Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

Rachael Zimlich, RN, BSN

There has been a flurry of fears and side effects linked to COVID-19 vaccination, but to people in their childbearing years, the chances of an impact on fertility and fetal health may carry the most weight.

Three experts sought to outline exactly what impact vaccination against COVID-19 could have on reproductive health, fertility, and infant outcomes during the 2022 American College of Obstetricians & Gynecologists' (ACOG) Annual Clinical & Scientific Meeting held in San Diego, California from May 6-8.

The session, titled “Fact or Fiction? The Impact of COVID-19 Vaccines on Reproductive Health and Pregnancy” was led by the University of California San Francisco’s Marcelle Cedars, MD, and Stephanie Gaw, MD, PhD; and Alison Edelman, MD, MPH, of Oregon Health & Science University.

Edelman says the panel was inspired to tackle this topic because of how reproductive fears about the vaccine can impact public health.

“The World Health Organization has identified vaccine hesitancy as one of the top 10 threats to global health,” Edelman told 

“Prior vaccines have been shown to be safe for reproductive-aged and pregnant individuals, but concerns around reproductive health and COVID-19 vaccines appear to be a significant factor in ongoing vaccine hesitancy.”

The goal of the presentation was to outline the results of a now solid body of evidence addressing concerns with different areas of reproductive health, she says.

“The public’s response to our findings on menstrual health funded by the [National Institute of Health] has been significant; there’s clearly widespread interest in these findings that demands ongoing research,” says Edelman, adding that she and the other presenters were, and continue to be actively involved in ongoing research on these topics. “We have all been bombarded with information and misinformation over the last several years, not to mention the weariness and burnout in providing care during a pandemic; as such, we designed this presentation to provide a useful and practical summary of this evidence to our colleagues at ACOG, in order to help them better care for their patients and address their concerns.”

A highlight of the presentation was the acknowledgment that there do appear to be some temporary changes in the length of menstrual cycles after vaccination, but long-term effects aren’t entirely clear. The menstrual cycle and fertility rates overall fluctuate naturally, and for many reasons like stress and illness. The presenters offered the results of their own ongoing research to put these changes and the effect of the vaccine into perspective using early observations.

According to data cited in the presentation, as of May 2021—about 18 months after the launch of COVID vaccines—there were 95 reports of menstrual irregularities among 72 million women who voluntarily reported vaccine side effects.

By September of that year, that number jumped to 2,301 reports out of more than 100 million vaccinated women participating. In the United Kingdom, reporting was similar with 37,754 out of 48.3 million vaccinated women reporting menstrual disorders as of September 2021. In each of these cases, changes were reported in less than 1% of women, while about 28% of women experienced menstrual changes after acute COVID-19 infection.

The same is true for fertility, the presenters explained, with some slight changes but no severe impact observed after COVID-19 vaccination on female hormone function, egg development, semen quality, implantation, or pregnancy loss. There is nothing in the early data to suggest that the vaccine will lead to long-term or serious reproductive effects, the presenters noted.

In regard to infant health, the presenters also revealed that while there have been reports of preterm birth, infants being born small for gestational age, and neonatal intensive care unit admissions among babies born to mothers who were vaccinated, these levels fell at or below average rates for all births regardless of the mother’s vaccination status. No deaths have been attributed to maternal vaccination.

Meanwhile, the presentation highlighted the vast difference—about 2% overall—in COVID-19 infection rates in pregnant mothers who were vaccinated vs those who were not. Reports have also found that mothers vaccinated during pregnancy transfer antibodies to their infants both in utero and through breast milk.

Overall, the presenters shared a 2022 data comparison published in 

 outlining the differences in COVID-19 infection vs COVID-19 vaccination in pregnant women. Fertility and miscarriage rates were the same in both populations, but maternal mortality rates and newborn infections or complications were higher in women who contracted COVID-19 during their pregnancy.

These results, however, were similar in frequency when compared to women who were not infected with the virus during pregnancy, and disproportionately affected minorities.

Meanwhile, studies have shown that maternal vaccination during pregnancy was 97% effective at preventing COVID-19 infections in the mother and 89% effective in preventing hospitalization. There is also no evidence that any components of that vaccine are passed to infants from their mothers through breast milk, the placenta, or cord blood.

