Comprehensive Notes: OTC Medicines (S2/S3), Infant Nutrition and Breastfeeding, and Parasites in the Community
Overview notes from three linked lectures: OTC medicines (S2/S3), infant nutrition and breastfeeding, and common parasites in the community. The notes summarize key concepts, definitions, protocols, examples, and practical guidance for pharmacy practice, with emphasis on safe use, patient counselling, and professional responsibilities.
Over-the-Counter Medicines: Scheduling (S2 and S3) and the Pharmacist’s role
Purpose of the lecture: role of the pharmacist in supplying non-prescription products, Schedule II (S2) and Schedule III (S3) medicines, and how they fit within a broader medicines policy.
Key objectives:
Distinguish between Schedule II and Schedule III medicines.
Explain rationale for some over-the-counter medicines.
Understand the pharmacist’s role in supplying S2/S3 products.
Context and policy:
S2 and S3 are over-the-counter medicines; S4 and S8 require prescriber input (prescriptions).
S2/S3 exclude complementary and alternative medicines (CAM) in some cases; many CAMs are listed or unregistered and not typical S2/S3 products.
In some remote areas, “poison sellers” may stock S2-like products due to access constraints; pharmacy is the preferred access point.
Core framework for safe supply (Quality Use of Medicines, National Medicines Policy):
Pillar: Quality Use of Medicines and medicine safety.
Objective: empower patients to participate in their healthcare, know the medicines they use, and use them safely and appropriately.
Guiding question when advising: Is this product used safely and correctly by the patient?
National Medicines Policy (Version 2):
Goal: world’s best health, social and economic outcomes for Australians through a supportive medicines policy environment.
Although not examinable in these particular lectures, you should understand pharmacists operate within this policy framework.
Product scheduling basics:
Non-scheduled products (General Sales): can be bought in supermarkets or pharmacies without supervision (e.g., a packet of 20 Panadol, Hydralyte).
Schedule II (Pharmacy Only): sold in a pharmacy; label on box indicates S2; more restriction than non-scheduled, but available without a prescription.
Schedule III (Pharmacist Only): available in a pharmacy, often behind the counter; needs a pharmacist to supply; not advertised widely; pharmacist must ensure safe use and patient understanding.
Schedule IV (Prescription Only): require a prescription from a prescriber; more harmful potential when misused.
Schedule VIII (Controlled Substances): require stricter controls and prescription.
How products move across schedules (principles):
Higher risk or potential for harm leads to greater restrictions (S4/S8 vs S2/S3).
Whether a product is S2 or S3 can depend on dosage form, strength, pack size, duration of treatment, and potential for misuse.
Practical examples of S2 products (pharmacy shelves):
Paracetamol (Panadol) commonly sold as S2 in typical pack sizes (e.g., 500 mg tablets, packs up to 50 tablets).
Ibuprofen, aspirin, antihistamines, cough and cold medicines, laxatives.
Topical antifungals, topical pain relief, iron supplements (oral iron sulfate).
Examples of S3 products (pharmacy-only access with pharmacist advice):
Pharmacist-only medicines may include internal use products with higher risk profiles or need for professional dosing advice.
Examples discussed include certain decongestants (e.g., pseudoephedrine historically moved from S2 to S3 due to abuse potential), some sedatives, melatonin in Australia (pharmacist-only), emergency contraception, and some weight management products (e.g., orlistat).
Vaginal antifungals and certain internal topical products may be S3 when used internally or in particular dosage forms; topical skin use may remain S2.
S2 vs S3: key differentiator is where they can be sold and the level of professional input required.
How to determine schedule for a specific product (SUSMP):
SUSMP (Standard for the Scheduling of Medicines and Poisons) provides the official schedules, including S2 and S3 determinations.
In practice, dispensing software often indicates the schedule; SUSMP is searchable online by drug name and schedule.
