1
Introduction

Nutrition plays a major role in promoting maternal and infant health. 16 Both the U.S. Preventive Services Task Force7 and the Expert Panel on the Content of Prenatal Cares8 identify nutrition services as an essential component of prenatal care. This view is supported and expanded by the attention given to the nutrition of mothers and newborn infants in Guidelines for Perinatal Care,9 a joint publication of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.

The goal of this document is to help those responsible for the health care of women and infants to understand the rationale for nutrition services and to incorporate appropriate nutrition services into their care delivery system.

A growing body of evidence indicates tangible health benefits and possibly economic benefits of nutrition services during pregnancy 10,11 and the first year after birth. A few examples follow:

  • The prenatal benefits of the Supplemental Food Program for Women, Infants, and Children (WIC)a may reduce the percentage of

a  

For an annotated bibliography on studies about the Supplemental Food Program for Women, Infants, and Children, see the Food Research and Action Center report WIC: A Success Story.12 WIC offers three kinds of important benefits to eligible low-income individuals: access to a monthly package of highly nutritious supplemental foods, nutrition education and counseling to help participants become more aware of the role nutrition plays in achieving health and well-being, and referrals.



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Nutrition Services in Perinatal Care 1 Introduction Nutrition plays a major role in promoting maternal and infant health. 1–6 Both the U.S. Preventive Services Task Force7 and the Expert Panel on the Content of Prenatal Cares8 identify nutrition services as an essential component of prenatal care. This view is supported and expanded by the attention given to the nutrition of mothers and newborn infants in Guidelines for Perinatal Care,9 a joint publication of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The goal of this document is to help those responsible for the health care of women and infants to understand the rationale for nutrition services and to incorporate appropriate nutrition services into their care delivery system. A growing body of evidence indicates tangible health benefits and possibly economic benefits of nutrition services during pregnancy 10,11 and the first year after birth. A few examples follow: The prenatal benefits of the Supplemental Food Program for Women, Infants, and Children (WIC)a may reduce the percentage of a   For an annotated bibliography on studies about the Supplemental Food Program for Women, Infants, and Children, see the Food Research and Action Center report WIC: A Success Story.12 WIC offers three kinds of important benefits to eligible low-income individuals: access to a monthly package of highly nutritious supplemental foods, nutrition education and counseling to help participants become more aware of the role nutrition plays in achieving health and well-being, and referrals.

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Nutrition Services in Perinatal Care infants born with low birth weight; this, in turn, may produce substantial savings in Medicaid costs for newborns and their mothers.13–15 Comprehensive nutritional care contributes to the survival of low birth weight and sick infants16 (see Chapter 5). Postpartum participation in WIC may reduce the risk of low birth weight in subsequent pregnancies.17 Home health visits with a nutrition component may contribute to earlier discharge of very-low-birth-weight infants.18 In some situations, the reduction in the number of low-birth-weight infants requiring expensive care in the hospital may offset the costs of prenatal nutrition counseling.19 Other studies20–23 suggest that comprehensive careb improves pregnancy outcomes such as birth weight, especially for high-risk women23 and for primiparous women,22 and that it reduces complications for women with preexisting diabetes mellitus and their infants.24 It is not clear, however, to what extent the nutrition services that were part of such care contributed to the improved outcomes. BACKGROUND INFORMATION The Food and Nutrition Board's Committee on Nutritional Status During Pregnancy and Lactation considered it important to revise the board's 1981 report Nutrition Services in Perinatal Care25 to be consistent with current recommendations for nutritional care. It also sought to provide expanded coverage of the preconceptional period and of breast-feeding, and to make the report adaptable to different systems of care delivery. For this revision, three documents from the National Academy of Sciences and the Institute of Medicine (IOM) provide much of the scientific foundation for its content: the 1989 revision of Recommended Dietary Allowances,26 Nutrition During Pregnancy,5 and Nutrition During Lactation.6 The expanded coverage of preconceptional nutrition in this second edition of Nutrition Services in Perinatal Care is consistent with one of the main messages in Caring for Our Future. The Content of Prenatal Cares8 and with the increased attention to this period now being given by the American College of Obstetricians and Gynecologists and other professional organizations. Similarly, the increased emphasis on breastfeeding is b   Comprehensive care constitutes an array of supportive services, one of which is nutrition services.

