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WIC Nutrition Risk Criteria: A Scientific Assessment (1996)

Chapter: 5 Biochemical and Other Medical Risk Criteria

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Suggested Citation:"5 Biochemical and Other Medical Risk Criteria." Institute of Medicine. 1996. WIC Nutrition Risk Criteria: A Scientific Assessment. Washington, DC: The National Academies Press. doi: 10.17226/5071.
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BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 149 5 Biochemical and Other Medical Risk Criteria Biochemical and other medical risk criteria are used during the certification process for the WIC program (Special Supplemental Nutrition Program for Women, Infants, and Children) to establish eligibility for participation in the program and as a basis for either preventive or curative nutrition or health interventions. WIC program regulations define this group of nutrition risks in two categories: • those determined by biochemical measures such as hemoglobin as a measure of anemia, and • other documented nutritionally related medical conditions, such as clinical signs of nutrition deficiencies, metabolic disorders, preeclampsia in pregnant women, failure to thrive in an infant, chronic infections in any person, alcohol or drug abuse or mental retardation in women, lead poisoning, history of high-risk pregnancies or factors associated with high- risk pregnancies (such as smoking; conception before 16 months postpartum; history of low birth weight, premature births, or neonatal loss; adolescent pregnancy; or current multiple pregnancy) in pregnant women, or congenital malformations in infants or children or infants born to women with alcohol or drug abuse histories or mental retardation (7 CFR Subpart C, Section 246.7(e)(2)(i and ii); Federal Register 60(75):19,487–19, 491). Currently, biochemical risk or documented nutrition-based medical conditions fall under Priority I for pregnant women, breastfeeding women, and infants; Priority III for children; and Priority VI for nonbreastfeeding postpartum women. Biochemical and other medical risk criteria are used to certify applicants for participation in the WIC program within the same priority as anthropometric risk criteria. These criteria are assigned a higher priority for participation

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 150 than dietary or predisposing risk criteria (e.g., homelessness or migrancy) (see Chapter 3, Table 3-2). In the WIC program's certification process, medical risk is based on an assessment by a competent professional authority on the staff of the WIC agency or is based on referral data submitted by a competent professional authority not on the staff of the WIC agency (7 CFR Subpart C, Section 246.7 (d)). This chapter covers the medical nutrition risk criteria related to nutrient deficiencies, medical conditions applicable to the entire WIC population, conditions related to intake of specific foods, conditions specific to pregnancy, conditions specific to infants, and potentially toxic substances. These groupings are somewhat different from those used by the WIC program to reduce overlap in content. A list of medical risk criteria that are used by state WIC programs appears in Table 5-1. A summary of the criteria as predictors of risk and benefit appears in Table 5-2. TABLE 5-1 Summary of Biochemical and Other Medical Risk Criteria in the WIC Program and Use by States States Using Risk Criterion Women Infants Children Criteria Related to Nutrient Deficiencies Anemia 54 54 54 Nutrient deficiencies including failure to thrive Malnutrition — 8 8 Nutrition related illness — 25 27 Failure to thrive — 30 27 Medical Conditions Applicable to the Entire WIC Population Gastrointestinal disorders 13 30 24 Nausea and vomiting of pregnancy 26 — — Chronic diarrhea — 16 15 Chronic vomiting — 15 7 Crohn's disease — 7 — Liver disease — 15 14 Hepatitis — 18 14 Intestinal diseases — 6 7 Cystic fibrosis — 30 32 Endocrine disorders — — 6 Diabetes mellitus (Types I and II) 54 35 41 Hypo- or hyperthyroidism 6 6 —

