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Nutritional Concerns of Women in the Preconceptional, Prenatal, and Postpartum Periods

This chapter reviews key aspects of maternal nutrition in three periods—before conception, during pregnancy, and after delivery—and identifies health conditions that call for special nutrition services during those periods. Because breastfeeding increases the need for postpartum nutrition services, breastfeeding women are distinguished from non-breastfeeding women.

PRECONCEPTIONAL NUTRITION

As noted in Caring for Our Future: The Content of Prenatal Care, "the preconception visit may be the single most important health care visit when viewed in the context of its effect on pregnancy" (p. 26).1

Goals of Preconceptional Nutrition Services

Preconception visitsa provide valuable opportunities to reduce women's exposure to risk factors that influence their nutritional status and thus to improve their overall nutritional status before conception. This, in turn,

a  

The term preconception visits may be applied to periodic health visits for women, to family planning visits, or to visits specifically targeted to preparing for conception.



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Nutrition Services in Perinatal Care 2 Nutritional Concerns of Women in the Preconceptional, Prenatal, and Postpartum Periods This chapter reviews key aspects of maternal nutrition in three periods—before conception, during pregnancy, and after delivery—and identifies health conditions that call for special nutrition services during those periods. Because breastfeeding increases the need for postpartum nutrition services, breastfeeding women are distinguished from non-breastfeeding women. PRECONCEPTIONAL NUTRITION As noted in Caring for Our Future: The Content of Prenatal Care, "the preconception visit may be the single most important health care visit when viewed in the context of its effect on pregnancy" (p. 26).1 Goals of Preconceptional Nutrition Services Preconception visitsa provide valuable opportunities to reduce women's exposure to risk factors that influence their nutritional status and thus to improve their overall nutritional status before conception. This, in turn, a   The term preconception visits may be applied to periodic health visits for women, to family planning visits, or to visits specifically targeted to preparing for conception.

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Nutrition Services in Perinatal Care may decrease the likelihood of unfavorable pregnancy outcomes, such as the delivery of a premature or low-birth-weight infant. Several sources agree that nutritional services should be one of several components of preconceptional care.1–4 The publications ACOG Guide to Planning for Pregnancy, Birth, and Beyond5 and Caring for Our Future: The Content of Prenatal Care1 list nutrition-related topics to address at a preconception visit. An increased emphasis on preconceptional care acknowledges that achieving substantial changes in diet and lifestyle often involves making incremental changes over time. It also recognizes that the primary prevention of nutrition-related fetal malformations or spontaneous abortions is possible only if risk reduction activities begin before conception; even an early prenatal visit would ordinarily be too late for effective intervention. Addressing behavioral change before conception can allow a woman to identify constructive actions and to delay conception until she has achieved a healthier physical state—one that will increase her chances for a successful pregnancy outcome. Providing nutritional assessment, education, and interventions to encourage an optimal state of health may also benefit the many women who do not desire pregnancy. For these women, the provision of nutritional care as part of a periodic health assessment can be a mechanism for promoting their health over the short term, with the potential for preventing problems in the event of an unplanned pregnancy and for preventing or retarding the development of chronic diseases later in life.6 The objectives of nutritional care in the preconceptional period are to encourage women to achieve appropriate weight for height and healthful dietary habits. To this end, a periodic health visit for women of childbearing age should include assessment to identify indicators of possible nutrition problems, education relating to healthful dietary practices, and counseling, referral, or other interventions as needed to solve or reduce the adverse effects of such problems. Detailed information on these care activities is given in Nutrition During Pregnancy and Lactation: An Implementation Guide.7 The following section briefly discusses the nutrition-related health conditions that have been most closely linked to unfavorable pregnancy outcomes. There are also other health conditions occurring prior to conception that may increase the risk of nutrition problems during pregnancy, but data on such relationships are sparse. Data are also lacking on the relationship of multiple socioeconomic problems prior to conception and the risk of nutrition-related difficulties during pregnancy.

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Nutrition Services in Perinatal Care Health Conditions Warranting Special Nutrition Services Before Pregnancy Exposure of a woman to either excessive or inadequate amounts of certain nutrients early in the first trimester of pregnancy may lead to spontaneous abortion or congenital malformations. Exposure to high, potentially harmful amounts of a nutrient is possible under several circumstances: if the woman has a metabolic condition (such as diabetes mellitus or phenylketonuria) that causes excessive maternal blood levels of one or more nutrients; if the mother takes high doses of retinol (preformed vitamin A); or if she takes a potentially teratogenic medication such as isotretinoin (a vitamin A analogue). Very low nutrient levels are possible if the mother's diet is chronically inadequate or if she takes certain medications or other substances that alter her metabolism or deplete her nutritional stores. For example, the medicines methotrexate and diphenylhydantoin (Dilantin ®) alter folate metabolism, and alcohol increases the urinary excretion of zinc. For more information on these topics, see, for example, Berkowitz and colleagues,8 Briggs and others,9 the 1990 Institute of Medicine report Nutrition During Pregnancy,10 and Niebyl.11 Preexisting Diabetes Mellitus Women whose pregnancies are complicated by preexisting diabetes mellitus are at increased risk for delivering infants with major congenital malformations.12 These malformations occur in the first weeks after conception, often well before many women enter prenatal care. Many of these anomalies, however, may be prevented by the normalization of maternal blood glucose values throughout the first 12 weeks of gestation.13 For blood glucose values to be normal at conception, it is desirable to provide the nutrition and medical services needed to achieve metabolic control well before conception.14,15 In one recent study that involved intensive education and treatment, the incidence of major congenital anomalies in the group treated before conception was 1.2%, compared with 10.9% in the group treated at 6 weeks of gestation or later.16 Scheffler and colleagues17 reported that early enrollment (before 8 weeks' gestation) in the California Diabetes and Pregnancy Program, which has a strong nutrition component, had a high cost-benefit ratio: for each $1 spent on the program, the estimated short-term savings exceeded $5.

