Nutrition Services in Perinatal Care

SECOND EDITION

Committee on Nutritional Status During Pregnancy and Lactation

Food and Nutrition Board

Institute of Medicine

National Academy of Sciences

National Academy Press
Washington, D.C.
1992



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Nutrition Services in Perinatal Care Nutrition Services in Perinatal Care SECOND EDITION Committee on Nutritional Status During Pregnancy and Lactation Food and Nutrition Board Institute of Medicine National Academy of Sciences National Academy Press Washington, D.C. 1992

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Nutrition Services in Perinatal Care NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This study was supported by project no. MCJ 117018 from the Maternal and Child Health Program (Title V, Social Security Act), Health Resources and Services Administration, U.S. Department of Health and Human Services. Library of Congress Catalog Card No. 92-60920 International Standard Book Number 0-309-04694-7 Additional copies of this report are available for sale from: National Academy Press 2101 Constitution Avenue, NW Washington, DC 20418 S553 Copyright 1992 by the National Academy of Sciences Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin. First Printing,July 1992 Second Printing,January 1993

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Nutrition Services in Perinatal Care COMMITTEE ON NUTRITIONAL STATUS DURING PREGNANCY AND LACTATION ROY M. PITKIN (Chair),* Department of Obstetrics and Gynecology, School of Medicine, University of California, Los Angeles, California BARBARA ABRAMS, Program in Public Health Nutrition, School of Public Health, University of California, Berkeley, California LINDSAY H. ALLEN, Department of Nutritional Sciences, University of Connecticut, Storrs, Connecticut MARGIT HAMOSH, Division of Developmental Biology and Nutrition, Georgetown University Medical Center, Washington, D.C. JANET C. KING, Department of Nutritional Sciences, University of California, Berkeley, California CHARLES MAHAN, Department of Health and Rehabilitative Services, State Health Office, Tallahassee, Florida JAMES MARTIN, Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi CHRISTINE OLSON, Division of Nutritional Sciences, Cornell University, Ithaca, New York LINDA A. RANDOLPH, Department of Community Medicine, Mount Sinai School of Medicine, on assignment to Carnegie Corporation of New York, New York, New York KATHLEEN M. RASMUSSEN, Division of Nutritional Sciences, Cornell University, Ithaca, New York JOHN W. SPARKS, Department of Pediatrics, University of Texas, Houston, Texas Staff CAROL WEST SUITOR, Study Director YVONNE L. BRONNER, Research Associate (until July 1991) SHEILA MYLET, Research Associate GERALDINE KENNEDO, Administrative Assistant *   Member, Institute of Medicine

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Nutrition Services in Perinatal Care FOOD AND NUTRITION BOARD M.R.C. GREENWOOD (Chair), University of California, Davis, California DONALD B. McCORMICK (Vice Chair), Emory University School of Medicine, Atlanta, Georgia PERRY L. ADKISSON, Department of Entomology, Texas A&M University, College Station, Texas LINDSAY H. ALLEN, Nutritional Sciences, University of Connecticut, Storrs, Connecticut DENNIS M. BIER, Pediatric Endocrinology and Metabolism, Washington University School of Medicine, St. Louis, Missouri EDWIN L BIERMAN, University of Washington School of Medicine, Seattle, Washington MICHAEL P. DOYLE, Department of Food Science and Technology, University of Georgia, Griffin, Georgia JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital, Boston, Massachusetts JOHN W. ERDMAN, Jr., University of Illinois, Urbana, Illinois NANCY FOGG-JOHNSON, Consumer Healthcare Division, Miles Incorporated, Elkhart, Indiana CUTBERTO GARZA, Division of Nutritional Sciences, Cornell University, Ithaca, New York K. MICHAEL HAMBIDGE, Department of Pediatrics, University of Colorado Medical Center, Denver, Colorado JANET C. KING, Department of Nutritional Sciences, University of California, Berkeley, California JOHN E. KINSELLA, University of California, Davis, California LAURENCE N. KOLONEL, Cancer Center of Hawaii, University of Hawaii, Honolulu, Hawaii SANFORD MILLER, Graduate School of Biomedical Sciences, University of Texas, San Antonio, Texas MALDEN C. NESHEIM, Office of the Provost, Cornell University, Ithaca, New York ROY M. PITKIN (Ex Officio), Department of Obstetrics and Gynecology, University of California, Los Angeles, California STEVE L. TAYLOR (Ex Officio), Department of Food Science and Technology, University of Nebraska, Lincoln, Nebraska

