Table 1 Publications (in chronological order) on health professionals' knowledge, attitudes and practices towards medication use and safety in breastfeeding

66 pharmacists working at Rabin Medical Center and from private pharmacies were interviewed (via telephone or personal visit). No details were provided on how participants were selected for the study and how their details were obtained.

To examine the rate of pharmacist counselling of women who use medications during pregnancy and/or breastfeeding.

Only 9% (6/66) of pharmacists said they made a practice of asking women two basic questions: "Are you pregnant or nursing?" and "Did you receive an explanation (of the drug(s) in question) from your physician? In no case did the pharmacist offer information at their own initiative.

Mail questionnaire sent to 939 GPs and 948 community pharmacists in the South and West NHS Executive region of Hampshire, Wiltshire, Dorset and the Isle of Wight. GPs were selected by systematically sampling every fifth name from lists supplied by the local health commission, and pharmacists were identified from information supplied by the Royal Pharmaceutical Society of Great Britain.

To investigate the knowledge and attitudes of GPs and community pharmacists to the safety of infants exposed to medications via breast milk and the importance of continuing breastfeeding.

RR (GPs) = 63% (590/939) and RR (pharmacists) = 68% (641/948). 80% (473/590) of GPs had personal/partner experience of breastfeeding, with the majority (83%, 490/590) agreeing/strongly agreeing with the statement that "Breastfeeding is a health promotion issue". Most pharmacists (82%, 523/641) also agreed/strongly agreed with this statement and many (66%, 422/641) had personal/partner experience of breastfeeding. The majority of GPs (93%, 551/590) said that they would always ask a woman with a baby how she was feeding her child before prescribing medications for her, with significantly fewer pharmacists (318/641, 50%) doing the same. Only 22% (129/590) of GPs said that they would always ask this question to a woman with a toddler. The importance of the breastfeeding relationship for women beyond 6 months was similarly underestimated by pharmacists. Most pharmacists (76%, 486/641) also said that GPs never contacted them for information on medication use and safety in breastfeeding, in contrast to some GPs who said that they would contact the pharmacist (15%), a drug information centre (9%) or the manufacturer (7%). GPs felt it was quite important to inform a woman of potential side effects of a medication if she continues to breastfeed whilst taking it, and they often did this. Pharmacists, on the other hand, while feeling that it was very important to inform a breastfeeding woman, didn't often do so, despite the fact that many reported being asked by women about medication safety (pertaining to, e.g. tranqulisers, hypnotics, oral contraceptives, cough/cold remedies, laxatives) from once a week (46%) to once a month (40%). 9 pharmacists stated that it was the woman's responsibility to inform them that she was breastfeeding and to initiate the query. 50% of GPs and 43% of pharmacists rated the quality of information available on medication use and safety in breastfeeding as acceptable, compared to 22% of GPs and 28% of pharmacists who thought it was of insufficient quality. Interprofessional workshops on the topic were appreciated more by pharmacists (72%, 459/641) than GPs (43%, 255/590). Pharmacists were also found to be more interested (83%) in undertaking a distance learning package in this area than GPs (45%).

Mail questionnaire sent in 1997 to all Ontario endocrinologists (92) and randomly selected family physicians (300) listed in the Canadian Medical Directory. Two case vignettes were presented in the survey - 1) a breastfeeding woman requires 300 mg/day of propylthiouracil (PTU) and has no preference for a feeding method; and 2) a woman on the same dose wishes to breastfeed. Participants were asked to state if they would recommend breastfeeding, and whether they had had to provide such advice in the past year. If the respondent was unsure of their recommendation, they were asked to select from a list which information sources they would consult to obtain an answer.

To examine physicians' attitude toward PTU therapy during breastfeeding.

RR = 72% (endocrinologists) and 38% (family physicians). 47% of endocrinologists, compared with only 1% of family physicians, had given advice within the last year on the use and safety of PTU during breastfeeding. Of all physicians who indicated that they would not recommend breastfeeding in case 1, 2 or both, 81% listed drug amount found in the breast milk as a primary reason for not recommending breastfeeding. 8 family physicians and 5 endocrinologists who were unsure of the compatibility of PTU with breastfeeding provided information sources they would consult. Reference books (66%) were favoured amongst family physicians, followed by colleagues (60%) and other sources (57.5%). Literature searches were chosen by all endocrinologists, followed by reference books and colleagues with or without an additional source. 1 in 4 endocrinologists who were found to be against breastfeeding during PTU treatment reported that they would change their advice to being in favour of breastfeeding if the woman wanted to breastfeed.

Mail questionnaire sent in 1998-99 to 265 pharmacists practicing in community pharmacies in Nebraska, with adequate representation of rural pharmacists by using a stratified sampling technique. No details were provided on how potential participants' details were obtained. Repeat mailing was done to all non-respondents using a modified Dillman technique.