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Nutrition Services in Perinatal Care Phenylketonuria Phenylketonuria (PKU) is an inherited condition involving the inability to metabolize phenylalanine, an essential amino acid. Until recently, treatment to control serum levels of phenylalanine18 had been targeted mainly to infants and children: if treatment with a phenylalanine-restricted diet is initiated early in infancy, it helps prevent abnormal brain development and severe mental retardation while allowing normal growth. This rather complicated diet (which requires the use of expensive, specially formulated low-phenylalanine products) is usually discontinued in adulthood, when elevated serum levels of phenylalanine have been presumed to be no longer neurotoxic. If pregnancy occurs, however, excessive amounts of phenylalanine in the maternal serum are associated with an extremely high incidence of mental retardation, microcephaly, low birth weight, and congenital heart disease among infants who themselves have not inherited PKU. 19–21 There is evidence that the occurrence of these problems can be reduced (although not perhaps eliminated) if the mother maintains a low serum phenylalanine level before conception and throughout pregnancy.21–24 To achieve and maintain the desired phenylalanine level, the mother should be identified before pregnancy25 and helped to modify her intake.26 For this purpose, she will need intensive support and follow-up by an interdisciplinary team, including a dietitian experienced in the treatment of this disorder. If the mother's intellectual abilities are limited (perhaps because of inadequate dietary control of her condition during her early years), simplified strategies for diet modification and skillful teaching will be needed.27 History of Poor Pregnancy Outcome Two adverse outcomes of a previous pregnancy—neural tube defects (such as spina bifida) and fetal alcohol syndrome—should alert the health care provider to the need for attention to preventive measures before pregnancy. Once a woman has delivered an infant with a neural tube defect, her risk of delivering another affected infant (often called a recurrent neural tube defect) is very high—2 to 10%.10. The results of a recent randomized clinical trial in Great Britain28 indicated that high-dose (4-mg/day) folic acid supplements given before conception and throughout the first trimester were protective against recurrent neural tube defects. (The critical

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Nutrition Services in Perinatal Care time for the development of the neural tube is 17 to 30 days after conception.) Subsequently, the Centers for Disease Control (CDC)29 issued specific recommendations for high-dose folic acid supplementation (preconceptionally and throughout the first trimester, under a physician's supervision) to reduce the risk of recurrent neural tube defects. Questions remain concerning the etiology of neural tube defects, the most appropriate dosage, and the appropriate role of nutrition in preventing first occurrences.30,31 Previous delivery of an infant with fetal alcohol syndrome calls for efforts to help the mother eliminate or greatly reduce her consumption of alcoholic beverages, if she has not already done so, and to achieve a healthful diet. (See the later section entitled ''Conditions Involving Unhealthy Behaviors.'') Extremes of Maternal Weight for Height The committee found no studies that examined the effects of losing or gaining weight before pregnancy on outcomes of pregnancy. However, because both high and low pregnancy weight are associated with increased risk of various unfavorable pregnancy outcomes, it is prudent to achieve normal weight for height before conception through healthful diet and exercise. Underweight women are at increased risk of delivering a low-birth-weight infant;10 they may also be at increased risk of pregnancy complications such as antepartum hemorrhage, premature rupture of the membranes, preterm delivery, anemia, and endometritis. 32,33 Obese women are at increased risk for complications (e.g., chronic hypertension, preeclampsia, gestational diabetes mellitus, and cesarean delivery34), and their infants are at increased risk for macrosomia or high birth weight—a condition associated with an increased risk of shoulder dystocia and of maternal and infant morbidity. 10 If gastric banding or stapling has been used to treat severe obesity, it is advisable to delay conception until metabolic function and dietary intake have stabilized and there has been time to replenish nutrient stores.35 Both of these types of surgery initially result in greatly reduced food intake; either type can precipitate potentially serious deficiencies of many essential nutrients.

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Nutrition Services in Perinatal Care Maternal Eating Disorders Anorexia nervosa, bulimia, and bulimia nervosa36,37 are serious eating disorders that affect a small proportion of U.S. women in their childbearing years. Severely restricting food intake may result in general malnutrition (which sometimes is so serious that it prevents ovulation), whereas purging may result in life-threatening fluid and electrolyte imbalances. 38 Women with eating disorders may begin pregnancy in a poor nutritional state; they are at risk of developing imbalances, deficiencies, or weight gain abnormalities during pregnancy if aberrant eating behaviors are not controlled.39 Because treatment for these conditions requires long-term psychotherapy and behavior modification, referral for care should be accomplished before conception if possible. Published information on this problem during pregnancy is largely anecdotal but suggests that increased efforts are needed to identify women with bulimia nervosa.40 Other Chronic Conditions or Diseases Prior to pregnancy, dietary counseling may substantially improve the nutritional status of women with serious chronic gastrointestinal disorders such as Crohn's disease, celiac disease, or liver disorders. Preconceptional nutritional interventions such as weight loss programs for the treatment of hypertension and modified diets to control blood lipids may be useful alternatives to medications that are not considered desirable for the fetus. PRENATAL NUTRITION Nutrition exerts an important influence on pregnancy outcome.10,41 The U.S. surgeon general,41 the publication Healthy People 2000,42 and many expert groups (e.g., the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists,2 the American Nurses Association,43 the Public Health Service Expert Panel on the Content of Prenatal Care,1 the Institute of Medicine,44 and the U.S. Preventive Services Task Force45) have all pointed out the value of interventions to help pregnant women achieve adequate diets. Congress has tangibly recognized the importance of prenatal nutrition by appropriating funds for the Special Supplemental Food Program for Women, Infants, and Children (WIC) continuously since 1974 (see Chapter 1). Moreover, at

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Nutrition Services in Perinatal Care least 18 states have appropriated state funds to extend the reach of the WIC program (B. Jendrysik, Food and Nutrition Service, U.S. Department of Agriculture, personal communication, 1991). Nutritional Demands of Normal Pregnancy During pregnancy, maternal requirements for all nutrients increase; this is reflected in higher Recommended Dietary Allowances (RDAs) 46 for most nutrients during pregnancy (see Table 2-1). For some nutrients, the evidence indicates a direct link between chronic maternal deficiencies and poor outcomes for the mother or the infant. For example, prolonged deficiency of iron, folate, or vitamin B12 (or any combination of these) may lead to anemia in the mother; deficiency of vitamin D may lead to neonatal hypocalcemia and to maternal osteomalacia; and deficiency of vitamin A may lead to restricted fetal growth.10 On the other hand, excessive intake of some nutrients may be harmful to the fetus, especially very early in pregnancy (see the previous section, "Preconceptional Nutrition"). In addition, total food intake (which serves as a proxy for energy intake) influences gestational weight gain. A large body of evidence indicates that gestational weight gain, particularly during the second and third trimesters, is an important determinant of fetal growth. Table 2-2 summarizes recommendations for total gestational weight gain. In a study of nearly 7,000 births, Parker and Abrams47 found that maternal weight gains within these recommended ranges were associated with better outcomes: fewer infants were either small for gestational age or large for gestational age, and fewer woman had cesarean deliveries. Nutrients A well-balanced diet is the appropriate source of nutrients during pregnancy. For the majority of pregnant women, iron is the only nutrient for which requirements cannot reasonably be met by diet alone. The 1990 IOM report Nutrition During Pregnancy10 recommends a daily supplement containing 30 mg of ferrous iron as a part of routine care during the second and third trimesters; the report also recommends that guidance be provided for the safe, effective use of this supplement. Routine determination of the hemoglobin value or hematocrit is advised to identify women who need higher iron intake.