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Nutrition Services in Perinatal Care Staff CATHERINE E. WOTEKI, Director MARCIA LEWIS, Administrative Assistant SUSAN WYATT, Financial Associate

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Nutrition Services in Perinatal Care Acknowledgments The committee wishes to express its appreciation to the many people who made important contributions to this report by providing source materials or special written reports, sharing their views during workshops, commenting on drafts, or otherwise serving as resource persons. In particular, the committee wishes to thank David H. Adamkin, Department of Pediatrics, University of Louisville, Louisville, Ky.; Diane M. Anderson, Medical University of South Carolina, Charleston, S.C.; Cheryl Bowen, Maryland Institute for Emergency Medical Services Systems, University of Maryland, Baltimore, Md.; Mary Sue Brady, Department of Nutrition and Dietetics, Indiana University School of Medicine, Indianapolis, Ind.; Helen Varney Burst, Nurse Midwifery Program, Yale University, New Haven, Conn.; Jennifer Burton, Nurses Association of the American College of Obstetricians and Gynecologists, Washington, D.C.; Ronald Chez, Department of Obstetrics and Gynecology, University of South Florida, Tampa, Fla.; Julie A. Clapp, Delaware Health and Social Services, Dover, Del.; Harriet H. Cloud, Nutrition Division, Sparks Center for Developmental and Learning Disorders, University of Alabama, Birmingham, Ala.; Garris Keels Conner, National Association of Neonatal Nurses, Birmingham, Ala.; Susan Conner, County of Riverside Department of Health, Riverside, Calif.; Carlyle Crenshaw, Jr., Department of Obstetrics and Gynecology, University of Maryland Hospital, Baltimore, Md.; Katherine Davis, University of Mississippi Medical Center, Jackson, Miss.; Diane Dimperio, Department of Obstetrics and Gynecology, University of Florida, Gainesville, Fla.; Judith A. Ernst, Department of

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Nutrition Services in Perinatal Care Nutrition and Dietetics, Indiana University School of Medicine, Indianapolis, Ind.; S. Ann Evans, American Association of Critical-Care Nurses, Aliso Viejo, Calif.; Walter Faubion, University of Michigan Medical Center, Ann Arbor, Mich.; Ann M. Ferris, Department of Nutritional Sciences, University of Connecticut, Storrs, Conn.; Kyle Grazier, School of Public Health, University of California, Berkeley, Calif.; Robert Graham, American Academy of Family Physicians, Kansas City, Mo.; Erica Gunderson, Children's Hospital of San Francisco, San Francisco, Calif.; Ronald Gutberlet, Department of Pediatrics, Mercy Medical Center, University of Maryland, Baltimore, Md.; Gordon L. Klein, University of Texas Medical Branch, Child Health Center, Galveston, Tex.; Ronald E. Kleinman, Massachusetts General Hospital, Boston, Mass.; Becky Klingbail, University of Louisville, Louisville, Ky.; Winston Koo, University of Tennessee, Memphis, Tenn.; Ann Koontz, Maternal and Child Health Bureau, Hyattsville, Md.; Michele Lawler, Food and Nutrition Service, U.S. Department of Agriculture (USDA); James A. Lemons, Riley Newborn Follow-up Program, Indiana University School of Medicine, Indianapolis, Ind.; Brenda Lisi, Food and Nutrition Service, USDA, Alexandria, Va.; Gerald B. Merenstein, University of Colorado, Denver, Colo.; Renee McCleery, University of Texas Medical Branch, Galveston, Tex.; Laurie J. Moyer-Mileur, Nutrition Research, University of Utah, Salt Lake City, Utah; Sue Murvich, Lutheran Hospital, La Crosse, Wis.; Betty Jo Nelsen, Food and Nutrition Service, USDA, Alexandria, Va.; Stephanie Phelps, University of Tennessee, Memphis, Tenn.; Karyl Rickard, Department of Nutrition and Dietetics, Indiana University, Indianapolis, Ind.; Sandra Robbins, George Washington University Medical Center, Washington, D.C.; Helen Schauffler, School of Public Health, University of California, Berkeley, Calif.; Shirley Shelton, American College of Obstetricians and Gynecologists, Washington, D.C.; Melody Thompson, Children's Hospital, Columbus, Ohio; Jacqueline Jones Wessel, Children's Hospital Medical Center, Cincinnati, Ohio; Catherine W. Wiggins, National Association of Neonatal Nurses, Washington, D.C.; and Debra Wilson, University of Michigan Medical Center, Ann Arbor, Mich. In particular, the committee wishes to acknowledge the essential role of the project director, Carol Suitor, in the development of this report. Without her assistance throughout the span from conception to printing, it could not have been done. Thanks also to many other staff members of the Food and Nutrition Board, the Institute of Medicine, and the Academy Complex, especially Catherine E. Woteki, Geraldine Kennedo, Yvonne Bronner, Sheila Mylet, Susan Wyatt, Sally Stanfield, and Leah Mazade.