To provide a better understanding of the role pharmacists play in counselling pregnant or breastfeeding women and to assess pharmacists' comfort level with counselling these patients.

RR = 42% (110/265). Respondents reported counselling pregnant/breastfeeding women an average of 2.8 times per week. Pharmacists rated themselves as both qualified to make, and comfortable with making, therapeutic recommendations for this patient group. Compared with pharmacists who had practiced for greater than 30 years, those who had practiced for less than 30 years felt more qualified and comfortable, and believed that pharmacy schools did not provide adequate training, and therefore placed greater value on continuing education, in this area. Pharmacists varied in their responses to whether they would recommend medications for 7 common OTC-treatable conditions (cough, cold, analgesia, constipation, diarrhoea, insomnia and heartburn) e.g. for cough, 55% said they wouldn't recommend any medications compared with only 38% who said the same for conditions requiring analgesia. Some pharmacists also recommended some medications that are unsafe in breastfeeding (e.g. 10% recommended diphenhyramine for insomnia and 16% recommended dextrometorphan for cough). Several commented about alternative, non-pharmacological treatments they would prefer to recommend first for 6/7 of the conditions.

See publication 22 in this table.

As for publication 22 in this table.

The figures reported in this publication differ slightly from those in publication 22, despite being the same study, and this publication reports less than, but similar results to, publication 22. Therefore, only new results are presented here. 80% of GPs had personal/partner experience of breastfeeding, and comments made by participants indicated that their experiences were different to those of the pharmacists. 3% (19/641) of pharmacists said that they were never asked about medication safety in breastfeeding by their customers, compared to 9% (60/641) who reported being asked around once a week. Both GPs (76%, 450/589) and pharmacists (81%, 522/641) thought it was difficult to stop breastfeeding abruptly and made varying comments about providing information to breastfeeding women on medication safety and use.

Attendees of the American College of Physicians 2003 annual meeting invited to undertake a web-based version of the KOWIE-II, a validated and reliable tool for investigating issues that affect women with epilepsy, such as effects of antiepileptic medicines on oral contraception, bone health, sexual function, pregnancy and breastfeeding. Participants could choose either 'true', 'false' or 'don't know' to each item.

To assess what physicians know about issues pertaining to women with epilepsy.

RR not calculated. 202 respondents completed the survey, the majority of whom were physicians (92%). 4% were medical students and the remaining 2% were other health professionals not named. Most respondents were male (66%) and their mean age was 38 years. The majority (80%) treated less than 10 patients with epilepsy per month. The most common specialty was internal medicine (74%), followed by pulmonology (14%) and general practice (3%). In response to the item, 'Most women taking antiepileptic drugs can safely breastfeed', only 47% identified the correct answer ('true'), with 22% responding in the negative ('false') and 32% not knowing ('don't know').

Mail questionnaire sent in 2007-8 for anonymous completion to 640 GPs who provided shared maternity care at the RWH in Melbourne, Victoria. Repeat mailing was done to all potential participants, and a reminder postcard was sent in-between the first and second mailings. See publication 21 in this table for information on how potential participants were identified in this study.

To describe GPs' current and preferred sources of information about the safety of medications during breastfeeding.

RR = 52% (335/640). Most respondents were women (70%, 233/333), and most (68%, 227/333) had personal/partner experience of breastfeeding for longer than 6 months. 70% of GPs used the internet during consultations and 82% found it to be helpful. Most (73%) obtained information about medications and breastfeeding from their software prescribing program or from dedicated books (61% predominantly used the RWH** reference text, Drugs and breastfeeding), and 51% used telephone advice (predominantly from the RWH pharmacy). However, some GPs wrongly assumed that the drug categories for pregnancy also applied to breastfeeding women. Their software prescribing program and a reliable internet database were preferred by respondents as information sources. The need for an internet database was appealed for using the example of ibuprofen - inconsistent recommendations in manufacturers' product information exist on its safety, and only 31% (102/330) of surveyed GPs were aware that it is safe in breastfeeding even though most (89%, 293/331) were confident about prescribing medications for breastfeeding women.

A random sample of 500 pharmacists registered in Ohio were sent a mail version of the KOWIE-II questionnaire (see publication × in this table for details of this tool), or completed it prior to a live continuing education seminar. The year of survey distribution was not given and participants' preferences for epilepsy education were not determined either. Data for both methods of administration was pooled and analysed. The percent correct score was calculated per pharmacist.

To assess what pharmacists know about issues pertaining to women with epilepsy.