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Nutrition Services in Perinatal Care Table 2-1 Recommended Dietary Allowances for Nonpregnant, Pregnant, and Lactating Womena   Nonpregnantb   Lactatingc   15–24 ≥25   1st 2nd Nutrient and Units yrs yrs Pregnantc 6 mos 6 mos Energy (kcal) 2,200 2,200 2,500 2,700 2,700 Protein (g) 44–46 50 60 65 62 Vitamin A (μg RE) 800 800 800 1,300 1,200 Vitamin D (μg) 10 5 10 10 10 Vitamin E (mg α-TE) 8 8 10 12 11 Vitamin C (mg) 60 60 70 95 90 Thiamin (mg) 1.1 1.1 1.5 1.6 1.6 Riboflavin (mg) 1.3 1.3 1.6 1.8 1.7 Niacin (mg NE) 15 15 17 20 20 Vitamin B6 (Mg) 1.5 1.6 2.2 2.1 2.1 Folacin (μg) 180 180 400 280 260 Vitamin B12 (μg) 2.0 2.0 2.2 2.6 2.6 Calcium (mg) 1,200 800 1,200 1,200 1,200 Phosphorus (mg) 1,200 800 1,200 1,200 1,200 Magnesium (mg) 280 280 305 355 340 Iron (mg) 15 15 30d 15 15 Zinc (mg) 12 12 15 19 16 Iodine (μg) 150 150 175 200 200 Selenium (μg) 55 55 65 75 75 a Adapted from the 10th edition of the National Research Council's Recommended Dietary Allowances.46 b This category includes women in the postpartum period if they are not breastfeeding. c Values apply to women of any age. d This intake cannot be met by the iron content of habitual U.S. diets; the daily use of a 30-mg supplement is recommended during the second and third trimesters of pregnancy. As explained in Nutrition During Pregnancy, evidence is not sufficient to warrant routine supplementation of all pregnant women with other nutrients. However, vitamin-mineral supplementation is recommended in certain situations. Therefore, the routine assessment of dietary practices is recommended for all pregnant women in the United States to determine the need for more intensive dietary counseling, for vitamin or mineral supplements, or both. A simple procedure for such assessment is described in Nutrition During Pregnancy and Lactation: An Implementation Guide.7

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Nutrition Services in Perinatal Care Table 2-2 Recommended Total Weight Gain Ranges for Pregnant Women a,b Prepregnancy Recommended Total Gain Weight-for-Height Category lb kg Low (BMIc <19.8) 28–40 12.5–18 Normal (BMI of 19.8 to 26) 25–35 11.5–16 High (BMI >26.0 to 29.0) 15–25 7.0–11.5 Obese (BMI >29.0) ≥15 ≥7.0 a Adapted from the Institute of Medicine's Nutrition During Pregnancy. 10 b For singleton pregnancies. The range for women carrying twins is 35 to 45 lb (16 to 20 kg). Young adolescents (<2 years after menarche) and African-American women should strive for gains at the upper end of the range. Short women (<62 in, or <157 cm) should strive for gains at the lower end of the range. c BMI = body mass index. The dispensing of supplements, however, is not considered a satisfactory substitute for a well-balanced diet or for taking steps to improve access to food.10 Energy Pregnant women need a sufficient intake of energy to support recommended weight gain. "Women who are thinner before pregnancy tend to have babies that are smaller than those of their heavier counterparts with the same gestational weight gain" (p. 8).10 Thus, women who enter pregnancy with low weight for height may need to devote extra attention to achieving adequate weight gain to reduce their risk of delivering low-birth-weight babies. Screening for factors that may interfere with adequate weight gain is recommended for all pregnant women, as is the monitoring of weight gain over the course of pregnancy. Nutrition in Complicated Pregnancies The combination of pregnancy and a health problem often leads to complex nutritional problems that require the attention of a specialized team. For example, pregnancy makes it more important (and more

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Nutrition Services in Perinatal Care difficult) to control the blood glucose of a woman with diabetes mellitus. On the other hand, some conditions that complicate pregnancy, such as multiple gestation and chronic hypertension, ordinarily require increased attention to basic nutrition services but not complex dietary management. The following section clarifies why certain conditions ordinarily warrant special nutrition services or extended basic services. The list begins with conditions specific to pregnancy. It then covers various systemic problems, conditions related to unhealthy behaviors, and miscellaneous disorders. Although many of the diseases are quite uncommon, the role of special nutrition services in promoting favorable pregnancy outcomes for some of them is clear. The list of conditions is not all-inclusive: for example, extremely rare conditions such as cystinuria and Wilson's disease are omitted. Conditions Specific to Pregnancy Hyperemesis Gravidarum. Severe hyperemesis gravidarum is a serious complication of pregnancy that involves intractable vomiting with dehydration, electrolyte imbalance, ketonuria, weight loss, and possibly neurologic disturbances and liver or renal abnormalities. Death has occurred with severe disease. Conservative therapy includes intravenous hydration, sedation, antiemetic medication, and brief psychotherapy. When these fail to arrest the condition, parenteral nutrition may be life saving.48,49 In addition to the emotional support and services of a psychotherapist, the advice of a dietitian is often helpful in directing therapy; it is invaluable when the woman is fed parenterally. Increased Risk for Preterm Birth. In the United States, approximately 7% of newborn babies are of low birth weight (that is, they weigh less than 2,500 g),42 and in the majority of cases, the cause is preterm delivery.44 At the first prenatal visit, it is advisable to evaluate all women for the possibility of preterm delivery. Many practitioners use a specific risk score based on a careful history and physical examination to evaluate the potential for this problem (e.g., see Meis et al.50 and Papiernik et al.51 ). Although there is debate over the accuracy of certain scoring systems, it is well documented that previous preterm birth and certain physical symptoms (uterine cramps, bloody spotting, and increased vaginal mucus discharge) are strong predictors of preterm birth. There is suggestive evidence that the risk of preterm birth can be reduced by a combination of intensive prenatal visits, uterine activity