Example walkthrough (paracetamol and nystatin):
Paracetamol: typically S2 for 500 mg tablets; pack size not more than 50; schedule can shift to S3 if certain combination products exceed thresholds (e.g., 500 mg paracetamol plus ibuprofen with 65 mg ibuprofen per unit in packs larger than 30 could move to S3 or vary by product). The SUSMP entries show schedule two vs three depending on dose, combination, and pack size.
Nystatin: S2 for skin topical products; S3 for vaginal preparations; S4 for internal topical forms; Nystatin cream (skin) is S2; vaginal products are S3; internal topical forms can be S4; dispensing software or SUSMP can be used to verify.
Responsibility and professional obligations:
The pharmacist in charge bears responsibility for what is sold in the pharmacy, including what the support staff dispense.
Pharmacy assistants can dispense S2 medicines, but the pharmacist must ensure safety, appropriate advice, and scope of practice.
Considerations for direct product requests vs symptom-based requests:
Gather information first, then make a recommendation, then provide information about safe use and when to seek further care.
A simple protocol for OTC supply (WAM framework):
WAM stands for Who, What symptoms, How long, What have they done so far; plus other factors like medications and medical conditions, allergies, pregnancy.
Who is the product for (child, elderly, third party request)? Tailor questions to age/weight and other medications.
Symptoms: open-ended questions about symptoms; follow up with targeted questions (e.g., cough type, color of sputum).
How long have symptoms persisted? If prolonged (e.g., fever lasting >5 days), consider referral.
What has been done already? To avoid duplicating therapy and to guide away from ineffective choices.
What other medications and medical conditions might interact with or be affected by the chosen product?
Allergies and pregnancy/breastfeeding considerations.
An important counseling and consent point:
Always assess safety and whether the patient and any caregiver understand the correct use (dosage, frequency, duration).
Effective use requires patient understanding; provide written information when possible; consider language and literacy barriers.
Morning-after pill (emergency contraception) example (S3 protocol in APF):
Professional obligations: privacy, duty of care, appropriate documentation for supply, consider third-party supply risks and the patient’s safety.
You may have the right to refuse supply (e.g., if supplying to a third party in a way that could be unsafe or inappropriate); provide alternatives or refer to another pharmacy that can supply.
Assessment steps: consider the person’s age, pregnancy risk, timing since intercourse, menstrual cycle details, prior contraceptive use, potential drug interactions, allergies, and pregnancy status.
The APF (Australian Pharmacy Formulary) provides step-by-step A–R guidance for schedule-three medicines; use it as a primary reference for protocolized steps.
Practical notes on using SUSMP and dispensing tools:
SUSMP is available online; you can search by drug name and review the schedule category and packaging limits.
Dispensing software is another quick route to confirm whether a product is S2, S3, or S4.
Some products may move between schedules depending on dose, combination, and pack size; verify current status in SUSMP and your software.
Summary takeaway:
Your role as a pharmacist includes ensuring safe use, providing appropriate information, and referring when a product is not appropriate or safe.
Your interactions with patients can be either direct product requests or symptom-based requests; in both cases, use a consistent information-gathering framework and emphasize safety and appropriateness of use.
Infant Nutrition and Breastfeeding (Liz’s presentation)
Core idea: breastfeeding is biologically optimal for infants; breastfeeding provides numerous short/long-term benefits for both child and mother, with societal and ecological benefits.
Global and national recommendations:
WHO/UNICEF (1990): exclusive breastfeeding for 4-6 months, continued breastfeeding with complementary foods until about 2 years or beyond if desired.
Australia (NHMRC guidelines): aims for exclusive breastfeeding to about 6 months; continued breastfeeding with solids to 12 months or beyond if desired.
Exclusive breastfeeding means only breast milk (including expressed milk) and allowable additions such as oral rehydration solutions and vitamins/minerals; no infant formula or non-human milk.