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 151 States Using Risk Criterion Women Infants Children Medical Conditions Applicable to the Entire WIC Population Chronic hypertension 54 19 25 Renal disease 54 35 35 Cancer 20 26 30 Central nervous system disorders — 12 10 Epilepsy 5 6 6 Cerebral palsy — 36 37 Spina bifida — 12 13 Myelomeningocele — — 6 Genetic and congenital disorders 21 — 38 Cleft lip or palate — 41 39 Down syndrome — 16 10 Pyloric stenosis — 7 — Thalassemia 14 6 7 Sickle cell anemia 16 20 21 History of an infant with congenital disorder 32 — — History of a genetic disorder in infant 17 — — Nutritionally significant genetic disease 8 — — Congenital disorder — 37 — Genetic disorder — 8 — Inborn errors of metabolism Phenylketonuria — 29 28 Maple syrup urine disease — 13 12 Galactosemia — 19 15 Metabolic disorder 32 24 26 Tyrosinemia and homocystinuria — 7 6 Other inborn errors of metabolism — 19 20 Chronic infections 52 21 10 Recurrent infections 25 — 11 Infectious disorder 28 — — Nutrition-related infectious disease 14 9 — Respiratory infections — 12 19 Tuberculosis — 25 25 Pneumonia — 19 18 Bronchitis — 7 12 Otitis media — 21 19 Meningitis — 14 15 HIV infection and AIDS 20 22 20 Recent surgery or trauma 18 28 27 Burns 10 24 24 Severe acute infections 28 — — Other medical conditions Juvenile rheumatoid arthritis — — — Arthritis 2 — —

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 152 States Using Risk Criterion Women Infants Children Medical Conditions Applicable to the Entire WIC Population Lupus erythematosus 6 — — Cardiorespiratory disorders 17 37 38 Conditions Related to the Intake of Specific Foods Food allergies 27 29 34 Celiac disease or intolerance — 24 24 Food intolerances Lactose intolerance — 20 16 Asthma — 6 8 Conditions Specific to Pregnancy Pregnancy at a young age 52 — — Pregnancy age older than 35 43 — — Closely spaced pregnancies 52 — — High parity 43 — — History of preterm delivery 42 — — History of postterm delivery 8 — — History of low birth weight 49 — — History of neonatal loss 43 — — History of previous birth of an infant with a 32 — — congenital or birth defect Lack of prenatal care 18 — — Multifetal gestation 51 — — Fetal growth restriction 17 — — Preeclampsia and eclampsia 54 — — Placental abnormalities 15 — — Conditions Specific to Infants and/or Children Prematurity — 39 6 Hypoglycemia 12 — — Fetal alcohol syndrome — 12 9 Potentially Toxic Substances Drug-nutrient interactions 9 — — Inappropriate use of medication — 23 23 Maternal smoking 51 — — Alcohol and illegal drug use Alcohol use 51 36 23 Illegal drug use 50 36 23 Lead poisoning 19 24 24 NOTE: Dashes indicate risk is not applicable or not reported for that population.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 153

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 154 CRITERIA RELATED TO NUTRIENT DEFICIENCIES Anemia Anemia is defined as a reduction of the red blood cell (erythrocyte) volume or hemoglobin concentration greater than two standard deviations below the mean (i.e., below the 2.5th percentile) occurring in healthy persons of the same age, gender, or, for women, stage of pregnancy (IOM, 1990, 1993). Anemias are generally classified into two groups—those resulting primarily from decreased production of red blood cells or hemoglobin, or those in which increased destruction or loss of red blood cells is the predominant mechanism. Megaloblastic anemia is associated with deficiencies of folate and vitamin B6 and/or vitamin B12. Microcytic anemia is associated with thalassemia trait, iron deficiency, and/or copper deficiency. The most common nutrition-related anemia is iron deficiency, which may be caused by diets low in iron, the insufficient assimilation of iron from the diet, the utilization of iron for rapid growth or pregnancy, or blood loss. Prevalence of and Factors Associated with Anemia Information on the prevalence of iron deficiency anemia in the United States comes from the National Health and Nutrition Examination Surveys (NHANES), conducted by the National Center for Health Statistics; the Pregnancy (PNSS) or Pediatric Nutrition Surveillance System (PedNSS), conducted by the Centers for Disease Control and Prevention (CDC); the U.S. Department of Agriculture's (USDA) WIC Eligibility Study; and the National WIC Evaluation. Between 1980 and 1991, the prevalence of anemia among United States infants and children through 5 years of age declined dramatically, from 7 to