In terms of timing, the presenters stressed that the best time to get vaccinated against COVID-19 during pregnancy is as soon as possible. To ensure an optimal amount of COVID-19 antibodies are passed to the baby, mothers should be vaccinated roughly 2 months before delivery. Antibodies can still be passed to baby through breast milk with vaccination after delivery, but these antibodies will not be transferred to the infant’s bloodstream.

1. Cedars M, Gaw S, Edelman A. Fact or fiction? The impact of COVID-19 vaccines on reproductive health and pregnancy. Presented at: 2022 American College of Obstetrics and Gynecology Annual Clinical & Scientific Meeting; May 6 to May 8, 2022.

Articles

A presentation at the 2022 American College of Obstetricians & Gynecologists' Annual Clinical & Scientific Meeting outlined the impact vaccination against COVID-19 could have on reproductive health, fertility, and infant outcomes.



Understanding the impact COVID-19 vaccines have on fertility and pregnancy 

There are a number of reasons that adults might choose to cut meat—or all animal products for that matter—from their diets. However, doing the same for infants can have big health consequences.

Donna Hallas, PhD, RN, PPCNP-BC, CPNP, PMHS, FAANP, FAAN, a pediatric nurse practitioner and professor at New York University Meyers College of Nursing in New York City, says although there are some vegan, plant-based, and vegetarian formulas for infants on the market, switching an infant to these types of diets isn’t a simple matter of preference. Even strict vegan mothers that breastfeed their infants need to be aware of the risks and take steps to make sure their babies grow and develop in a healthy way when using these diets, she said.

“I am opposed to strict vegan diets for babies,” Hallas said. “Because I work with very high risk children in my practice. Whenever I encounter a family who wanted to pursue a strict vegan diet, their babies did not thrive.”
Brain growth in the first 3 years of a child’s life is critical to their overall development, Hallas explained, adding that proper nutrition is a key part of healthy brain development. A number of nutritional deficiencies can occur with diets that lack certain minerals and nutrients, including rickets and overall malnutrition.

A study in early 2021 revealed that the risk of nutritional deficiency increased with more restrictive diets. Some of the deficiencies noted in children who followed vegan and vegetarian diets include

Guidelines used throughout North America tend to support well-planned and executed vegan and vegetarian diets for any age, the study continues, but European guidance recommends strongly against them without close medical and dietary supervision.

Pediatricians who are asked about vegan formulas—or even breastfeeding by a strictly vegan mother—should be aware of the nutritional concerns and advise patients and caregivers on appropriate supplementation. Not all families come forward with the choice to live a vegan or vegetarian lifestyle, Hallas said, and mothers who are breastfeeding might not even be as healthy as they think.

Strict vegan mothers who breastfeed should continue taking prenatal vitamins while nursing, she said, and pediatricians should do their best to assess the mother’s intake and have them do a recall of a few days worth of their diet. One 2020 case study shared a report of a 13-month-old breastfed infant that developed rickets due to the mother’s nutritional deficiencies and lack of supplementation.

“A lot of vegan mothers who aren’t in the high risk group will willingly give you the list of foods they’re eating,” Hallas said, adding pediatricians can use this information and their assessment of the infant to make appropriate nutrition and supplementation recommendations.

Sometimes, however, families don’t share their diet preferences either out of omission or simply a lack of time. Hallas noted she has seen some cases where infant vegan diets weren’t obvious until deficiencies resulted in serious nutrition, growth, or development problems.

“Sometimes I think in today’s world maybe more telehealth visits will be helpful because people are in and out so quick [at pediatric visits], how much time is there to discuss diet?” Hallas said.

There is also a matter of trust and whether vegan parents regard the pediatrician as a source of expertise when it comes to nutrition. One recent paper detailed the refusal of a family to follow the dietary advice of a pediatrician caring for a young child with failure to thrive. Follow-up was almost non-existent and the family failed to show up for appointments after the initial visit or utilize the recommended diet and supplements. The report authors caution that pediatricians need to be well versed in vegan and vegetarian preferences among patients and families, adding that interest in these types of diets has increased by an estimated 350% over the last decade.

Allergens are another issue when it comes to helping families choose formulas and breastfeeding plans that align with different food allergy concerns. Hallas said oral immunotherapy has proven effective in managing peanut allergies, although use of this therapy in practice depends a lot on the individual assessment and family history. She recommends that families with a strong history of food allergies or anaphylaxis from a food allergy see a specialist for more exact testing. A good assessment is important in cases of food allergies, Hallas said, adding that it’s important to know where the family’s concern is coming from—a family history or a report on a blog?