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Nutrition Services in Perinatal Care a logical consequence of activities (including many research projects) that were stimulated by the Surgeon General's Workshop on Breastfeeding and Human Lactation.27,28 This revision retains the original title even though the book now covers a period that extends well beyond that encompassed by the traditional definition of perinatal. The first edition of Nutrition Services in Perinatal Care was written to identify ''the personnel, competency levels, and support necessary to provide nutritional assessment and education and services within . . . a regionalized system'' of perinatal care (p. 1).25 In recognition of the current debate about the benefits29–34 and evolution34–38 of regionalized systems of perinatal care, this revised report was designed to be relevant, regardless of the system of perinatal care that is in place. New information about these systems may be forthcoming from the National Perinatal Information Center and the National Foundation, March of Dimes, both of which have been examining how regionalized systems have fared and what changes are indicated. In the meantime, Guidelines for Perinatal Care9 addresses the current regionalized perinatal care system in detail. During this period of transition in the delivery of regionalized perinatal care, changes have been occurring in the content of nutritional care for pregnant and lactating women and their infants, the sites at which such care is delivered, the personnel involved, and the ethnic composition of the populations that are served. Some of these changes have resulted from the growth of the Special Supplemental Food Program for Women, Infants, and Children,c the increase in the number of dietitiansd available to provide nutrition counseling services upon referral, numerous technological developments in caring for very premature infants, increased immigration of Hispanics and Southeast Asians to the United States, and, most recently, the development of mechanisms for the reimbursement of nutrition services through Medicaid.39–41 Moreover, the challenge of providing adequate nutrition services for pregnant migrant workers and homeless women is of growing concern.42,43 c   In 1990, WIC served approximately 2,447,000 women and infants under the age of 1 year-2. 4 times as many as it did in 1981 (J. Hirschman, Food and Nutrition Service, USDA, personal communication, 1991). d   In this document, the term dietitian is used to represent a qualified nutrition professional, ordinarily a registered or licensed dietitian or a nutritionist who is eligible for registration.

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Nutrition Services in Perinatal Care STUDY APPROACH AND SCOPE The committee conducted an extensive search of the literature concerning regionalized perinatal care and nutrition services during the preconceptional, prenatal, postpartum, and neonatal periods. It requested and received written comments on the first edition of Nutrition Services in Perinatal Care25 from a variety of organizations and content experts, and it supplemented these responses with a workshop to examine directions that the revision might take and to seek additional input from organizations. After deliberating and making revisions, the committee sought additional assistance and comments from health care providers and government agencies. Two of the publications on which this book is based—Nutrition During Pregnancy5 and Nutrition During Lactation6—make it clear that optimal nutritional care of women before, during, and after pregnancy is assessment based. That is, recommendations on nutrition are based on the interpretation of findings from the woman's history and physical examination. Thus, this revision of Nutrition Services in Perinatal Care develops the theme that there are two levels of nutritional care—basic and special—and that the level of care required by an individual is determined by the assessment. Chart 1-1 gives characteristics of these two levels of care. The theme of two levels of nutritional care was also used in developing a companion document to the two IOM reports noted above. That document, Nutrition During Pregnancy and Lactation: An Implementation Guide, 44 presents information in a practical form to assist those involved in the delivery of basic nutritional care to expectant and new mothers. The document was developed by the Subcommittee for a Clinical Applications Guide in collaboration with this committee; its purpose is to translate the recommendations from the recent IOM reports Nutrition During Pregnancy5 and Nutrition During Lactation6 into a form that can be applied easily in the clinical setting. Consequently, such content is excluded from this revised edition. The second edition of Nutrition Services in Perinatal Care focuses on nutrition services beginning in the preconceptional period and extending well beyond birth, and it gives the rationale for recommending that such services be provided. It briefly describes the necessary elements of these services and indicates the personnel and the knowledge, skills, and specialized education or training that may be needed to deliver them. It is not intended to set standards of care. However, it should prove useful to policymakers, hospital administrators, directors of health centers, physicians in private or group practice, and others responsible for setting such standards and for overseeing health care services for expectant and new mothers and their infants.