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 155 3 percent, according to most recent data from the PedNSS, a low-income sample that includes many WIC program participants (Yip et al., 1992). However, there has been negligible decrease in anemia among black and Hispanic infants and children less than 2 years of age (Figure 17, p. 20, Yip et al., 1992). In 1990, the PNSS reported prevalences of iron deficiency anemia of 10, 14, and 33 percent in the first, second, and third trimesters of pregnancy, respectively, for low-income pregnant women of all races (Kim et al., 1992). Black women exhibited a significantly higher prevalence of iron deficiency anemia than did women of other races. PNSS data show that the prevalence of iron deficiency anemia among low-income pregnant women has remained stable since 1979. Estimates of the prevalence of iron deficiency anemia among the population potentially eligible for participation in the WIC program were reported in the 1985 WIC Eligibility Study (USDA, 1987) and were based on data from the NHANES II survey. These prevalence estimates were 2.3 percent for women 12 through 49 years of age, 14.3 percent for infants 6 to 11 months of age, 13.5 percent for children 12 to 23 months of age, 14.8 percent for children 2 to 3 years of age, 8.6 percent for children 3 to 4 years of age, and 8.4 percent for children 4 to 5 years of age. Factors associated with anemia in women include poverty, low education, high parity, and black and Hispanic ethnicity (IOM, 1990; LSRO, 1991), with pregnancy imposing increased iron needs for the growth of the fetus and for expansion of the maternal blood volume (IOM, 1993). Factors associated with anemia in infants and children include poverty, inadequate dietary intake, malabsorption, and moderate to severe malnutrition (Behrman, 1992; IOM, 1993). Low-birth-weight (LBW) infants are at increased risk of developing anemia because of low neonatal iron stores (IOM, 1993). Anemia as an Indicator of Nutrition and Health Risk Anemia can impair energy metabolism, temperature regulation, immune function, and work performance (IOM, 1993). Anemia during pregnancy may increase the risk of prematurity, poor maternal weight gain, LBW, and infant mortality (IOM, 1990). CDC recently confirmed earlier associations between anemia during pregnancy, hemoglobin concentrations of less than 10 g/dl in the first trimester, and delivery of LBW infants (Kim et al., 1992). Other studies (Ulmer and Goepel; 1988; Scholl et al., 1992) report that maternal iron deficiency is associated with both LBW and poor gestational weight gain. Data from the National WIC Evaluation (Rush et al., 1988b) showed a significant negative relationship between the woman's initial hemoglobin concentration and birth weight. There was no evidence of a relationship between a hemoglobin concentration of less than 10 g/dl or greater than 14 g/dl and adverse

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 156 perinatal outcomes among white women. Among a small group of black WIC participants, however, a high hemoglobin concentration (> 14 g/dl) at entry in either the first or second trimester was associated with LBW, and low hemoglobin concentration (< 10 g/dl) in the first trimester was associated with LBW. There was no association of low hemoglobin concentration at entry in the second trimester with LBW. In infants and children, the greatest risk from iron deficiency anemia (even if mild) is a delay in mental and motor development. Consistently, the mental and motor development scores of iron deficient anemic infants and toddlers fall behind those of children of the same age with replete iron stores (Idjradinata and Pollitt, 1993; Lozoff et al., 1982; Walter et al., 1989). Among preschool and school age children, iron deficiency anemia is associated with comparatively poor scores in tests of intelligence, school achievement, and specific cognitive processes (Pollitt et al., 1989; Seshadri and Gopaldas, 1989; Soewondo et al., 1989). Anemia as an Indicator of Nutrition and Health Benefit Because low-income women (and to a lesser extent infants and children) are at increased risk for iron deficiency anemia, their potential to benefit through participation in the WIC program is clear. Iron is one of the nutrients targeted in the WIC program food package through the provision of iron-fortified cereals and infant formula. The WIC program food package also supplies sources of folate and vitamin B12, which can assist in the prevention of other nutritional anemias. Additionally, the WIC program encourages mothers to breastfeed their infants, which normally ensures adequate iron status for the first 4 to 6 months in infants born at term. Studies have shown that the provision of supplemental iron (through food or supplements, or both) can reduce the prevalence of iron deficiency anemia in women, infants, and children (IOM, 1990, 1993; Rush et al., 1988a, b; Yip et al., 1992). The large decline in the prevalence of anemia since 1980 is principally attributed to participation in the WIC program. Studies show that prevention or treatment of anemia during pregnancy improves pregnancy outcomes (primarily LBW) (Kim et al., 1992; Rush et al., 1988b). Studies in infants and children have revealed mixed results in the reversal of cognitive delays and behavioral changes through the delivery of supplemental iron (Lozoff et al., 1991; Pollitt, 1993). Some studies have shown that impaired cognitive function is still present at the time when formerly anemic children enter school, whereas others have shown strong evidence of complete recovery in response to iron treatment. Among infants, the administration of iron-fortified infant formula contributed to the prevention of anemia and of the motor delays