Some common food allergies that cause concern with infant diets include milk proteins and gluten. The Asthma and Allergy Foundation of American makes several recommendations for formulas that meet the needs of infants with food allergies

Breastfeeding is the preferred feeding choice for infants with food allergies, the organization notes, and homemade formulas are not recommended at all.

This article was initially published by our sister publication Contemporary Pediatrics.

1. Kiely, M. Risks and benefits of vegan and vegetarian diets in children.

 2021;80(2):159-164. doi:10.1017/S002966512100001X

2. Michaelsen KF, Neufeld LM, Prentice AM. Global Landscape of Nutrition Challenges in Infants and Children.

Nestlé Nutr Inst Workshop Ser. Nestlé Nutrition Institute.

 2020;93:103–110. doi: 10.1159/000503348

3. Lemoine A, Giabicani E, Lockhart V, Grimprel E, Tounian P. Case report of nutritional rickets in an infant following a vegan diet. 

. 2020;27(4):219-222. doi:10.1016/j.arcped.2020.03.008

4. Farella I, Panza R, Baldassarre ME. The difficult alliance between vegan parents and pediatrician: a case report. 

International Journal of Environmental Research and Public Health

. 2020;17(17):6380. doi: 10.3390/ijerph17176380.

5. Asthma and Allergy Foundation of America. Formula options for infants and toddlers with food allergies. Accessed October 5, 2021. 

https://www.kidswithfoodallergies.org/formula-options-for-infants-with-food-allergies.aspx

Using vegan, plant-based, and vegetarian formulas isn't as easy as an adult choosing to have such a diet and making that choice for an infant can carry consequences.



Discussing formula options with parents who are vegan

Roughly 20% of all babies born in the United States are supplemented with formula in their first few days of life.1 Although they may be exclusively breastfed later on, a new study raises questions about how early exposure to cow’s milk proteins might help shape future allergies.

the Journal of Allergy and Clinical Immunology

 was done using a multilocation randomized control trial across 4 hospitals in Japan. During the trial, early formula feeding practices were investigated to determine if there were safe and practical ways to prevent the development of cow’s milk allergy.

Researchers examined when infants were exposed to cow’s milk proteins, for how long, and whether they later developed cow’s milk allergies. They concluded that early cow’s milk formula introduction—along with consistent exposure—may help prevent the development of cow’s milk allergy. When formula is used for the first few days, even as a supplement, and then discontinued, this could have the opposite effect and increase the chances of cow’s milk allergy development later on, the study notes.2

The significance of the study results, according to Tetsuhiro Sakihara, MD, lead author and a pediatrician at Heartlife Hospital in Okinawa, Japan, is that the strategy doesn’t compete with breastfeeding. Instead, research suggests that small-dose supplementation of cow’s milk formula—not enough to replace breast milk nutritionally—may have a protective effect against cow’s milk allergy development.

Cow’s milk allergies affect between 0.5% and 3% of infants globally by age 1 year. Genetics play a role in the development of some of these allergies, and cow’s milk allergies often appear alongside other food allergies. However, a number of environmental factors during the prenatal and postnatal periods can also have an impact.3

In this study, none of the 31 participants who avoided cow’s milk formula for the first 3 days of life later developed a cow’s milk allergy, suggesting that avoiding this type of formula in the days after birth could help prevent future allergies. However, when cow’s milk formula was used, continued exposure until at least 3 months of age—even in small doses—appeared to help prevent a later reaction, Sakihara said.

“We guess that early discontinuation of cow’s milk formula ingestion might be associated with the development of cow’s milk allergy,” said Sakihara.

A subgroup was investigated during the study involving infants who developed a cow’s milk allergy at 6 months of age. The research team broke these infants into categories, comparing those who stopped using cow’s milk formula before 1 month of age, at 1 to 2 months of age, and between 3 and 5 months of age. The group that stopped using cow’s milk formula the earliest had the highest rates of allergy development, according to the study.

“Early discontinuation of cow’s milk formula ingestion, particularly in the first month of life, increased the risk of cow’s milk allergy in infants who received cow’s milk formula in the first 3 days of life,” Sakihara says.

