7
Closing Remarks and Recommendations

Nutrition clearly makes a difference to the health of women, to outcomes of pregnancy and lactation, and to the health, growth, and development of infants. Of the many contenders for health care resources, nutrition services warrant substantial attention and support. This chapter summarizes underlying themes of the report and presents the committee's major recommendations.

It is customary to consider nutrition services in relation to a specific type of patient (e.g., a pregnant or a breastfeeding woman) as has been done in this report. However, the committee preferred to consider the delivery of nutrition services in relation to growing families rather than specific types of patients. It agreed that such delivery could be improved by five general measures:

  • explicit recognition by all health team members of the essential role of nutrition in promoting health and growth;

  • a team effort to provide nutritional care that is individualized and patient centered;

  • the active involvement of families or other supportive persons in the formulation and implementation of a nutritional care plan;

  • the implementation of concrete steps to achieve continuity of nutritional care; and

  • nutrition education and training for health care providers.



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Nutrition Services in Perinatal Care 7 Closing Remarks and Recommendations Nutrition clearly makes a difference to the health of women, to outcomes of pregnancy and lactation, and to the health, growth, and development of infants. Of the many contenders for health care resources, nutrition services warrant substantial attention and support. This chapter summarizes underlying themes of the report and presents the committee's major recommendations. It is customary to consider nutrition services in relation to a specific type of patient (e.g., a pregnant or a breastfeeding woman) as has been done in this report. However, the committee preferred to consider the delivery of nutrition services in relation to growing families rather than specific types of patients. It agreed that such delivery could be improved by five general measures: explicit recognition by all health team members of the essential role of nutrition in promoting health and growth; a team effort to provide nutritional care that is individualized and patient centered; the active involvement of families or other supportive persons in the formulation and implementation of a nutritional care plan; the implementation of concrete steps to achieve continuity of nutritional care; and nutrition education and training for health care providers.

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Nutrition Services in Perinatal Care Each of these measures requires adequate allocation of time and financial resources to allow clinicians to interact with, teach, and learn from other health care providers, the patient, and family members. The following sections provide further clarification of most of the measures mentioned above. MEASURES FOR IMPROVING NUTRITIONAL CARE Patient-Centered, Individualized Care Patient-centered nutritional care requires an individualized approach. This means that a nutritional assessment should precede decisions concerning nutritional care. The term nutritional assessment covers a wide range of activities, not all of which are appropriate for all individuals. However, basic nutritional assessment for all patients encompasses the measurement of height or length and weight, the determination of hemoglobin or hematocrit values, and the assessment of dietary practices. Abnormal findings may indicate the need for more thorough assessment and intensive nutritional care. Appropriate patient-centered care often requires that the health care team seek assistance for the patient from outside sources, generally through referral. This assistance may involve, for example, transport of neonates with complex nutrition and feeding requirements to a neonatal intensive care unit; referral to a center for the treatment of inborn errors of metabolism or diabetes mellitus; referral to the Special Supplemental Food Program for Women, Infants, and Children (WIC) for food supplementation and nutrition education; or referral to a program for the treatment of eating disorders. Structured procedures are needed to facilitate implementation of the referral, to track whether appropriate follow-up has occurred, and to indicate how care is to be altered, if at all, as a result. If transportation or other logistical difficulties make it impossible to arrange for a referral or to incorporate the required specialist into the health care team, the health care provider is urged to consult with a dietitian who specializes in either maternal or neonatal nutrition and with other specialists as needed.

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Nutrition Services in Perinatal Care Family Involvement in Care Support from family or friends may have a strong impact on how well the woman or her infant, or both, are nourished. Improving maternal weight gain, addressing breastfeeding problems, or initiating an alternative feeding method (such as tube feeding) often calls for the involvement of supportive persons in developing and implementing the care plan. For breastfeeding women, influential friends may need to be involved, as well as the woman's partner. To lay the foundation for appropriate home care of premature or sick infants, those who will be the principal caregivers at home should be involved in nurturing and feeding the infant in the hospital. They also need guidance to form realistic expectations for the infant's development and to understand how development relates to the progression of feedings. Team Care For healthy women or infants, the minimal team comprises the patient and her health care provider (physician or midwife). The efforts of nurses, dietitians, social workers, and health educators increase the potential to address common problems that interfere with normal nutrition; they can also increase the patient's understanding of healthful diets and how to achieve them. If a dietitian is not a member of the practice or of the health team, the committee recommends that an active, formalized relationship be established with a dietitian for periodic in-service education, consultation about patient care, and information about useful nutrition-related resources. A coordinated, multidisciplinary health care team is essential to deal with complex nutrition problems. Depending on the nature of the problem, such a team would ordinarily include the physician, nurses, a dietitian, and an assortment of other providers such as a pharmacist, social worker, breastfeeding specialist, and physical therapist. For families that have difficulty dealing with the medical system because of language or cultural barriers, learning disorders, or other reasons, a trained peer counselor may help serve as a bridge between them and the rest of the health care team (see Nutrition During Pregnancy and Lactation: An Implementation Guide1 ).