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Nutrition Services in Perinatal Care Chart 1-1 Characteristics of Basic and Special Nutrition Services   Type of Nutritional Care   Basic Special Provider Primary care providers such as physicians, midwives, nurse practitioners A multidisciplinary team that includes an experienced dietitian or other nutrition-related specialists Recipients All women receiving preconceptional care All expectant mothers All infants Women or infants with health conditions that affect dietary intake, digestion, or the absorption, utilization, or excretion of nutrients Elements of care Early identification of nutritional risk factors Core provision of health maintenance activities, such as education about pregnancy weight gain or breastfeeding Implementation of common interventions Follow-up of basic care Basic care plus intensive nutrition services (e.g., detailed assessments, complex diet modifications, diet counseling, close monitoring, extended follow-up) PREVIOUSLY PUBLISHED RECOMMENDATIONS AND UNDERLYING ASSUMPTIONS In addition to accepting the recommendations of the previous IOM reports, the committee agreed that the following principles and philosophies would guide its work.

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Nutrition Services in Perinatal Care Patient-Centered, Individualized Care A patient-centered, individualized approach promotes high-quality nutritional care. This means that a nutritional assessment should precede decisions concerning nutritional care. As used in this book, the term nutritional assessment covers a wide range of activities, not all of which are appropriate for all individuals. The measurement of height or length and weight, the determination of hemoglobin values, and the assessment of dietary practices are components of basic nutritional assessment for all. Abnormal findings may indicate the need for more thorough assessment and sometimes for intensive nutritional care. Family Involvement in Care Ideally, nutritional care for pregnant women and their infants involves supportive networks of people; often these people are family members and friends. Support from significant others may have a strong impact on how well the woman, her infant, or both are nourished. Team Care A team effort enhances nutritional care, just as it does other aspects of health care. The committee takes the position that the physician or midwifee is responsible for ensuring that nutrition services are provided as an integral aspect of health care and that various team members, with proper training, can provide basic nutrition services. The dietitian may serve either as a team member or as a resource person (i.e., to provide training and consultation to the health care providers, as well as direct nutritional services to women requiring special nutritional care). The specific roles of the dietitian will depend on how care is organized within the setting and on the complexity of the nutrition problem. Continuity of Care Continuity of nutritional care comprises many elements: consistency in the guidance provided by different team members, avoidance of dup e   In this document, the term midwife is used to represent a qualified licensed midwife, ordinarily a certified nurse-midwife.

