Nutrition During Pregnancy and Lactation


Subcommittee for a Clinical Application Guide

Committee on Nutritional Status During Pregnancy and Lactation

Food and Nutrition Board

Institute of Medicine

National Academy of Sciences

National Academy Press
Washington, D.C.

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Nutrition During Pregnancy and Lactation AN IMPLEMENTATION GUIDE Subcommittee for a Clinical Application Guide Committee on Nutritional Status During Pregnancy and Lactation Food and Nutrition Board Institute of Medicine National Academy of Sciences National Academy Press Washington, D.C. 1992

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National Academy Press 2101 Constitution Avenue, NW Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This study was supported by project no. MCJ 117018 from the Maternal and Child Health Program (Title V, Social Security Act), Health Resources and Services Administration, U.S. Department of Health and Human Services. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Subcommittee for a Clinical Application Guide. Nutrition during pregnancy and lactation : an implementation guide / Subcommittee for a Clinical Application Guide, Committee on Nutritional Status during Pregnancy and Lactation, Food and Nutrition Board, Institute of Medicine, National Academy of Sciences. p. cm. Includes bibliographical references and index. ISBN 0-309-04738-2 1. Pregnancy—Nutritional aspects. 2. Lactation—Nutritional aspects. 3. Nutrition counseling. I. Title. [DNLM: 1. Lactation. 2. Nutrition—in pregnancy. 3. Prenatal Care—standards. WQ 175 I595n] RG559.156 1992 618.2'4—dc20 DNLM/DLC for Library of Congress 92-19175 CIP Copyright 1992 by the National Academy of Sciences The body mass index and weight gain charts and materials designated for the patient may be reproduced for patient use and for other educational purposes. No other part of this book may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise copied for public or private use, without written permission from the publisher, except for the purposes of official use by the U.S. Government. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin. First Printing, July 1992 Second Printing, September 1993 Third Printing, November 1993 Fourth Printing, May 1997

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SUBCOMMITTEE FOR A CLINICAL APPLICATION GUIDE CHRISTINE OLSON (Co-Chair), Division of Nutritional Sciences, Cornell University, Ithaca, New York JUDY WILSON (Co-Chair), District of Columbia WIC State Agency, Commission of Public Health, Department of Human Services, Washington, D.C. BARBARA ABRAMS, Program in Public Health Nutrition, School of Public Health, University of California, Berkeley, California IRENE ALTON, Health Start Inc., St. Paul, Minnesota RONALD A. CHEZ, Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida PETER DALLMAN, Department of Pediatrics, University of California, San Francisco, California PATRICIA DOLAN MULLEN, Center for Health Promotion Research and Development, School of Public Health, Houston, Texas LISA L. PAINE, School of Public Health, Boston University, Boston, Massachusetts MINDY ANN SMITH, Department of Family Practice, University of Michigan, Ann Arbor, Michigan RICHARD A. WINDSOR (until February 15, 1991), School of Public Health, University of Alabama, Birmingham, Alabama Staff CAROL WEST SUITOR, Study Director YVONNE L. BRONNER, Research Associate (until June 30, 1991) SHEILA MYLET, Research Associate GERALDINE KENNEDO, Administrative Assistant

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COMMITTEE ON NUTRITIONAL STATUS DURING PREGNANCY AND LACTATION ROY M. PITKIN (Chair), *Department of Obstetrics and Gynecology, School of Medicine, University of California, Los Angeles, California BARBARA ABRAMS, Program in Public Health Nutrition, School of Public Health, University of California, Berkeley, California LINDSAY H. ALLEN, Department of Nutritional Sciences, University of Connecticut, Storrs, Connecticut MARGIT HAMOSH, Division of Developmental Biology and Nutrition, Georgetown University Medical Center, Washington, D.C. JANET C. KING, Department of Nutritional Sciences, University of California, Berkeley, California CHARLES MAHAN, Department of Health and Rehabilitative Services, State Health Office, Tallahassee, Florida JAMES MARTIN, Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi CHRISTINE OLSON, Division of Nutritional Sciences, Cornell University, Ithaca, New York LINDA A. RANDOLPH, Department of Community Medicine, Mount Sinai School of Medicine, on assignment to Carnegie Corporation of New York, New York, New York KATHLEEN M. RASMUSSEN, Division of Nutritional Sciences, Cornell University, Ithaca, New York JOHN W. SPARKS, Department of Pediatrics, University of Texas, Houston, Texas *   Member, Institute of Medicine