Breastfeeding uptake and challenges in Australia:
Data are limited by measurement challenges; latest large-scale data show that many infants are not exclusively breastfed for as long as guidelines recommend.
2017–2018 ABS snapshot: around 60% of children aged 4–7 months had been exclusively breastfed to about 4 months; higher rates in two-parent families than single-parent; higher socioeconomic areas had higher rates.
Complex, multifactorial determinants: cultural, social, workplace support, hospital support, and community support.
Composition of human milk and its unique benefits:
Macronutrients: mostly water, with trace fat, lactose as primary carbohydrate, and small amounts of protein.
Protein: human milk protein is whey-predominant and easier to digest than cow’s milk proteins; animal milks have higher total protein and different amino acid profiles.
Vitamins/minerals: generally sufficient for the first six months; vitamin D supplementation of 400 IU per day recommended for exclusively breastfed infants for the first 12 months; formula-fed infants typically receive fortified vitamin D via formula.
Immunological components: antibodies (immunoglobulins), live cells, hormones, enzymes, growth factors, anti-inflammatory factors; probiotics; protection against pathogens; environment-specific antibodies tailored to the mother’s environment.
Milk is dynamic and changes through stages:
Colostrum: first milk, very high in antibodies, yellow color.
Transitional milk: during the first days post-partum; milks begin to resemble mature milk.
Mature milk: higher fat content; reduced immunoglobulins/lactoferrin/protein relative to colostrum.
Hindmilk vs foremilk: hindmilk has 2–3× more fat than foremilk; composition adapts to baby’s needs.
Milk production physiology:
Hormonal control: prolactin (milk production) stimulated by nipple stimulation and suckling; oxytocin (milk ejection) associated with let-down and a calming response.
Supply is demand-driven after an initial establishment period (~6 weeks) when frequent feeding promotes adequate milk production.
Common issues: lactation difficulties, perceived insufficient supply, and the role of lactation consultants, midwives, and early childhood nurses.
Breastfeeding problems and management principles:
Common problems: sore/damaged nipples; nipple thrush; mastitis; persistent issues require referral to lactation consultants or clinicians.
Non-drug measures first: correct latch/attachment, frequent feeds, skin-to-skin contact, ensuring baby’s adequate hydration and weight gain, reassurance.
Pharmacologic or medical management if indicated (e.g., antibiotics for mastitis; antifungals for thrush) with explanation about impacts on breastfeeding.
Guidance on continuing breastfeeding during nipple trauma or minor bleeding is offered; refer to lactation support as needed.
Expressing and storage of breast milk:
Expression can be by hand or with manual/electric pumps; use appropriate storage conditions and guidelines.
Guidelines for storage and handling are available on NHMRC infant feeding guidelines and ABA (Australian Breastfeeding Association) resources.
Breastfeeding problems and practical solutions:
Common issues include nipple soreness; thrush (nipple and infant oral involvement); mastitis (breast tissue inflammation that may require antibiotics); adjust management to protect baby’s safety while supporting mother.
When to refer: persistent pain, signs of infection, poor weight gain, dehydration in the infant, or suspicion of mastitis or thrush that requires medical management.
Infant formula basics (when breastfeeding is not possible or not exclusive):
When not exclusively breastfeeding or partially breastfeeding, commercial infant formulas are recommended until 12 months (though WHO updated guidance in 2023 allows cow’s milk to be introduced from 6 months in some settings, with iron fortification considerations and careful monitoring of iron status).
WHO 2023 update: after 6 months, some babies may be given whole cow’s milk; evidence shows no clear growth/development advantage to continuing formula beyond 6 months, but this is not universally adopted in NHMRC guidelines for Australia.
Australian NHMRC stance remains to continue infant formula use through 12 months when breast milk alone is not suitable; iron fortification in formula reduces risk of iron deficiency anemia.
Commercial infant formulas:
All formulas meet strict nutritional standards; are designed to approximate human milk; iron and vitamins are added.