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Nutrition Services in Perinatal Care monitoring, and patient education.50 So far, studies have not identified which elements of prenatal care are more powerful in preventing preterm birth. As a part of comprehensive care, women found to be at high risk for preterm birth should be the beneficiaries of intensive evaluation, diet counseling, and, if necessary, food and vitamin-mineral supplementation. Because cigarette smoking, excessive alcohol intake, and illegal substance use all lead to an increased likelihood of preterm birth, the entire health care team needs to assist the woman who uses these substances to quit and to obtain outside help. If preterm labor occurs and is treated with bedrest and tocolytic therapy, the woman may need extra nutritional care to deal with problems (e.g., decreased appetite, increasing constipation, glucose intolerance) associated with one or both of these treatments. Multiple Pregnancy. The presence of more than one fetus in a gestation imparts added risk for preterm labor, preeclampsia, and diabetes mellitus. The mother will benefit from nutritional counseling to help her meet her increased nutritional demands comfortably and within any limits that may be imposed on her physical activity. Vitamin-mineral supplementation is advisable in combination with a well-balanced diet.10 One study52 indicates that nutritional intervention may reduce the occurrence of low birth weight and of very low birth weight among twins. Fetal Growth Restriction. The term fetal growth restriction, formerly called intrauterine growth retardation, refers to infants born at an abnormally low weight for their gestational age. Among the nutrition-related factors associated with fetal growth restriction are the abuse of many kinds of substances,53–57 low weight for height, low weight gain during the second and third trimesters,10 and serious maternal infectious diseases such as acquired immune deficiency syndrome (AIDS). Prenatal participation in WIC (which includes food supplementation and nutrition education) is associated with higher birth weight even among infants born before 37 weeks of gestation.58 Women who are suspected of having a growth-restricted fetus may need expert and intensive nutritional management. Systemic Health Problems Diabetes Mellitus. A primary aim of pregnancy management for the woman with diabetes mellitus is the maintenance of normal blood

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Nutrition Services in Perinatal Care feres with adequate dietary intake. Glucose intolerance may occur, further complicating nutritional management. Other. Cancer, cerebral palsy, and many other conditions may greatly complicate the nutritional care of pregnant women if they interfere with adequate food intake by mouth. POSTPARTUM NUTRITION Basic nutrition services for all women warrant increased attention during the postpartum period, but nutritional requirements and the kinds of nutrition services needed at this time differ, depending on whether or not the woman is breastfeeding. The main nutritional focus may be on efforts to replenish nutrient stores, achieve adequate nutrient intake during lactation, or assist with breastfeeding (see Chapter 4). Regardless of breastfeeding status, many women are concerned about returning to their prepregnancy weight and are likely to need guidance to do so in a way that promotes their health. A study by Caan and colleagues109 indicates that interconceptional dietary intervention may improve the outcome of a subsequent pregnancy. Women with intervals of ≤27 months between pregnancies, who did not breastfeed but who received benefits from WIC during the first 5 to 7 months of the postpartum period, had heavier, longer infants in their second pregnancy than did women who received WIC benefits for 2 months or less post partum. This difference occurred even though both groups of women had received WIC benefits during pregnancy. On average, infants born to the women who were supplemented for 5 to 7 months postpartum weighed 131 g more, were 0.3 cm longer, and had a lower risk of being of low birth weight. Replenishing Nutrient Stores Stores of several nutrients (e.g., calcium, vitamin B6 , folate) may need to be replenished during the postpartum period. Women who do not consume an adequate diet despite counseling, or those who are in high-risk categories because of having carried more than one fetus or because of heavy smoking, alcohol abuse, or abuse of illegal drugs,10 may benefit from continuing to take the low-dose multivitamin-mineral supplement that was prescribed during pregnancy.

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Nutrition Services in Perinatal Care Dietary iron requirements during the postpartum period decrease to nonpregnant levels unless blood loss exceeded the usual amount lost during a vaginal delivery (approximately 500 ml).110 Hemoglobin and hematocrit values ordinarily rise post partum with the contraction of blood volume to nonpregnant levels. In addition, the gradual disintegration of excess red blood cells releases iron that can be used for the synthesis of new hemoglobin. Nutrition Recommendations for Lactating Women Diet and Lactation in General As described in Nutrition During Lactation,111 lactation is a robust process. Milk quantity and quality are maintained reasonably well within a wide range of maternal diets, presumably reflecting subsidy of lactation by maternal stores. The RDAs for most nutrients are increased during lactation (see Table 2-1)—in some cases by more than 50%.46 The extra nutrient intake needed to cover exclusive breastfeeding for 4 to 6 months is substantially greater than that needed to cover the entire pregnancy. It is appropriate to encourage intake of a wide assortment of nutritious foods during lactation to help meet a woman's increased nutrient needs. Specific Nutrients and Energy During lactation, the nutrients that are most likely to be consumed in lower than recommended amounts are calcium, magnesium, zinc, vitamin B6, and folate.111 In general, an additional 500 kcal of energy daily is recommended throughout lactation.46 This recommendation assumes that there will be gradual loss of maternal body fat to supply some of the energy needed during lactation. A higher increment in energy intake is recommended for lactating women who are slender. Higher energy intake is also needed by women who produce unusually large amounts of milk (for example, those who nurse more than one infant or who donate to a milk bank) and by women who are very active physically (such as those who participate in more than 45 minutes of aerobic exercise daily).

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Nutrition Services in Perinatal Care Diet for and Supplementation of the Lactating Woman The increased needs for nutrients of a lactating woman can be provided by a well-balanced diet.111 Nutrition During Pregnancy and Lactation: An Implementation Guide7 outlines appropriate dietary guidance for healthy lactating women. For women enrolled in WIC, the program provides food supplements that help supply the extra nutrients needed during lactation. Among apparently healthy lactating women, situations that may justify nutrient supplementation can be identified by a brief screening process. 111 However, measures to improve dietary intake of nutrients are strongly preferred over supplementation with pharmaceutical preparations, 111 especially since lactation substantially increases the demand for energy, protein, and minerals such as calcium. Multivitamin-mineral supplements do not provide energy or protein, and they provide little calcium. Weight Loss From the standpoint of the patient, return to prepregnancy body weight appears to be one of the most common postpartum nutritional concerns. Women who need or want assistance with weight loss can be helped with information about expected weight changes: many women will gain weight during the first 4 days after delivery, but by the fifth postpartum day, most will have begun to lose weight.112 An above-average rate of weight loss immediately post partum occurs among women who experienced hypertension or preeclampsia during pregnancy—probably because of postpartum diuresis.113 Women ordinarily lose weight through 4 to 6 months post partum;114 however, some women gain weight, even if they are breastfeeding. After a period of rapid weight loss in the first few weeks post partum, the average rate of weight loss by lactating women is 0.5 to 1.0 kg (~1 to 2 lb) per month through the sixth month post partum.111 If weight loss is an appropriate goal, the woman should be encouraged to set a reasonable body weight goal, and she should be assisted in developing a healthful plan for achieving that goal. For overweight breastfeeding women, the maximum suggested rate of weight loss after the first month post partum is about 2 kg (~4.5 lb)/month.111 The total energy intake by these women should not be less than 1,800 kcal/day to allow adequate intakes of protein, vitamins, and minerals. Although this level of energy intake may seem high to some women who are familiar with reducing diets, it takes into account the energy required for