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Nutrition Services in Perinatal Care Contents     List of Tables and Charts   xiii     Executive Summary   1 1   Introduction   5     Background Information   6     Study Approach and Scope   8     Previously Published Recommendations and Underlying Assumptions   9     Patient-Centered, Individualized Care   10     Family Involvement in Care   10     Team Care   10     Continuity of Care   10     Organization of the Report   11     References   11 2   Nutritional Concerns of Women in the Preconceptional, Prenatal, and Postpartum Periods   15     Preconceptional Nutrition   15     Goals of Preconceptional Nutrition Services   15     Health Conditions Warranting Special Nutrition Services Before Pregnancy   17

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Nutrition Services in Perinatal Care     Prenatal Nutrition   20     Nutritional Demands of Normal Pregnancy   21     Nutrition in Complicated Pregnancies   23     Postpartum Nutrition   30     Replenishing Nutrient Stores   30     Nutrition Recommendations for Lactating Women   31     Weight Loss   32     Conditions Warranting Special Nutrition Services   33     Special Considerations at the Postpartum Visit   33     Summary   34     References   34 3   Basic and Special Nutrition Services for Women in the Preconceptional, Prenatal, and Postpartum Periods   41     Delivery of Basic Nutrition Services   42     Overview of Basic Services   42     Personnel   43     Knowledge Base and Clinical Skills   48     Delivery of Special Nutrition Services   50     Overview of Special Services   50     Personnel   51     Knowledge Base and Clinical Skills   53     Summary   55     References   55 4   Basic Nutrition Services for Newborn Infants   57     Basic Care for the Neonate   57     Planning for the Support of the Breastfeeding Woman   58     Home Visits and Other Early Follow-up   60     Delivery of Basic Nutrition Services for Infants   61     Personnel   62     Knowledge Base and Clinical Skills   62     Summary   64     References   65 5   Newborns Who Need Special Nutritional Care   67     Background   67     Conditions That Often Require Special Nutritional Care   67

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Nutrition Services in Perinatal Care     Challenges That Confront Clinicians   68     The Nutritional Care Plan   71     Feeding Methods   71     Enteral Feedings   72     Methods of Enteral Feeding   73     Parenteral Feeding   75     Monitoring   76     Food and Fluid Intake and Output   76     Anthropometric Changes   78     Laboratory Values   80     Clinical Observations   80     Nutrition Services Delivery for Neonates with Special Needs and Their Families   80     Components of Special Nutrition Services   81     Personnel   84     Education and Training of Health Care Providers   85     Knowledge Base and Clinical Skills   86     Summary   88     References   88 6   Providing for the Continuity of Nutritional Care   93     Coordinated Services   94     Patient-Carried Health Diaries   95     Computer-Based Patient Records and Systems   97     Summary   98     References   98 7   Closing Remarks and Recommendations   101     Measures for Improving Nutritional Care   102     Patient-Centered, Individualized Care   102     Family Involvement in Care   103     Team Care   103     Nutritional Care Plans   104     Education and Training of Practitioners   104     Recommendations   104     References   106     Index   107

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Nutrition Services in Perinatal Care List of Tables and Charts Tables 2-1   Recommended Dietary Allowances for Nonpregnant Pregnant, and Lactating Women   22 2-2   Recommended Total Weight Gain Ranges for Pregnant Women   23 Charts 1-1   Characteristics of Basic and Special Nutrition Services   9 3-1   Basic Nutritional Care Activities for Expectant and New Mothers   44 3-2   Eligibility for Federal Food and Nutrition Programs and Program Benefits   46 3-3   Special Nutritional Care Activities for Expectant and New Mothers with Complex Needs   52 5-1   Examples of Conditions That Require Special Nutrition Management of the Neonate   68 5-2   Nutrition-Related Variables That May Need to Be Monitored for Newborns Who Require Special Care   77 5-3   Examples of Nutrition-Related Problems of Preterm, Infants That Can Be Detected by Laboratory Tests   81

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