Some formulas advertise prebiotic/probiotic components; evidence for added benefit is not conclusive.
Be wary of marketing claims about brain development or eyes; many claims lack robust evidence.
Formula types and stages:
Stage 1: birth to 6 months; Stage 2: 6–12 months; Stage 3 and 4: not essential in first year.
Types: cow milk-based, soy-based, specialized formulas (hydrolyzed protein, amino-acid formulas for allergies).
Goat milk-based formulas are less studied and generally not preferred; soy-based formulas may be used for specific intolerances or cultural reasons but may have controversy around phytoestrogens and isoflavones.
Stage 1 and 2 are most relevant in first year; stage 3/4 are generally not necessary.
Important cautions about infant formulas:
Do not use unmodified cows’ milk or other animal milks as a sole infant diet before 12 months.
Some infants with cow’s milk protein allergy may require hydrolyzed or amino-acid-based formulas.
Watch for iron deficiency in older infants if introducing non-fortified milks early; fortified formulas help prevent iron deficiency.
Preparation and safe handling of formula:
Practice safe preparation to minimize contamination (wash hands, use clean area, sterilize bottles and caps, use correctly boiled water, and cool to lukewarm before feeding).
Use the scoop provided by the manufacturer; measure water first, then add powder; shake until dissolved; test temperature on inner wrist before feeding.
Do not use microwave to warm formula; avoid overheating; avoid preparing too far in advance; prepared formula should be refrigerated and used within 24 hours.
If re-warming is needed, use warm water bath for up to 15 minutes or a bottle warmer; discard any leftover formula after a feeding.
Introducing complementary foods (solids):
Initiation between 4–6 months, based on infant’s developmental readiness and iron needs.
From about 6 months, complementary foods rich in iron and zinc, fats and proteins are introduced to support growth and development.
Progression: purées from 6 months, then mashed/blended foods; finger foods from around 8 months; by 12 months, family foods can be shared.
Common early foods: iron-enriched cereals, pureed meats, cooked tofu, legumes; introduce gradually and monitor for allergies.
Complementary foods and allergy considerations:
High-risk infants should still be introduced to allergenic foods (peanuts, cooked egg, dairy, wheat) within the first year; supervision may be required, and guidelines exist on how to approach at-risk infants.
Avoid honey before 12 months (botulism risk); avoid unpasteurized milk; avoid juice; limit sugars and processed foods to reduce tooth decay risk.
Practical guidance and resources for pharmacists:
Provide evidence-based guidance, support breastfeeding, and respect parental choice while ensuring safe use and timely referrals when necessary.
Useful guidelines and resources: NHMRC Infant Feeding Guidelines, ABA, ASCI (Australian Society of Clinical Immunology and Allergy) guidelines for allergen introduction.
Counseling points for common questions:
How to choose infant formula: consider stage, type, iron fortification, and family preferences; avoid claims without robust evidence.
How to handle transitioning to solids: readiness signs, iron-rich foods, and safe feeding practices.
How to counsel on bottle-feeding practices to prevent choking or tooth decay and how to introduce a cup around 6 months.
Summary takeaway:
Pharmacists play a key role in breastfeeding support, infant nutrition education, safe formula use, and guidance on complementary feeding, while respecting family choices and following established guidelines.
Parasites in the Community (Clinical and Public Health Focus)
Overview and scope:
The lecture covers common parasites encountered in the community in Sydney, with emphasis on practical recognition, life cycles, symptoms, and when to refer.
Parasites discussed include threadworms (Enterobius vermicularis), head lice (Pediculus humanus capitis), and scabies (Sarcoptes scabiei).
Other parasites mentioned (not exam targets in detail here) include bedbugs, Cryptosporidium, Giardia, malaria, dengue, Zika, encephalitis, pubic lice, trichomoniasis, ticks, toxoplasmosis.