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Preface Nutritional care is viewed as an essential component of prenatal care, but many women receive little or no guidance regarding nutrition as part of the health care they receive during the preconception, prenatal, or postpartum periods. This guide is motivated by the need for all health care providers to put into action that which is agreed to be desirable—the inclusion of nutritional care in comprehensive health care. This guide provides practical, easy-to-use information and tools for many kinds of care providers to use with patients of different economic, social, and cultural backgrounds. Some nutrition problems require the expertise and skills of a registered dietitian or a nutritionist; these are indicated in appropriate places in the guide along with questions other care providers should ask to help them to identify nutritional problems. We encourage all members of the health care team, especially nurses and physicians, to become more involved in providing nutritional care from preconception through the postpartum period. The IOM reports Nutrition During Pregnancy1 and Nutrition During Lactation2 provide the basis for most of the content areas and principal recommendations covered in this guide. As in those IOM reports, the focus is primarily on healthy women. Breastfeeding promotion and support activities in this guide merit special attention. Such activities have been strongly supported by the Surgeon General's workshops on breastfeeding and human lactation, the Surgeon General's Report on Nutrition and Health,3 and Healthy

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People 2000.4 The special needs of the breastfeeding mother-infant pair make it appropriate to include information on breastfeeding and to ensure that practitioners provide nutritional care for lactating women. Only basic information is included here, since many authoritative books and other resources are available. Well-targeted, basic nutritional care can make an important contribution to the health of women and their families. Yet the use of this guide is only one step in promoting optimal nutrition during pregnancy and lactation. Action is also needed at the policy level and in related areas of health care. To benefit from the suggestions contained in this guide, women must have access to health care. In addition, steps must be taken to make it more economically feasible to include dietitians and nutritionists in the delivery of care to pregnant and lactating women. Young people must arrive at the reproductive period in their lives literate in the basics of nutrition and health and valuing their health as an important personal resource. The subcommittee urges action in these areas to enhance and make more effective the recommendations contained in the guide. Christine Olson Co-Chair, Subcommittee for a Clinical Application Guide Judy Wilson Co-Chair, Subcommittee for a Clinical Application Guide Roy M. Pitkin Chair, Committee on Nutritional Status During Pregnancy and Lactation Dedication This guidebook is dedicated to Joel C. Kleinman, 1946-1991. We warmly remember his contributions to the IOM report Nutrition During Pregnancy and his commitment to improving maternal and child health in the United States.

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Acknowledgments This project was made possible by a grant from the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services. During the development of this guidebook, many people made important contributions by providing the subcommittee with resource materials or special written reports, sharing their views during workshops, or otherwise serving as resource persons. In addition, more than 40 practitioners and academicians from across the nation reviewed a draft and provided the basis for extensive revisions prior to formal review. The subcommittee thanks Louise Acheson, Case Western Reserve, Cleveland, Ohio; Joanna Asarian, WIC Program, Los Angeles, Calif.; Karen Bertram, Perinatal Unit, Sacramento, Calif.; Dan Bier, Wisconsin Association for Perinatal Care, Madison, Wisc.; Judith E. Brown, University of Minnesota, Minneapolis, Minn.; Doris Clements, Virginia Department of Health, Richmond, Va.; Annette Dickinson, Council for Responsible Nutrition, Washington, D.C.; Diane Dimperio, North Central Florida Maternal and Infant Care Project, Gainesville, Fla.; Ofelia Dirige, San Diego State University, San Diego, Calif.; Kittie Frantz, Santa Monica, Calif.; Phillip J. Goldstein, Sinai Hospital of Baltimore, Baltimore, Md.; Ann Gulbransen, Cleveland, Ohio; Terry F. Hatch, Carle Foundation Hospital, Urbana, Ill.; Barbara Heiser, Ellicott City, Md.; Eric Henley, Public Health Service Indian Hospital, Albuquerque, N.Mex.; Carol A. Hickey, University of Alabama, Birmingham, Ala.; Patricia Higgins, Albuquerque, N.Mex.; Vergie Hughes, Georgetown University Hospital, Washington, D.C.; Mary Ann Hylander, Takoma Park, Md.; Mildred Kaufman, Jacksonville, Fla.; John H. Kennell, Rainbow Baby Children's Hospital, Cleveland, Ohio; Karen Knoll, Minneapolis Department of Health, Minneapolis, Minn.; Mary Koenen, Holy Family Birth Center, Weslaco, Tex.; Ruth Lawrence, University of Rochester, Rochester, N.Y.; Minda Lazarov, Tennessee Department of Health, Nashville, Tenn.; Janet Lebeuf, North Carolina WIC Program, Raleigh, N.C.; Diana Lee, Department of Health Services, Emeryville, Calif.; R. Dee Legako, Edmond, Okla.; Barbara Luke, Johns Hopkins Hospital, Baltimore, Md.; Alice Lockett, District of Columbia General Hospital, Washington, D.C.; Stanley Malnar, Spokane, Wash.; Irwin R. Merkatz, Albert Einstein College of Medicine, Bronx, N.Y.; Sister Angela Murdaugh, Holy Family Birth Center, Weslaco, Tex.; Audrey Naylor, Wellstart, San Diego, Calif.; Vicky Newman, Wellstart, San Diego, Calif.; H. James Nickerson,