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Nutrition Services in Perinatal Care breastfeeding. Liquid diets and weight loss medications are not recommended. Conditions Warranting Special Nutrition Services Most women have no need for special nutrition services immediately after delivery. Those who have delivered by cesarean section may require temporary diet modifications that consider the effects of the surgery and anesthesia on their gastrointestinal function. Women with chronic disorders that call for modified diets require postpartum modifications to adjust for their changing physiologic status and nutrient needs, especially if they are breastfeeding. For example, breastfeeding women who require insulin are at increased risk for hypoglycemia and thus need adequate monitoring and diet counseling. 115 Special Considerations at the Postpartum Visit The postpartum visit (usually 4 to 6 weeks following delivery) offers an opportunity to address new or continuing nutritional problems or breastfeeding concerns (see Chapter 4 for information about breastfeeding support). Many women experience some emotional lability (especially symptoms of mild depression) during the postpartum period; some families find it difficult to adapt to the newborn; and families with twins or multiple offspring are confronted with special challenges. Consequently, it is advisable for the primary care provider to determine whether any such stresses are present and whether they are adversely affecting the mother's appetite, access to food, and sleeping or eating habits. In addition, it is recommended that care be taken to identify cases of substance abuse or addiction (including cigarette smoking, alcohol consumption, or illicit use of other mood-altering drugs). The health status of women who experienced complications during pregnancy should be reassessed at the postpartum visit. For example, assessment of blood glucose status is appropriate for women who experienced gestational diabetes, assessment of blood pressure and of renal status may be indicated for women who experienced preeclampsia, and monitoring of iron status is desirable for women at increased risk of anemia because of hemorrhage associated with delivery. If any abnormal findings are observed, special nutrition services may be initiated. The postpartum visit also offers an opportunity to promote healthful eating for the entire family and to verify that the infant is receiving well

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Nutrition Services in Perinatal Care baby care. Information can be provided about meal planning, food preparation, and nutritious food choices for children in the household as well as for adults. A diet rich in grains and cereals, fruits and vegetables, and low-fat dairy products and meats is as appropriate for children over 2 years of age as it is for adults. SUMMARY Beginning before conception and extending throughout pregnancy and lactation, primary care providers need to integrate basic nutrition services into their care and to be on the alert for conditions that call for special nutrition services. REFERENCES 1. Department of Health and Human Services. 1989. Caring for Our Future: The Content of Prenatal Care. A Report of the Public Health Service Expert Panel on the Content of Prenatal Care. Public Health Service, Washington, D.C. 2. American Academy of Pediatrics/American College of Obstetricians and Gynecologists. 1992. Guidelines for Perinatal Care, 3rd ed. American Academy of Pediatrics, Elk Grove, Ill. 3. Harrison, E.A. 1990. Preconception and postconception care of women with medical illness. Pp. 89–108 in I.R. Merkatz and J.E. Thompson, eds. New Perspectives on Prenatal Care. Elsevier, New York. 4. Jack, B., and L. Culpepper. 1990. Preconception care. Pp. 69–88 in I.R. Merkatz and J.E. Thompson, eds. New Perspectives on Prenatal Care. Elsevier, New York. 5. American College of Obstetricians and Gynecologists. 1990. ACOG Guide to Planning for Pregnancy, Birth, and Beyond. American College of Obstetricians and Gynecologists, Washington, D.C. 6. National Research Council. 1989. Diet and Health: Implications for Reducing Chronic Disease Risk. Report of the Committee on Diet and Health, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C. 7. 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. 8. Berkowitz, R., D. Coustan, and T. Mochizuki. 1986. Handbook for Prescribing Medications During Pregnancy. Little, Brown, and Co., Boston. 9. Briggs, G.G., R.K. Freeman, and S.J. Yaffe. 1990. Drugs in Pregnancy and Lactation, 3rd ed. Williams and Wilkins, Baltimore. 10. Institute of Medicine. 1990. Nutrition During Pregnancy: Weight Gain and Nutrient Supplements. Report of the Subcommittee on Nutritional Status and Weight Gain During Pregnancy and the Subcommittee on Dietary Intake and Nutrient Supplements

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Nutrition Services in Perinatal Care During Pregnancy, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board. National Academy Press, Washington, D.C. 11. Niebyl, J.R., ed. 1988. Drug Use in Pregnancy, 2nd ed. Lea & Febiger, Philadelphia. 12. Becerra, J.E., M.J. Khoury, J.F. Cordero, and J.D. Erickson. 1990. Diabetes mellitus during pregnancy and the risks for specific birth defects a population-based case-control study. Pediatrics 85:1–9. 13. Langer, O. 1990. Critical issues in diabetes and pregnancy: early identification, metabolic control, and prevention of adverse outcome. Pp. 445–460 in I.R. Merkatz and J.E. Thompson, eds. New Perspectives on Prenatal Care. Elsevier, New York. 14. Centers for Disease Control. 1986. Public health guidelines for enhancing diabetes control through maternal- and child-health programs. Morbid. Mortal. Wkly. Rep. 35:201–213. 15. Hollingsworth, D.R., O.W. Jones, and R. Resnick. 1984. Expanded care in obstetrics for the 1980s: preconception and early postconception counseling. Am. J. Obstet. Gynecol. 149:811–814. 16. Kitzmiller, J.I., L.A. Gavin, G.D. Gin, L. Jovanovic-Peterson, E.K. Main, and W.D. Zigrang. 1991. Preconception care of diabetes. Glycemic control prevents congenital anomalies. J. Am. Med. Assoc. 265:731–736. 17. Scheffler, R.M., L.B. Feuchtbaum, and C.S. Phibbs. 1992. Prevention: the cost-effectiveness of the California. Diabetes and Pregnancy Program. Am. J. Public Health 82:168–175. 18. Schuett, V.E., and E.S. Brown. 1984. Diet policies of PKU clinics in the United States. Am. J. Public Health 74:501–503. 19. Dimperio, D. 1990. Preconceptional nutrition. J. Pediatr. Perinatal Nutr. 2:65–78. 20. Drogari, E., I. Smith, M. Beasley, and J.K. Lloyd. 1987. Timing of strict diet in relation to fetal damage in maternal phenylketonuria. Lancet 2:927–930. 21. Trahms, C.M. 1989. Maternal hyperphenylalaninemia. Pp. 193–199 in B.S. Worthington-Roberts and S.R. Williams, eds. Nutrition in Pregnancy and Lactation, 4th ed. Times Mirror/Mosby, St. Louis. 22. Koch, R., E. Wenz, C. Bauman, E.G. Friedman, C. Azen, K. Fishler, and W. Heiter. 1988. Treatment outcome of maternal phenylketonuria. Acta Paediatr. Jpn. 30:410–416. 23. Lenke, R.R., and H. L. Levy. 1980. Maternal phenylketonuria and hyperphenylalaninemia. An international survey of the outcome of untreated and treated pregnancies. N. Engl. J. Med. 303:1202–1208. 24. Lynch, B.C., D.B. Pitt, T.G. Maddison, J.E. Wraith, and D.M. Danks. 1988. Maternal phenylketonuria: successful outcome in four pregnancies treated prior to conception. Eur. J. Pediatr. 148:72–75. 25. Waisbren, S.E., L.B. Doherty, I.V. Bailey, F.J. Rohr, and H.L. Levy. 1988. The New England Maternal PKU Project: identification of at-risk women. Am. J. Public Health 78:789–792. 26. American Academy of Pediatrics, Committee on Genetics. 1991. Maternal phenylketonuria. Pediatrics 88:1284–1285. 27. Davidson, D.C. 1989. Maternal phenylketonuria. Postgrad. Med. J. 65 (suppl. 2):S10-S20. 28. MRC Vitamin Study Research Group. 1991. Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. Lancet 338:131–137. 29. Centers for Disease Control. 1991. Use of folic acid for prevention of spina bifida and other neural tube defects-1983–1991. Morbid. Mortal. Wkly. Rep. 40:513–516. 30. Lancet. 1991. Folic acid and neural tube defects (editorial). Lancet 338:153–154.