Threadworms (Enterobius vermicularis): the most common helminth in temperate and developed countries
Prevalence:
About 20% of people in the community at any given time.
In institutional settings (close quarters), prevalence can be as high as ~65%.
Life cycle and transmission:
Eggs ingested; eggs hatch in the bowel; adult worms develop in the cecum.
They migrate to the anus; in the evening, they lay eggs around the perianal area.
Eggs become sticky and can contaminate hands and nails; hand-to-mouth transmission is key.
Eggs can contaminate surfaces/food; retro-infection possible; very rare inhalation of dry eggs.
Symptoms and signs:
Perianal itching, especially at nighttime; irritability in children; in some cases reduced appetite or general malaise.
Many people are asymptomatic.
Diagnosis:
Tape test (sticky tape applied to perianal area to collect eggs) is a common diagnostic method; eggs visible on tape.
Treatment and public health measures:
Anthelmintics used: Pyrantel and Mebendazole (often in chocolate-flavoured forms for children).
Dosing considerations:
Dose depends on body weight; two-dose regimens are typically required, spaced ~two weeks apart to cover re-emergence of eggs from the external environment.
Pyrantel is a neuromuscular blocker; Mebendazole inhibits glucose uptake in the worm.
Pyrantel is poorly absorbed from the gut, working locally.
Age considerations and pregnancy:
Use above 6 months generally; caution in pregnancy; some regimens may be contraindicated in pregnancy; improvement requires medical assessment in some cases.
Public health measures:
Emphasize handwashing with soap and water after toileting and after handling nappies; soap and water preferred to sanitizers.
Wash bedding, clothes, and nappies in hot water; clean toilets; treat family members as appropriate to prevent recurrence.
Do not necessarily treat pets for threadworms (generally not a risk for humans).
Head lice (Pediculosis capitis)
Epidemiology and transmission:
Head-to-head contact is the primary mode of transmission.
No seasonal pattern; prevalence varies (roughly ~10% of children at school at any given time).
More common in girls, possibly due to longer hair.
Clinical features and diagnosis:
Itchy scalp; signs of moving lice; nits attach to hair shafts near scalp.
Gold standard diagnostic method: conditioner/comb test to reveal moving lice; visual inspection for nits and lice.
Treatment options:
Physical methods: conditioner-based wet combing to remove lice and nits; not always highly effective alone.
Pharmacologic options: permethrin (neurotoxic to lice), malathion (KP24), benzyl alcohol, dimethicone, pyrethrins with piperonyl butoxide; various formulations and application times.
Important practice points:
Treat only affected individuals (not every family member) unless there is a public health reason to treat all.
Follow the product-specific instructions (application area, duration, and whether to rinse or leave-on).
Re-treat about 7–14 days later to cover the life cycle and any newly hatched lice.
Protect eyes; check product specifics for children; some products require dilution for younger children or avoidance in very young infants.
Wash bedding and personal items; consider school re-entry policy after treatment (no automatic exclusion; check school guidelines).
Practical considerations:
Raw insecticides can cause skin irritation; dimethicone and other non-neurotoxic agents may be preferred for some families.
Avoid using pets as a treatment, as head lice primarily infest humans.
Scabies (Sarcoptes scabiei)
Transmission and epidemiology:
Requires close personal contact; common in households, intimate settings, and residential care facilities; higher prevalence in crowded environments and among children.
Life cycle and clinical presentation:
Infestation can take 2–6 weeks to become symptomatic on first exposure; reinfestation can present more quickly due to immune memory.
Mites burrow into skin; intense itching and red papules in typical web spaces (between fingers, wrists, genitals, intertriginous areas); lesions may be widespread with secondary infection.
Diagnosis and management:
Diagnosis is usually clinical, based on itching pattern and presence of burrows; sometimes there is a need to confirm with skin scrapings (not always necessary in primary care).
