study.

“At the clinic, it is not unusual to see mothers who are very tired and sometimes very anxious and depressed,” High said. “Moms are trying hard to understand their child’s needs and meet those needs. Sometimes they feel inadequate when they can’t console their baby.”

The study is based on responses to the Rhode Island PRAMS, an ongoing, confidential survey of women who have recently given birth. The state is one of 32 participating in PRAMS, which is funded by the federal Centers for Disease Control and Prevention and aims to improve the health of new mothers and their babies. Each month, women are randomly chosen to receive the survey, which covers topics such as prenatal care, smoking, and nutrition and breast-feeding.

High is a member of the Rhode Island PRAMS steering committee. The committee was able to choose a few state-specific questions that would be added to the standard survey. The survey already asked about depression. Wondering if there was a connection to colic, High suggested another: “How inconsolable is your baby?”

The new question appeared on Rhode Island’s first PRAMS survey, administered in 2002, and again in 2003. A total of 4,214 new mothers got the questionnaire and 2,927 responded. The majority of mothers were white, married, had household incomes of more than $40,000 per year and had health insurance. Most of their babies were between two and four months of age.

The results: 19 percent of mothers reported moderate to severe symptoms of postpartum depression, and 8 percent reported that their babies were difficult to console. Responses showed a strong connection between the two. Mothers reporting depression were more than twice as likely to report infant inconsolability, and women with inconsolable babies were more than two times as likely to report depression. Even when other variables were controlled - such as age, race and income - the two were closely related.

“Depression and inconsolability are strong predictors of one another,” High said. “One in three women with fussy infants acknowledged that they were depressed.”

Researchers say the study sends a clear message to pediatricians: If you are treating a colicky baby, check on the moms, too. Ask them how they are feeling and if they have support from family and friends. When appropriate, refer women to mental health providers.

“This study is a terrific example of the use of survey data to further our understanding of maternal and child health issues and develop recommendations for improving public health practices,” Viner-Brown said. “It also shows the benefits of partnerships between state governments, universities and hospitals.”

New study links colic, maternal depression to family problems

Some families with new babies face excessive infant crying, or colic. And some new mothers go through maternal post-partum depression (PPD) following childbirth. Neither situation is considered healthy, but a recent study published in the Infant Mental Health Journal has found that the combined impact of colic and PPD can have a highly toxic outcome. Researchers have linked colicky babies and maternal depression to decrease in overall family functioning.

“We found that severe depressive symptoms in the mothers were related to fussy, or difficult infant temperament, more parenting stress, lower parental self-esteem and more family-functioning problems,” says senior author Barry Lester, PhD with the Bradley Hasbro Children’s Research Center (BHCRC) and Brown Medical School.

Dr. Lester founded the Colic Clinic at the Infant Development Center at Women and Infant’s Hospital in Providence, RI, and is the foremost colic researcher in the country. His new book Why is My Baby Crying? was published last month by Harper-Collins and is touted as ‘the parent’s survival guide for coping with crying problems and colic’.

“Colic is ultimately defined by the parental threshold for infant crying,” says Lester and his co-authors, “so one possibility is that cry-related problems like colic act as a catalyst for dysfunction in already stressed families.”

Examples of family dysfunction might include poor communication, confusion over roles, difficulty in solving family problems, poor family interaction and a lack of emotional responsiveness.

Other studies have shown that depression can alter the way a mother perceives and responds to her baby’s cry signals. In light of this, the authors conclude that the co-occurrence of infant colic and maternal depression might be especially risky for infant development outcomes such as behavior skills or forming relationships.

“Forty-four percent of the women showing up at the Colic Clinic are depressed which is pretty devastating and now we have evidence to show that it’s harmful to the whole family,” says Lester.

Maternal postpartum depression (PPD) has been described as the most common unrecognized postpartum complication and occurs in 15 to 20 percent of women following childbirth. According to the American Psychiatric Association, PPD symptoms include loss of pleasure or interest in usual activities coupled with sleep or appetite changes, loss of energy and/or recurrent thoughts of death for at least 2 weeks.

The authors hope the study will prompt pediatricians to ask more questions about parental and family well-being during an infant’s regular check-up.

“By recognizing the potential risk that crying and maternal depression presents, pediatric healthcare providers have an opportunity to refer treatment that could potentially prevent future problems within the family,” the authors conclude.

New review confirms Colief’s efficacy in the reduction of colic related crying time

For the parents of a baby with colic, the periods of unbroken crying can drive them to the brink of despair. Being a new parent is difficult enough but the inability to console a baby who appears distressed and in pain can prove too much and lead to a total loss of parental confidence. Now a new review published in the GP’s magazine the Prescriber [1], offers fresh hope to suffering parents.

The review by Dr Dipak Kanabar, consultant paediatric gastroenterologist at Guys Hospital, compared 6 alternative approaches to the treatment of colic symptoms in babies. Findings showed that while other options offered some relief, only preincubation of baby milk with a lactase enzyme such as Colief Infant Drops dramatically reduced the crying time in colicky babies.

Although there is no single cause for colic, undigested lactose in food as a result of Transient Lactase Deficiency has been identified as a causative factor in many babies suffering from colic. Undigested lactose leads to bacteriological and metabolic changes in the gut, which in turn cause pain and distress.

The review published in Prescriber confirms the findings of a double blind, placebo controlled study carried out at the Department of Paediatrics at Guys Hospital in 2001 [2], which showed that pre-treatment of feeds with lactase typically reduces crying time in responders of 45% or more.

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