Executive Summary

In 1988, the Food and Nutrition Board's Committee on Nutritional Status During Pregnancy and Lactation was constituted to reexamine important questions relating to nutritional care of pregnant and lactating women and their infants. The committee's work has been supported by the Maternal and Child Health Program (Title V, Social Security Act) of the U.S. Department of Health and Human Services. Together with three of its subcommittees, this broadly based committee issued Nutrition During Pregnancy and Nutrition During Lactation, thoroughly researched reports that present the committee's findings and recommendations in these areas. Subsequently, the committee's joint effort with a fourth subcommittee resulted in the publication Nutrition During Pregnancy and Lactation: An Implementation Guide, which is intended to help health care providers apply the recommendations made in the first two reports.

Because it was recognized that the actual application of recommendations and guidelines in specific care settings would require administrative support and possibly some organizational changes, the committee was also charged with revising the 1981 publication Nutrition Services in Perinatal Care. That first edition covered prenatal, postpartum, and neonatal nutrition services—including the personnel, competency levels, and support necessary to provide the services in a regionalized perinatal care system. This second edition updates the coverage of nutrition and nutrition services in a manner that would be applicable regardless of the system of care. Moreover, it expands the coverage of nutrition services for two important periods that received little attention previously: preconception and



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Nutrition Services in Perinatal Care Executive Summary In 1988, the Food and Nutrition Board's Committee on Nutritional Status During Pregnancy and Lactation was constituted to reexamine important questions relating to nutritional care of pregnant and lactating women and their infants. The committee's work has been supported by the Maternal and Child Health Program (Title V, Social Security Act) of the U.S. Department of Health and Human Services. Together with three of its subcommittees, this broadly based committee issued Nutrition During Pregnancy and Nutrition During Lactation, thoroughly researched reports that present the committee's findings and recommendations in these areas. Subsequently, the committee's joint effort with a fourth subcommittee resulted in the publication Nutrition During Pregnancy and Lactation: An Implementation Guide, which is intended to help health care providers apply the recommendations made in the first two reports. Because it was recognized that the actual application of recommendations and guidelines in specific care settings would require administrative support and possibly some organizational changes, the committee was also charged with revising the 1981 publication Nutrition Services in Perinatal Care. That first edition covered prenatal, postpartum, and neonatal nutrition services—including the personnel, competency levels, and support necessary to provide the services in a regionalized perinatal care system. This second edition updates the coverage of nutrition and nutrition services in a manner that would be applicable regardless of the system of care. Moreover, it expands the coverage of nutrition services for two important periods that received little attention previously: preconception and

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Nutrition Services in Perinatal Care lactation. This edition also focuses increased attention on the rationale for the recommended nutrition services. PREVIOUS RECOMMENDATIONS AND UNDERLYING ASSUMPTIONS Relevant content and recommendations from Nutrition During Pregnancy, Nutrition During Lactation, and Recommended Dietary Allowances (another recent Food and Nutrition Board publication) are incorporated in this book. In addition, the committee agreed that the following assumptions would guide its work: A patient-centered, individualized approach promotes high-quality nutritional care. The development of nutritional care plans is a key element of nutrition services. Supportive family members or friends should be involved in the development and implementation of the nutritional care plan. A team effort enhances nutritional care, especially if health, economic, or social problems are involved. Efforts should be made to promote continuity of nutritional care. OVERVIEW The second edition of Nutrition Services in Perinatal Care describes two basic types of nutrition services: (1) basic nutrition services , which should be available to all women and infants in the course of usual health care, and (2) special nutrition services, which should be provided to women with health problems that complicate their nutritional care, to preterm infants, and to full-term infants with serious health problems. Basic nutrition services that address the mother's nutritional needs include early identification of women at risk for nutrition-related health problems, health maintenance activities for promoting adequate nutrition, and, as needed, basic nutrition interventions including counseling, food or vitamin-mineral supplementation, support, and referrals. Special nutrition services, which address complex nutritional problems related to medical or surgical conditions, usually require that a nutrition specialist, ordinarily an experienced registered dietitian, serve on the health care team. Examples of such health problems include insulin dependent diabetes mellitus, severe gastrointestinal disorders, and phenylketonuria; other examples are provided in the text.

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Nutrition Services in Perinatal Care CONTENTS OF THE REPORT The seven chapters are organized as follows: introductory material; a brief review of the nutritional concerns of women in the preconceptional, prenatal, and postpartum periods—including the reasons selected health problems call for special nutrition services; elements of basic and special nutrition services for women during the three periods mentioned above; nutrition services for newborn infants, with a new focus on supporting breastfeeding; elements of special nutrition services for preterm and sick newborns, prefaced by brief descriptions of the challenges such infants present and the feeding methods available; the chapter also includes a summary of the importance and complexity of monitoring; an entirely new chapter on strategies for promoting the continuity of nutritional care; and further comments and the committee's recommendations, the highlights of which are given below. RECOMMENDATIONS This report presents eight key recommendations: Basic, patient-centered, individualized nutritional care should be integrated into the primary care of every woman and infant—beginning prior to conception and extending throughout the period of breastfeeding. All primary care providers should have the knowledge and skills necessary to screen for nutritional problems, assess nutritional status, provide basic nutritional guidance, and implement basic nutritional care. Nutritional care should be documented in the permanent medical record. When health problems that benefit from special nutritional care are identified, there should be consultation with and often referral to an experienced registered dietitian or other appropriate specialists. Attention should be directed toward aspects of nutritional care that have been seriously neglected in the past: providing care prior to conception and in support of breastfeeding, and ensuring the continuity of nutritional care despite changes in providers.

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Nutrition Services in Perinatal Care Action should be taken to make appropriate policy and structural changes for the promotion and support of breastfeeding. Where not already in place, mechanisms should be established to pay for basic and special nutrition services in both the public and the private sectors. Cost-effective strategies for implementing the nutritional care recommended in this report should be developed and tested.