Treatment options:
Permethrin (Lyclear/5% cream): commonly used; recommended to apply to the entire body from the neck down; leave on for 8–14 hours, then wash off.
Benzyl benzoate (20–25%): applied and left for 24 hours; can be more irritating; patch testing recommended for sensitive individuals.
Dosing and practicalities: treatment may need to be repeated in 7 days to ensure eradication due to life cycle; ensure full body coverage including interdigital spaces; avoid eyes and mucous membranes.
Public health and household considerations:
Treat all household or close contacts in many settings to prevent reinfestation; wash bedding and clothing in hot water; treat skin after initial treatment.
Pregnant or breastfeeding women require consideration; some regimens may be appropriate, but consult guidelines; patch-testing may be prudent for benzyl benzoate in sensitive individuals.
Special populations and precautions:
Immunocompromised individuals may have atypical presentations and may require specialist input.
Professional practice points across the parasite lectures:
Recognize common infections in primary care; know when to refer (e.g., severe infections, immunocompromised patients, or treatment failures).
Emphasize non-pharmacologic measures (hygiene, environmental cleaning, proper application of topical treatments).
Communicate clearly with families about the life cycle, the rationale for repeat dosing, and the importance of treating all affected individuals when appropriate.
Safe handling and public health messaging: avoid unnecessary antibiotic use, emphasize prevention, and provide practical, implementable advice to families.
Connections to foundational principles and real-world relevance
The three sections (OTC medicines, infant nutrition, parasites) all revolve around safe medication use, patient-centered counselling, and public health considerations.
Core cross-cutting themes:
Patient safety and appropriate use: always ask, assess, advise, then refer when needed.
Evidence-based practice: rely on SUSMP schedules, NHMRC guidelines, WHO/UNICEF recommendations where applicable, and APF/APIs for protocol-driven decisions.
Ethical and social dimensions: respect patient autonomy in infant feeding decisions; recognize industry influence on infant formula marketing; promote breastfeeding support while acknowledging that formula is life-saving when needed.
Interprofessional collaboration: refer to lactation consultants, early childhood nurses, GPs, or specialists when appropriate; use established protocols (APF, NHMRC guidelines).
Notes on LaTeX expressions and numerical references used in this summary
PHARMACY SCHEDULING details (illustrative formatting):
Paracetamol (500 mg or less, S2) with pack size not exceeding 50 tablets:
Combined paracetamol and ibuprofen products (30 dosage units or less) may affect scheduling; otherwise, the paracetamol-only product remains S2.
Nystatin: topical skin use -> Schedule II; vaginal preparations -> Schedule III; other topical uses -> Schedule II unless specified; internal topical uses -> Schedule IV.
Vitamin D supplementation for exclusively breastfed infants:
Formula stages and changes in guidelines (WHO 2023 vs NHMRC):
Stage 1: birth to 6 months; Stage 2: 6–12 months; Stage 3/4: not essential; transition to cow’s milk after 12 months remains standard in NHMRC guidance for Australia, with evolving WHO guidance to begin animal milks at 6 months in some settings.
Key numerical references (summary):
4–6 months exclusive breastfeeding (WHO/UNICEF target) and continued breastfeeding with solids until ~2 years.
6 months exclusive breastfeeding (NHMRC-specific target) and continued breastfeeding with solids to 12 months.
20% community prevalence of threadworms at any time; up to ~65% in institutional settings.
10% head lice prevalence at school-aged children; variable by school.
6 weeks to establish full milk supply after birth; ~2–6 weeks post-lactation onset is a critical window for establishing supply.
If you’d like, I can restructure these notes into a simpler three-part outline (OTC/S2-S3, Infant Nutrition and Breastfeeding, Parasites) with a dedicated page or slide-friendly format for quick revision. I can also extract a concise checklist for use in day-to-day pharmacy practice (e.g., WAM steps, SUSMP lookup steps, and the morning-after pill protocol) if that would help with your study plan.