RR = 22% (109/500, mail survey). 43 surveys were completed at the continuing education seminar. 45% of respondents were female, their mean age was 51 years, and most identified themselves as community pharmacists (79%). Participants' mean number of years spent in their current practice setting was 19 and the average number of patients with epilepsy seen per month was 14. 50% of the respondents treated less than 10 patients with epilepsy per month. In response to the item, 'Most women taking antiepileptic drugs can safely breastfeed', only 34% identified the correct answer, with 36% responding in the negative and 31% not knowing.

Written questionnaire administered at pharmacy sites by a student researcher in 2007, to 36/47 pharmacists in Rhode Island (1 questionnaire per pharmacist per site). This was preceded by distribution of the reference text, Medication and Mothers Milk (Hale) to pharmacists by the Rhode Island Department of Health in 2006, following preliminary feedback from a number of pharmacists that the book was not available.

To determine what strategies and resources pharmacists were using to identify breastfeeding women and guide medication recommendations.

RR = 92% (33/36). 58% of respondents never asked women if they were breastfeeding and some were concerned that asking this question would cause offense. 61% believed that women should self-disclose to the pharmacist that they are breastfeeding, and one-third thought that the prescribing physician should alert the pharmacy or that they could check by identifying if the woman had received prenatal vitamins. Most pharmacists (85%) reported feeling somewhat or very comfortable giving advice to breastfeeding women. Nearly half (45%) reported receiving enquiries daily or weekly and used various resources to guide their recommendations, most commonly the Physician's Desk Reference, the respective pharmacy chain's intranet, and Medication and Mothers Milk. All but one pharmacist who had received the latter reference reported using it at least monthly.

See publication 17 in this table.

To determine GPs' attitudes to breastfeeding; knowledge of one medication that has a side effect of reducing milk supply; advice for breastfeeding women regarding several medications (paracetamol, ibuprofen, metronidazole, St John's wort and lithium); reports of adverse events for infants; and most preferred sources of information about medications for breastfeeding women.

See RR for publication 17. Over half of the GPs were generally supportive of breastfeeding, disagreeing with unsupportive statements e.g. "In most cases a breastfeeding mother must temporarily wean her baby while she is taking prescription medications" (89%, 295/333). 64% (215/335) of respondents could correctly name one medication that had a side effect of reducing milk supply; however, 22% (75) skipped this question. Less than one third knew that ibuprofen (30%, 102/335) and metronidazole (22%, 72/335) are compatible with breastfeeding. Only 2% of GPs (6/333) knew that St John's wort is relatively compatible. Many (51%, 168/330) said they need to look into the use of lithium (the infant needs to be monitored and breastfeeding is usually discontinued) or that they have concerns about its use (42%, 140/330). Most knew (88%, 291/331) that paracetamol is compatible. The majority of respondents (90%) drew on previous clinical experience to make decisions around medication safety in breastfeeding, with few (n = 6) having told women to stop breastfeeding during therapy. Concern about medico-legal issues was common (76%, 250/330 rated it as an 'important/very important' factor in decision-making for medicines for breastfeeding women). Only 18% (61/335) were able to report an adverse event associated with maternal use of medications whilst breastfeeding (where the most commonly reported adverse event was associated with antibiotic use), and none of the events were serious. GPs wanted practical information about medications for breastfeeding women available via their software prescribing program (68%) or a reliable internet database (57%).

See publication 17 in this table. Additional detail about how participants were identified was given in this publication: a current list of 666 GPs was obtained from the RWH. However, details on how 640 of them were selected as potential participants were not provided.

Using content analysis, to determine factors governing GPs' decision-making in response to a question about prescribing medications for a breastfeeding woman.

See RR for publication 17. The most common conditions for which GPs had last had to decide about medication use for a breastfeeding woman were mastitis (24%), other infections (24%) and depressive disorders (21%), where the decision to use anti-infectives was reported to be easier than determining antidepressant use. The 6 organising themes that emerged from 253 responses were: "certainty around decision-making", "uncertainty around decision making", "need for drug information to be available, consistent and reliable", "joint decision-making", "the vulnerable third party", and "infant feeding decision". Certainty was associated with positive feelings such as being happy, comfortable and confident, compared to uncertainty that was associated with negative feelings such as concern and doubt. Various sources were accessed by GPs for information on medication safety in lactation, including pharmacists whose opinions sometimes clashed with their own. The need for reliable and consistent information was noted, especially on complementary medications. Involving the mother and other health professionals in a joint decision-making process was felt to be necessary in facilitating a safe outcome for the woman and increasing the chances of her compliance with the recommended/prescribed medication. GPs undertook "benefits versus risk" assessments when considering medication safety, however didn't consider the potential exposure to the infant (the "third party"). Some GPs advised unnecessary cessation of breastfeeding during medication use and others emphasised its continuance. "Complexity of managing risk in prescribing for breastfeeding women" was identified as the global theme.