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Nutrition Services in Perinatal Care licated activities, a clear progression of care as the woman moves from the preconceptional period through pregnancy and breastfeeding, and building on previous nutritional care if the woman changes providers for any reason. It is assumed that efforts to promote continuity of nutritional care will enhance its quality. ORGANIZATION OF THE REPORT Throughout this book, distinctions are made between basic and special nutrition services. Chapter 2 provides the rationale for both kinds of nutrition services in the preconceptional, prenatal, and postpartum periods; it also provides a brief review of changes in maternal nutrient needs during those periods. The preconceptional and postpartum periods receive more detailed coverage than in the first edition. Chapter 3 describes the basic and special services that should be available to women in the preconceptional, prenatal, and postpartum periods; the respective personnel requirements; and the knowledge base and clinical skills required for both levels of care. Chapter 4 addresses the basic nutrition services needed for healthy neonates, for older infants who have been discharged from special care, and for mothers or other caregivers responsible for feeding such infants. Chapter 5 deals with the special nutrition services required by high-risk neonates and those responsible for their care. Chapter 6 summarizes three approaches that hold promise for improved continuity of nutritional care for mothers and their infants. Finally, Chapter 7 presents further comments and the committee's recommendations. REFERENCES 1. 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. 2. Department of Health and Human Services. 1998. The Surgeon General's Report on Nutrition and Health. DHHS (PHS) Publ. No. 88-50210. Public Health Service. U.S. Government Printing Office, Washington, D.C. 3. Department of Health and Human Services. 1990. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS (PHS) Publ. No. 91-50212. Public Health Service, Office of the Assistant Secretary for Health, Washington, D.C. 4. Farthing, M.A.C., and M. Kaufman. 1990. Serving women, infants, and children. Pp. 139–171 in M. Kaufman, ed. Nutrition in Public Health. Aspen Publishers, Inc., Rockville, Md. 5. 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 During

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Nutrition Services in Perinatal Care Pregnancy, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board. National Academy Press, Washington, D.C. 6. 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. 7. U.S. Preventive Services Task Force. 1989. Guide to Clinical Preventive Services. Williams & Wilkins, Baltimore, Md. 8. 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. 9. American Academy of Pediatrics/American College of Obstetricians and Gynecologists. 1992. Guidelines for Perinatal Care, 3rd ed. American Academy of Pediatrics, Elk Grove, Ill. 10. Disbrow, D.D. 1989. The costs and benefits of nutrition services: a literature review. II. Ambulatory nutrition care: pregnant women. J. Am. Diet. Assoc. 89 (4, suppl.):S10–S14. 11. Trouba, P.H., N. Okereke, and P.L. Splett. 1991. Summary document of nutrition intervention in prenatal care. J. Am. Diet. Assoc. 91 (11, suppl.):S21–26. 12. Food Research and Action Center. 1991. WIC: A Success Story, 3rd ed. Food Research and Action Center, Washington, D.C. 13. 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, U.S. Department of Agriculture. U.S. Government Printing Office, Washington, D.C. 14. New York State Department of Health. 1990. The New York State WIC Evaluation: The Association Between Prenatal WIC Participation and Birth Outcomes. New York State Department of Health, Albany, N.Y. 15. Stockbauer, J. 1987. WIC prenatal participation and its relation to pregnancy outcomes in Missouri: a second look. Am. J. Public Health 77.813–818. 16. Heird, W.C., and A. Cooper. 1988. Nutrition in infants and children. Pp. 944–968 in M.E. Shils and V.R. Young, eds. Modern Nutrition in Health and Disease. 7th ed. Lea and Febiger, Philadelphia. 17. 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. 18. Brooten, D., S. Kumar, L.P. Brown, P. Butts, S.A. Finkler, S. Bakewell-Sachs, A. Gibbons, and M. Delivoria-Papadopoulos. 1986. A randomized clinical trial of early hospital discharge and home follow-up of very-low-birth-weight infants. N. Engl. J. Med. 315:934–939. 19. Orstead, C., D. Arrington, S.K. Kamath, R. Olson, and M.B. Kohrs. 1985. Efficacy of perinatal nutrition counseling: weight gain, infant birth weight, and cost-effectiveness. J. Am. Diet. Assoc. 85:40–45. 20. Buescher, P.A., and N.I. Ward. 1992. A comparison of low birth weight among Medicaid patients of public health departments and other providers of prenatal care in North Carolina and Kentucky. Public Health Rep. 107:54–59. 21. Korenbrot, C.C. 1984. Risk reduction in pregnancies of low-income women. Mobius 4:34–43. 22. McLaughlin, F.J., W.A. Altemeier, M.J. Christensen, K.B. Sherrod, M.S. Dietrich, and D.T. Stern. 1992. Randomized trial of comprehensive prenatal care for low-income women: effect on infant birth weight. Pediatrics 89:128–132. 23. Taren, D.L., and S.N. Graven. 1991. The association of prenatal nutrition and educational services with low birth weight rates in a Florida program. Public Health Rep. 106:426–436.