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Nutrition Services in Perinatal Care Nutritional Care Plans Using the nutritional assessment as a base, a nutritional care plan should be developed for all pregnant and lactating women and for infants. For many, the care plan will simply call for routine monitoring and one or two specific objectives for improving or maintaining nutritional status. However, many situations and health problems call for more detailed care plans. An essential method for communicating the care plan is thorough documentation in the permanent medical record. The specification of follow-up care is a standard component of care plans but one that needs to be emphasized. Education and Training of Practitioners For basic nutritional care before, during, and after pregnancy, the publication Nutrition During Pregnancy and Lactation: An Implementation Guide,1 provides sound guidance and sources of supplementary information for practicing physicians, midwives, nurses, dietitians, and other care providers. The use of that guidebook can be enhanced by short training sessions. For the more complex nutritional care of pregnant and lactating women with health problems and of infants with special needs, providers should have specialized training or closely supervised experience. Specialized training requires both didactic and clinical multidisciplinary learning experiences over weeks or months. Moreover, because of rapid developments in maternal and neonatal nutrition, members of the health care team need access to periodic updates through conferences or short courses. RECOMMENDATIONS This report contains 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. The components of such care are defined in this document and described in greater detail in Nutrition During Pregnancy and Lactation: An Implementation Guide.

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Nutrition Services in Perinatal Care 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. This knowledge and the development of these skills should be part of the education of primary care providers. Several reports have indicated that nutrition education in medical schools and clinical residencies is often inadequate.2–6 Medical schools, accreditation bodies, and professional organizations should address these deficiencies. The committee recommends that practitioners who need to develop these skills participate in training sessions based on the content of Nutrition During Pregnancy and Lactation: An Implementation Guide. Nutritional care should be documented in the permanent medical record. Documentation may be simplified through the use of forms or computerized systems. 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. Ongoing communication and cooperation between the primary care provider and special care provider(s) are essential to maintain quality care. Attention should be directed toward aspects of care that have been seriously neglected: nutritional care prior to conception, care in support of breastfeeding, and ensuring the continuity of nutritional care despite changes in providers. To achieve the latter, the committee urges continuing efforts to coordinate Maternal and Child Health programs with WIC programs, to implement the one-stop shopping concept, and to adopt the use of patient-carried health diaries with a strong nutritional component. Moreover, it urges experts in maternal and infant nutrition to become involved in the development of the computer-based patient record as described in a recent Institute of Medicine report. 7 Action should be taken to make appropriate policy and structural changes for the promotion and support of breastfeeding. Employers, for example, could be encouraged to eliminate barriers to breastfeeding in the workplace. This might involve allowing sufficient time for the mother to feed her infant or pump her breasts and the provision of a private area for such activities; it might also involve provision of a pump and refrigeration or the establishment of a nearby infant care center. At many sites, a major barrier to the implementation of the recommendations in this document is the lack of financial coverage for the time or personnel involved in providing nutrition services. Where not already in place, mechanisms should be established to pay for basic and special nutrition services in both the public and private sectors. For instance, time for the provision of basic nutrition services should be

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Nutrition Services in Perinatal Care factored into cost-based reimbursement calculations for primary care. Special nutritional care should be a reimbursable item. Cost-effective strategies for implementing the nutritional care recommended in this report should be developed and tested. For example, studies are needed to identify effective methods of incorporating nutrition services in home visits and to clarify the costs and benefits of such visits at various points during and after pregnancy. REFERENCES 1. Institute of Medicine. 1992. Nutrition During Pregnancy and Lactation: An Implementation Guide. Report of the Subcommittee for a Clinical Applications Guide, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board. National Academy Press, Washington, D.C. 2. Boker, J.R., R.L. Weinsier, C.M. Brooks, and A.K. Olson. 1990. Components of effective clinical-nutrition training: a national survey of graduate medical education (residency) programs. Am. J. Clin. Nutr. 52.568–571. 3. Feldman, E.B. 1991. Educating physicians in nutrition—a view of the past, the present, and the future. Am. J. Clin. Nutr. 54:618–622. 4. National Research Council. 1985. Nutrition Education in U.S. Medical Schools. Committee on Nutrition in Medical Education, Food and Nutrition Board. National Academy Press, Washington, D.C. 5. Weinsier, R.L., J.R. Boker, E.B. Feldman, M.S. Read, and C.M. Brooks. 1986. Nutrition knowledge of senior medical students: a collaborative study of southeastern medical schools. Am. J. Clin. Nutr. 43:959–965. 6. Weinsier, R.L., J.R. Boker, C.M. Brooks, R.F. Kushner, A.K. Olson, D.A. Mark, S.T. St. Jeor, V.A. Stallings, M. Winick, D. Heber, and W.J. Visek. 1991. Nutrition training in graduate medical (residency) education: a survey of selected training programs. Am. J. Clin. Nutr. 54:957–962. 7. Institute of Medicine; Dick, R.S., and E.B. Steen, eds. 1991. The Computer-Based Patient Record: An Essential Technology for Health Care. National Academy Press, Washington, D.C.