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 157 observed among iron deficient anemic infants who received non-iron-fortified formula (Moffat et al., 1994). Similarly, in a randomized trial, the administration of ferrous sulfate led to the saturation of iron stores among previously anemic infants and toddlers and was accompanied by a full reversal of the developmental delays in these children (Idjradinata and Pollitt, 1993). Such developmental improvement was not observed among those anemic children who received a placebo. In other studies, iron treatment failed to improve performance on the Bayley Mental Development Scale (Pollitt, 1994). Various experimental and quasi-experimental studies have shown that iron repletion therapy among anemic preschool and school children improves cognitive test performance and school achievement (Watkins and Pollitt, in press). Use of Anemia as a Nutrition Risk Criterion in the WIC Setting Measurement of either hemoglobin or hematocrit concentration is used to detect the presence of anemia or putative iron deficiency because both are easy to use and inexpensive. These measurements are the methods most frequently used to identify the presence of anemia among participants in the WIC program. Among women and children, hemoglobin and hematocrit values vary by age, stage of pregnancy, smoking status, and altitude (see Table 5-3). During pregnancy, hemoglobin values gradually fall to a low point near the end of the second trimester, largely because of expanded blood volume. From this point until term, the concentration of hemoglobin rises again. Serum ferritin concentration, erythrocyte protoporphyrin, mean corpuscular volume, serum iron concentration and iron-binding capacity, and serum transferrin receptor concentration are other biochemical tests used to define anemia. However, they are more expensive and less practical for use in the WIC program. In the WIC program, anemia is the most frequently cited nutrition risk among participants in all categories. (The WIC program's priority system gives individuals with hematologic- and anthropometric-based nutrition risks priority for participation in the WIC program.) According to 1992 state WIC agency plans, all states use hematocrit or hemoglobin concentration measurements to evaluate the risk of anemia (see Table 5-1) (USDA, 1994). The recommended cutoff values for anemia from the CDC (1989) and the Institute of Medicine (IOM, 1993) are found in Table 5-3. The cutoff points for anemia currently in use vary substantially among states and by participant category.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 158 TABLE 5-3 Cutoff Points for Anemia Used in the WIC Program and Recommended Cutoff Points from the Centers for Disease Control and Prevention and the Institute of Medicine for Women, Infants, and Children Cutoff Point Population WIC Programs CDCa IOMa, b Pregnant Women First trimester 10.0-12.6 g/dl Hgb 11.0 g/dl Hgb 11.0 g/dl Hgb, 30-38% Hct 33% Hct with ferritin <20 µg/l Second trimester 10.0-12.0 g/dl Hgb 10.5 g/dl Hgb 10.5 g/dl Hgb, 30-37% Hct 32% Hct and 20 µg/l ferritin Third trimester 10.0-12.6 g/dl Hgb 11.5 g/dl Hgb 11.0 g/dl Hgb, 30-37% Hct 34% Hct and no ferritin collected Lactating Women 12.0 g/dl Hgb 36% 12.0 g/dl Hgb 12.0 g/dl Hgb Hct 36% Hct 36% Hct Postpartum, 12.0 g/dl Hgb 36% 12.0 g/dl Hgb 12.0 g/dl Hgb Nonlactating Women Hct 36% Hct 36% Hct Infants (birth to 6 mo) 9.9-15 g/dl Hgb N/A N/A 11.0 g/dl Hgb 30.9-44% Hct 33% Hct Children (> 6 mo to 23 mo) 9.9-13 g/dl Hgb 11.0 g/dl Hgb 11.0 g/dl Hgb 30.9-39% Hct 33% Hct 33% Hct (2 to 5 yr) 10.0-12.7 g/dl Hgb 11.0 g/dl Hgb 11.0 g/dl Hgb 31-38% Hct 33% Hct 33% Hct NOTE: Hgb = hemoglobin; Hct = hematocrit. a Adjustments for altitude (> 5,000 feet, add 0.5 g/dl hemoglobin or 1.5 percent hematocrit) or smoking (add 0.3 to 0.5 g/dl hemoglobin or 1 to 1.5 percent hematocrit, depending on the number of cigarettes smoked per day) should be added to the cutoff points for pregnant, breastfeeding, and nonlactating postpartum women. b The IOM recommendations listed here for lactating and nonlactating postpartum women correspond to the IOM recommendations for women of childbearing age. SOURCE: WIC program cutoff values reported in 1992 state plans (USDA, 1994); CDC guidelines for pregnant women (CDC, 1989); Report of the Committee on the Prevention, Management, and Treatment of Iron Deficiency Anemia Among U.S. Infants, Children, and Women of Childbearing Age (IOM, 1993). Recommendation for Anemia The risk of anemia is well documented for women, infants, and children; anemia can be identified by measures of hemoglobin or hematocrit concentration.