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Nutrition Services in Perinatal Care 31. Willett, W.C. 1992. Folic acid and neural tube defect: can't we come to closure? (commentary). Am. J. Publ. Health 82:666–668. 32. Edwards, L.E., I.R. Alton, M.I. Barrada, and E.Y. Hakanson. 1979. Pregnancy in the underweight woman. Course, outcome, and growth patterns of the infant. Am. J. Obstet. Gynecol. 135:297–302. 33. Schramm, W.F. 1981. Obesity, Leanness and Pregnancy Outcome, Missouri Center for Health Statistics, Jefferson City. 34. Abrams, B., and J. Parker. 1988. Overweight and pregnancy complications. Int. J. Obes. 12:293–303. 35. Richards, D.S., D.K., Miller, and G.N. Goodman. 1987. Pregnancy after gastric bypass for morbid obesity. J. Reprod. Med. 32:172–176. 36. American Psychiatric Association. 1987. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. American Psychiatric Association, Washington, D.C. 37. Garner, D.M., M.P. Olmstead, and J. Polivy. 1983. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int. J. Eating Disorders 2:15–34. 38. Burke, M.E., and J. Vangellow. 1990. Anorexia nervosa and bulimia nervosa: chronic conditions affecting pregnancy. J. NAACOGS Clin. Issu. Perinat. Women's Health Nurs. 1:240–254. 39. Stewart, D.E., J. Raskin, P.E. Garfinkel, O.L. MacDonald, and G.E. Robinson. 1987. Anorexia nervosa, bulimia, and pregnancy. Am. J. Obstet. Gynecol. 157:1194–1198. 40. Willis, D.C., and C.S. Rand. 1988. Pregnancy in bulimic women. Obstet. Gynecol. 71:708–710. 41. Department of Health and Human Services. 1988. The Surgeon General's Report on Nutrition and Health. DHHS (PHS) Publ. No. 88–50211. Public Health Service. U.S. Government Printing Office, Washington, D.C. 42. Department of Health and Human Services. 1990. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Public Health Service, Office of the assistant Secretary for Health, Washington, D.C. 43. American Nurses' Association. 1987. Access to Prenatal Care: Key to Preventing Low Birth weight. American Nurses' Association, Kansas City, Mo. 44. Institute of Medicine. 1985. Preventing Low Birth weight. Report of the Committee to Study the Prevention of Low Birth weight, Division of Health Promotion and Disease Prevention. National Academy Press, Washington, D.C. 45. U.S. Preventive Services Task Force. 1989. Guide to Clinical Preventive Services. Williams & Wilkins, Baltimore, Md. 46. National Research Council. 1989. Recommended Dietary Allowances, 10th ed. Report of the Subcommittee on the Tenth Edition of the RDAs, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C. 47. Parker, J.D., and B. Abrams. 1992. Prenatal weight gain advice: an examination of the recent prenatal weight gain recommendations of the Institute of Medicine. Am. J. Obstet. Gynecol. 79:664–669. 48 Levine, M.G., and D. Esser. 1988. Total parenteral nutrition for the treatment of severe hyperemesis gravidarum: maternal nutritional effects and fetal outcome. Obstet. Gynecol. 72:102–107. 49. Zibell-Frisk, D., K.-L.C. Jen, and J. Rick. 1990. Use of parenteral nutrition to maintain adequate nutritional status in hyperemesis gravidarum. J. Perinatol. 10:390–395. 50. Meis, P.J., J. M. Ernest, M.L. Moore, R. Michielutte, P.C. Sharp, and P.A. Buescher. 1987. Regional program for prevention of premature birth in northwestern North Carolina. Am. J. Obstet. Gynecol. 157:550–556.