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Nutrition Services in Perinatal Care 24. 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. 25. National Research Council. 1981. Nutrition Services in Perinatal Care. Committee on Nutrition of the Mother and Preschool Child, Food and Nutrition Board, Assembly of Life Sciences. National Academy Press, Washington, D.C. 26. 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. 27. Department of Health and Human Services. 1984. Report of the Surgeon General's Workshop on Breastfeeding and Human Lactation. DHHS Publ. No. HRS-D-MC 84-2. Health Resources and Services Administration, Public Health Service, Rockville, Md. 28. Spisak, S., and S.S. Gross. 1991. Second Followup Report: The Surgeon General's Workshop on Breastfeeding and Human Lactation. National Center for Education in Maternal and Child Health, Washington, D.C. 29. Burkett, M.E. 1989. The tertiary center and health departments in cooperation: the Duke University experience. J. Perinat. Neonatol. Nurs. 2:11–19. 30. Cordero, L., and F.P. Zuspan. 1988. Very low-birth weight infants: five years experience of a regional perinatal program. Ohio Med. 84:976–978. 31. Hanau-Walsh, J. 1982. Evaluating the effectiveness of a perinatal outreach education program. J. Obstet. Gynecol. Neonatal Nurs. 11:226–229. 32. Handler, A., D. Rosenberg, M. Driscoll, M. Cohen, E. Swift, P. Garcia, and J. Cohn. 1991. Regional perinatal care in crisis: a case study of an urban public hospital. J. Public Health Pol. 12:184–198. 33. Harness, B. 1989. The benefits of cooperation in perinatal health care. Trustee 42:19, 27. 34. Hulsey, T.C., H.C. Heins, T.A. & Marshall, M.L. Martin, T.W. McGee, M.C. Meglen, S.F. Peden, W.B. Pittard, and D.H. Wells. 1989. Regionalized perinatal care in South Carolina. J. S. C. Med. Assoc. 85:357–384. 35. Borker, S., C. Rudolp T. Tsuruki, and M. Williams. 1990. Interhospital referral of high-risk newborns in a rural regional perinatal program. J. Perinatal. 10:156–163. 36. Gagnon, D., S. Allison-Cooke, and R.M. Schwartz. 1988. Perinatal care: the threat of deregionalization. Pediatr. Ann. 17:447–452. 37. Grassi, L.C. 1988. Life, money, quality: the impact of regionalization on perinatal/neonatal intensive care. Neonatal Netw. 6:53–59. 38. Kanto, W.P., Jr. 1987. Regionalization revisited (editorial). Am. J. Dis. Child. 141:403–404. 39. Caldwell, M. 1991. Financing nutrition programs. Pp. 289–302 in C. Sharbaugh, ed. Call to Action: Better Nutrition for Mothers, Children, and Families. National Center for Education in Maternal and Child Health, Washington, D.C. 40. Hill, I.T., and T. Bennett. 1990. Enhancing the Scope of Prenatal Services. National Governors' Association, Washington, D.C. 41. Schleuning, D., G. Rice, and R.A. Rosenblatt. 1991. Addressing barriers to perinatal care: a case study of the Access to Maternity Care Committee in Washington State. Public Health Rep. 106:47–52. 42. Stephens, D., E. Dennis, M. Toomer, and J. Holloway. 1991. The diversity of case management needs for the care of homeless persons. Public Health Rep. 106:15–19. 43. Wiecha, J.L., J.T. Dwyer, and M. Dunn-Strohecker. 1991. Nutrition and health services needs among the homeless. Public Health Rep. 106:364–374. 44. 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.

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