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Marhfield Clinic, Marshfield, Wisc.; Donna O'Hare, Maternal and Infant Care-Family Planning Program, New York, N.Y.; Henry Osborne, WRC-TV, Washington, D.C.; Ruth Palombo, Department of Public Health, Boston, Mass.; Suzanne Pelican, Indian Health Service, Santa Fe, N.Mex.; Duc Quan, WIC Program, Anaheim Hill, Calif.; David Rath, Arkansas Department of Health, Little Rock, Ark.; Roger B. Rodrique, Wilmington, Del.; Eunice Romero-Gwynn, University of California, Davis, Calif.; Marjorie Scharf, Maternal and Infant Health, Philadelphia, Pa.; Christine A. Shannon, New Hampshire Division of Public Health Services, Concord, N.H.; Carolyn Sharbaugh, National Center for Education in Maternal and Child Health, Washington, D.C.; Mary Story, University of Minnesota Health Center, Minneapolis, Minn.; Peter C. Van Dyck, Utah Department of Health, Salt Lake City, Utah; Janet L. Washington, Brigham and Women's Hospital, Boston, Mass.; Doris Weyl-Feyling, University of California Medical Hospital, San Francisco, Calif.; Catherine Wong, San Francisco Department of Public Health, San Francisco, Calif.; Bonnie Worthington-Roberts, University of Washington, Seattle, Wash.; Michal Young, D.C. General Hospital, Washington, D.C.; and others who worked behind the scenes. Feasibility testing of the guidebook occurred at 10 sites across the United States and led to further revisions. The subcommittee gives special thanks to the liaisons and participants at those sites, some of whom are listed here: Kenneth Berneis, Otsego, Mich.; Patty Brown, Mary Imogene Bassett Hospital, Cooperstown, N.Y.; Harriet Charney, Kaiser Permanente Medical Center, Hayward, Calif; Alfredo Czerwinski and Mary Lind, Kelsey Seybold Clinic, P.A., Houston, Tex.; Kim Deltano, St. Margaret's Hospital for Women, Boston, Mass.; Pat Franz, Model Cities Health Center, St. Paul, Minn.; Cecelia M. Jevitt, Tampa General Hospital, Tampa, Fla.; John Niles, Washington, D.C.; Susan Velasquez, Public Health Service Indian Hospital, Fort Defiance, Ariz.;Joe Weick, Oregon Health Sciences University, Portland, Or. The subcommittee also expresses its appreciation to the staff at the Institute of Medicine who helped to guide this project to completion. In particular, we thank Carol W. Suitor, Study Director, for her outstanding support. Thanks also go to Catherine E. Woteki, Director of the Food and Nutrition Board; Gerri Kennedo, Administrative Assistant; Yvonne Bronner and Sheila Mylet, Research Associates; and Enriqueta C. Bond, Executive Officer of the IOM—and to consultants Betsy Turvene and Michael Hayes. In addition, staff at National Academy Press—especially Linda Humphrey and Sally Stanfield—were exceptionally helpful in the development and production of user-friendly versions of the guidebook.

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Contents PART I New Tools and Clinical Care Outlines   1 1   Introduction   3 2   The Preconception/Interconception Visit   19 3   The First Prenatal Visit   33 4   Follow-up Visits   51 5   Postpartum Visits   69 PART II Supplementary Information   89 6   General Strategies for Providing Effective Nutritional Care   91 7   Dietary Assessment and Guidance   97 8   Assessing Weight Change   105 9   Nutrient Supplementation   109 10   Nutrition Referrals and Resources   113 References   125 Index   127

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