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Nutrition Services in Perinatal Care 51. Papiernik, E., J. Bouyer, J. Dreyfus, D. Collin, G. Winisdorffer, S. Guegen, M. Lecomte, and P. Lazar. 1995. Prevention of preterm births: a perinatal study in Haguenau, France. Pediatrics 76:154–158. 52. Dubois, S., C. Dougherty, M.-P. Duquette, J.A. Hanley, and J.M. Moutquin. 1991. Twin pregnancy: the impact of the Higgins Nutrition Intervention Program on maternal and neonatal outcomes. Am. J. Clin. Nutr. 53:1397–1403. 53. Dombrowski, M.P., H.M. Wolfe, R.A. Welch, and M.I. Evans. 1991. Cocaine abuse is associated with abruptio placentae and decreased birth weight, but not shorter labor. Obstet. Gynecol. 77:139–141. 54. Hadeed, A.J., and S.R. Siegel. 1989. Maternal cocaine use during pregnancy: effect on the newborn infant. Pediatrics 85:205–210. 55. Hanson, J.W., A.P. Streissguth, and D.W. Smith. 1978. The effects of moderate alcohol consumption during pregnancy on fetal growth and morphogenesis. J. Pediatr. 92:457–460. 56. Petitti, D.B., and C. Coleman. 1990. Cocaine and the risk of low birth weight. Am. J. Public Health 80:25–28. 57. Zuckerman, B., D.A. Frank, R. Hingson, H. Amaro, S.M. Levenson, H. Kayne, S. Parker, R. Vinci, K. Aboagye, L.E. Fried, H. Cabral, R. Timperi, and H. Bauchner. 1989. Effects of maternal marijuana and cocaine use on fetal growth. N. Engl. J. Med. 320:762–768. 58. Devaney, B., L. Bilheimer, and J. Schore. 1990. The Savings in Medicaid Costs for Newborns and Their Mothers from Prenatal Participation in the WIC Program. 281-075/20915. Food and Nutrition Service, Office of Analysis and Evaluation, Department of Agriculture. U.S. Government Printing Office, Washington, D.C. 59. Blumenthal, S.A., and R.W. Abdul-Karim. 1987. Diagnosis, classification, and metabolic management of diabetes in pregnancy: therapeutic impact of self-monitoring of blood glucose and of newer methods of insulin delivery. Obstet. Gynecol. Surv. 41:593–604. 60. Langer, O., J. Levy, L. Brustman, A. Anyaegbunam, R. Merkatz, and M. Divon. 1989. Glycemic control in gestational diabetes mellitus—how tight is tight enough small for gestational age versus large for gestational age? Am. J. Obstet. Gynecol. 161:646–653. 61. Metzger, B.E., and the Organizing Committee. 1991. Summary and recommendations of the Third International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes 40 (suppl. 2):197–201. 62. Fuhrmann, K., H. Reiher, K. Semmler, and E. Glockner. 1984. The effect of intensified conventional insulin therapy before and during pregnancy on the malformation rate in offspring of diabetic mothers. Exp. Clin. Endocrinol. 83:173–177. 63. Lucas, M.J., K.J. Leveno, M.L. Williams, P. Raskin, and P.J. Whalley. 1989. Early pregnancy glycosylated hemoglobin, severity of diabetes, and fetal malformations. Am. J. Obstet. Gynecol. 161:426–431. 64. Miller, E., J.W. Hare, J.P. Cloherty, P.J. Dunn, R.E. Gleason, J.S. Soeldner, and J.L. Kitzmiller. 1981. Elevated maternal hemoglobin A1c in early pregnancy and major congenital anomalies in infants of diabetic mothers. N. Engl. J. Med. 304:1331–1334. 65. Rowe, B.R., C.J. Rowbotham, and A.H. Barnett. 1987. Pre-conception counseling, birth weight, and congenital abnormalities in established and gestational diabetic pregnancy. Diabetes Res. 6:33–35. 66. Anderson, J.W. 1989. Recent advances in carbohydrate nutrition and metabolism in diabetes mellitus. J. Am. Coll. Nutr. 8:61S–67S. 67. Garner, C. 1986. Nutritional care of the pregnant diabetic woman. J. Arkansas Med. Soc. 83:245–250.

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Nutrition Services in Perinatal Care 68. Knopp, R.H., M.S. Magee, V. Raisys, and T. Benedetti. 1991. Metabolic effects of hypocaloric diets in management of gestational diabetes. Diabetes 40 (suppl. 2):165–171. 69. Jovanovic-Peterson, L., and C.M. Peterson. 1990. Dietary manipulation as a primary treatment strategy for pregnancies complicated by diabetes. J. Am. Coll. Nutr. 9:320–325. 70. Arky, R., J. Wylie-Rosett, and B. El-Beheri. 1982. Examination of current dietary recommendations for individuals with diabetes mellitus. Diabetes Care 5:59–63. 71. Dornhorst, A., J.S.D. Nicholls, F. Probst, C.M. Paterson, K.L. Hollier, R.S. Elkeles, and R.W. Beard. 1991. Calorie restriction for treatment of gestational diabetes. Diabetes 40 (suppl. 2):161–164. 72. Hollingsworth, D.R., and D.M. Ney. 1988. Dietary management of diabetic pregnancy. Pp. 285–311 in A. Reece and D.R. Coustan, eds. Diabetes Mellitus in Pregnancy: Principles and Practice. Churchill Livingstone, New York. 73. Newman, V., and J.T. Fullerton. 1990. Role of nutrition in the prevention of preeclampsia. J. Nurse-Midwifery 35:282–291. 74. Rosso, P. 1990. Nutritional care of gravidas with special problems. Pp. 264–311 in Rosso, P., ed. Nutrition and Metabolism in Pregnancy Mother and Fetus. Oxford University Press, New York. 75. Belizán, J.M., J. Villar, L. Gonzalez, L. Campodonico, and E. Bergel. 1991. Calcium supplementation to prevent hypertensive disorders of pregnancy. N. Engl. J. Med. 325:1399–1405. 76. Marcoux, S., J. Brisson, and J. Fabia. 1991. Calcium intake from dairy products and supplements and the risks of preeclampsia and gestational hypertension. Am. J. Epidemiol. 133:1266–1272. 77. Fröhling, P.T., M. Birnbaum, H. Halle, and K. Lindenau. 1986. Successful pregnancy of a woman with advanced renal failure on nutritional treatment. Nephron 44:195–197. 78. Charny, A., and E.K. Ludman. 1991. Treating malnutrition in AIDS Comparison of dietitians' practices and nutrition care guidelines. J. Am. Diet. Assoc. 91:1273–1274, 1277. 79. Raiten, D.J. 1990. Nutrition and HIV Infection. Life Sciences Research Office, Federation of American Societies for Experimental Biology, Bethesda, Md. 80. Aron, J.M. 1991. Toward rational nutritional support of the human immunodeficiency virus-infected patient. J. Parenter. Enteral Nutr. 15:121–122. 81. Archer, D.L. 1989. Food counseling for persons infected with HIV strategy for defensive living. Public Health Rep. 104:196–198. 82. Filice, G.A., and C. Pomeroy. 1991. Preventing secondary infections among HIV-positive persons. Public Health Rep. 106:503–517. 83. Armstrong, B.G., A.D. McDonald, and M. Sloan. 1992, Cigarette, alcohol, and coffee consumption and spontaneous abortion. Am. J. Public Health 82:85–87. 84. McDonald, A.D., B.G. Armstrong, and M. Sloan. 1992. Cigarette, alcohol, and coffee consumption and prematurity. Am. J. Public Health 82:87–90. 85. Schoenborn, C., and G. Boyd. 1989. Smoking and other tobacco use United States 1987. National Center for Health Statistics: Vital and Health Statistics 10:169. 86. Bruerd, B. 1990. Smokeless tobacco use among Native American school children. Public Health Rep. 105:196–201. 87. Schinke, S.P., R.F. Schilling II, L.D. Gilchrist, M.R. Ashby, and E. Kitajima. 1989. Native youth and smokeless tobacco prevalence rates, gender differences, and descriptive characteristics. Pp. 39–42 in G.M. Boyd and C.A. Darby, eds. Smokeless Tobacco Use in the United States. NCI Monographs. NIH Publ. No. 89–3055. National Cancer Institute, Bethesda, Md.