The research team used its study to come up with the suggestion that ingesting 10 milliliters or less of cow’s milk formula daily between 1 and 2 months of age could help prevent the development of cow’s milk allergies later on. The small volume means that this strategy doesn’t have to compete with breastfeeding as a nutrition source, Sakihara adds.

In fact, Sakihara says this strategy might be particularly helpful at helping infants who may have had supplemental formula feedings in the first few days of life avoid cow’s milk allergies once they become more exclusively breastfed.

1. Centers for Disease Control and Prevention. Breastfeeding Report Card. Updated September 17,2020.


https://www.cdc.gov/breastfeeding/data/reportcard.htm

2. Sakihara T, et al. Randomized trial of early infant formula introduction to prevent cow’s milk allergy. 

Food Allergy and Gastrointestinal Disease

. 2021;147(1):224-232. doi: 10.1016/j.jaci.2020.08.021

3. Flom JD, Sicherer SH. Epidemiology of Cow's Milk Allergy. 

. 2019;11(5):1051. doi: 10.3390/nu11051051

This article was originally posted on Contemporary Pediatrics®. 

Early exposure to peanuts has been shown to reduce the risk of peanut allergy. Is the same true with cow's milk?

Ingesting cow's milk formula prevents cow's milk allergies

Doctors don’t talk enough to their young patients about sex, and neither do parents-but parents also aren’t sure that it’s a clinician’s place to have “the talk” with their children, according to a new study.

“Let’s talk about sex: Do adolescents’ parents and primary care physicians talk to them about sex?” was presented as an abstract at the Pediatric Academic Societies (PAS) 2018 meeting in Toronto in May 2018 by Brinda Desai. Co-author Kari Schneider, MD, an assistant professor in the Department of Pediatrics at the University of Minnesota, Minneapolis, says the research project demonstrates the need to increase attention on why these conversations aren’t happening more and what can be done.

The goal of the study was to assess the frequency at which teenagers and young adults were asked about their sexual activity and screened for sexually transmitted infections (STIs). Researchers polled 582 adolescents aged 13 to 17 years and 516 parents who attended the Minnesota State Fair in 2017 for the report.

Adolescents and young adults have more STIs than all other ages combined, Schneider says, and parents and clinicians have to address the risks and discuss safe sex practices with them.

However, the study found that nearly half of all teenagers-45%-say they have not been asked regularly about sex by their primary care providers. Only 13% say their doctor offered them screening for STIs. On top of not being asked about sex by their doctors, just 39% of teenagers reported talking about sex with their parents, despite the fact that 90% of parents reported having “the talk” with their children.

The study also found that older teenagers were asked about sex and STIs more frequently than younger teenagers, and white female patients were more likely to encounter these assessments than minority females and males.

When discussions with clinicians did occur, 49% of parents stated that it happened with their knowledge, while 24% were unaware that the conversation had taken place. In regard to parent communications, mothers or female caregivers were most often the ones to address sex with their teenagers.

It was unclear from this study whether adolescents felt comfortable discussing sex with their doctors, although the study did address the comfort level of parents in regard to this line of questioning.

A quarter of the parents polled felt that primary care physicians should not be discussing sex with teenagers and young adults, according to the researchers.

“We were truly astonished to find such a large percentage felt that (practitioners) should not be discussing sex with their children,” Schneider adds.

Addressing parental concerns about sex-related discussions conducted by clinicians is an important next step in addressing this problem, Schneider adds.

“Having everyone involved-parents, adolescents, and providers-on the same page that these discussions, done in a confidential way, are imperative to comprehensive preventive care of adolescent patients should be the ultimate goal,” she adds.

Schneider says she hopes the study will prompt clinicians to reflect on their own discussions with patients.

“I am hopeful that (practitioners) will note that a low percentage of adolescents feel that they are being asked about sex at primary care visits,” Schneider says. “Perhaps they are being asked but just not in a way that is meaningful or memorable to the adolescent.”

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1. Desai B,  Schneider K. Let’s talk about sex: Do adolescents’ parents and primary care physicians talk to them about sex?. Pediatric Academic Societies (PAS) 2018 Meeting.

Rachael Zimlich, RN, BSN

Articles

Understanding the impact COVID-19 vaccines have on fertility and pregnancy

Discussing formula options with parents who are vegan

Ingesting cow's milk formula prevents cow's milk allergies

Let’s talk about sex . . . or not