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Nutrition Services in Perinatal Care 88. Windsor, R.A., M.E. Dalmat, C.T. Orleans, and E.R. Gritz. 1990. The Handbook to Plan, Implement & Evaluate Smoking Cessation Programs for Pregnant Women. March of Dimes Defects Foundation, White Plains, N.Y. 89. Shipp, M., M.S. Croughhan-Minihane, D.B. Petitti, and A.E. Washington. 1992. Estimation of the break-even point for smoking cessation programs in pregnancy. Am. J. Public Health 82:383–390. 90. Garn, S.M., K. Hoff, and K.D. McCabe. 1979. Is there nutritional mediation of the ''smoking effect'' on the fetus? Am. J. Clin. Nutr. 32:1181–1187. 91. Metcoff, J., P. Costiloe, W.M. Crosby, S. Dutta, H.H. Sandstead, D. Milne, C.E. Bodwell, and S.H. Majors. 1985. Effect of food supplementation (WIC) during pregnancy on birth weight. Am. J. Clin. Nutr. 41:933–947. 92. Rush, D., Z. Stein, and M. Susser. 1980. A randomized controlled trial of prenatal nutritional supplementation in New York City. Pediatrics 65:683–697. 93. Rosett, H.L. 1980. A clinical perspective of the fetal alcohol syndrome. Alcoholism 4:119–122. 94. Sokol, R.J., S.S. Martier, and J.W. Ager. 1989. The T-ACE questions practical prenatal detection of risk-drinking. Am. J. Obstet. Gynecol. 160:863–870. 95. Beresford, T.P., F.C. Blow, E. Hill, K. Singer, and M.R. Lucey. 1990. Comparison of CAGE questionnaire and computer-assisted laboratory profiles in screening for covert alcoholism. Lancet 336:482–485. 96. Masis, K.B., and P.A. May. 1991. A comprehensive local program for the prevention of fetal alcohol syndrome. Public Health Rep. 106:484–489. 97. Streissguth, A.P., T.M. Grant, H.M. Barr, Z.A. Brown, J.C. Martin, D.E. Mayock, S.L. Ramey, and L. Moore. 1991. Cocaine and the use of alcohol and other drugs during pregnancy. Am. J. Obstet. Gynecol. 164:1239–1243. 98. Mohs, M.E., R.R. Watson, and T. Leonard-Green. 1990. Nutritional effects of marijuana, heroin, cocaine, and nicotine. J. Am. Diet. Assoc. 90:1261–1267. 99. Granström, L., L. Granström, and L. Backman. 1990. Fetal growth retardation after gastric banding. Acta Obstet. Gynecol. Scand. 69:533–536. 100. Kirby, D.F., V. Fiorenza, and R.M. Craig. 1988. Intravenous nutritional support during pregnancy. J. Parenter. Enteral Nutr. 12:72–80. 101. Gatenby, S.J. 1987. Maintenance of pregnancy in Crohn's disease by parenteral nutrition a case study. Human Nutrition Applied Nutrition 41A:345–349. 102. Landon, M.B., S.G. Gabbe, and J.L. Mullen. 1986. Total parenteral nutrition during pregnancy. Clin. Perinat. 13:57–72. 103. Lee, R.V., B.D. Rodgers, C. Young, E. Eddy, and J. Cardinal. 1986. Total parenteral nutrition during pregnancy. Obstet. Gynecol. 68:563–571. 104. Mughal, M.M., J.L. Shaffer, M. Turner, and M.H. Irving. 1987. Nutritional management of pregnancy in patients on home parenteral nutrition. Br. J. Obstet. Gynaecol. 94:44–49. 105. Nugent, F.W., M. Rajala, R.A. O'Shea, P.F. Kolack, M.A. Hobin, M.K. Haimes, and M.L Ingalls. 1987. Total parenteral nutrition in pregnancy conception to delivery. J. Parenter. Enteral Nutr. 11:424–427. 106. Watson, L.A., A.A. Bommarito, and J.F. Marshall. 1990. Total peripheral parenteral nutrition in pregnancy. J. Parenter. Enteral Nutr. 14:485–489. 107. Canny, G.J., M. Corey, R.A. Livingstone, S. Carpenter, L. Green, and H. Levison. 1991. Pregnancy and cystic fibrosis. Obstet. Gynecol. 77:850–853. 108. Valenzuela, G.J., F.L. Comunale, B.H. Davidson, R.R. Dooley, and T.C.-S. Foster. 1988. Clinical management of patients with cystic fibrosis and pulmonary insufficiency. Am. J. Obstet. Gynecol. 159:1181–1183.

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Nutrition Services in Perinatal Care 109. Caan, B., D.M. Horgen, S. Margen, J.C. King, and N.P. Jewell. 1987. Benefits associated with WIC supplemental feeding during the interpregnancy interval. Am. J. Clin. Nutr. 45:29–41. 110. Ueland, K. 1976. Maternal cardiovascular dynamics. VII. Intrapartum blood volume changes. Am. J. Obstet. Gynecol. 126:671–677. 111. Institute of Medicine. 1991. Nutrition During Lactation. Report of the Subcommittee on Nutrition During Lactation, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board. National Academy Press, Washington, D.C. 112. Greene, G.W., H. Smiciklas-Wright, T.O. Scholl, and R.J. Karp. 1988. Postpartum weight change: how much of the weight gained in pregnancy will be lost after delivery? Obstet. Gynecol. 71:701–707. 113. Dennis, K.J., and W.R. Bytheway. 1965. Changes in body weight after delivery. J. Obstet. Gynaecol. Br. Commonw. 72:94–102. 114. Schauberger, C.W., B.L. Rooney, and L.M. Brimer. 1992. Factors that influence weight loss in the puerperium. Obstet. Gynecol. 79:424–429. 115. Ferris, A.M., C.K. Dalidowitz, C.M. Ingardia, E.A. Reece, F.D. Fumia, R.G. Jensen, and L.H. Allen. 1988. Lactation outcome in insulin-dependent diabetic women. J. Am. Diet. Assoc. 88:317–322.