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 159 There is empirical evidence and a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of anemia as a nutrition risk criterion for women, infants, and children in the WIC program, using cutoff values from the CDC (1989) or the IOM (1993) (see Table 5-3). Use of higher cutoff values is not recommended because the yield of risk will be very low for both anemia and iron deficiency. The committee's recommendations for biochemical and other medical risk criteria are summarized in Table 5-4. Failure to Thrive and Other Nutrient Deficiency Diseases Failure to thrive (FTT) is ordinarily a mild form of protein-energy malnutrition (PEM) that is manifested by a reduction in the rate of somatic growth. Severe PEM presents as marasmus or kwashiorkor. Marasmus (less than 60 percent median weight for age) is characterized by severe loss of muscle and fat. Kwashiorkor is characterized by edema and hypoproteinemia, but loss of lean body mass and fat is less severe than in marasmus. Examples of micronutrient deficiencies include scurvy (vitamin C deficiency) and vitamin D deficiency rickets. Prevalence of and Factors Associated with Failure to Thrive and Other Nutrient Deficiency Diseases Although clinically obvious undernutrition is relatively uncommon in the United States, it does occur; FTT is the form most commonly encountered among infants and young children. On occasion, severe forms of protein-energy malnutrition (PEM) or micronutrient deficiency diseases are encountered. PEM results from a combination of social, economic, biologic, and environmental factors (Torun and Chew, 1994). Impaired family dynamics, lack of knowledge on the part of the caregiver for the infant or child, and, in some instances, organic diseases are all major factors contributing to failure to thrive in infants and young children in this country. Whatever the primary factor, however, malnutrition is the final common pathway. Inappropriately low weight for the stature of the infant or child provides a clear indication of recent malnutrition. Impaired linear growth, with weight appropriate for stature, is also a frequent end result of malnutrition, although other causes, e.g., endocrinopathies, need to be excluded. Approximately 1 to 5 percent of all pediatric hospital admissions are for FTT (Bithoney et al., 1991; Phelps, 1991). A large number of infants and children with FTT are managed as outpatients by physicians throughout the United States (Mitchell et al., 1980). FTT without an apparent medical cause accounts for a majority of cases of FTT

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BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 164 (Powell, 1988). As discussed in Chapter 4, weight change is the anthropometric measurement that is most indicative of recent malnutrition, especially in infants and young children. No data were available to the committee on the prevalence of failure to thrive in the WIC population. Clinically evident deficiencies of micronutrients other than iron are generally uncommon in otherwise healthy infants and children in the United States. Increased rates of breastfeeding and supplementation of infant formulas with vitamins and trace elements have undoubtedly reduced the risk of micronutrient deficiencies. However, overdilution of formula or substitution of sugar-based beverages for formula can lead to general malnutrition. Breastfed infants are at risk for deficiency of vitamin D if they do not receive adequate exposure to sunlight but are otherwise at very low risk of nutrient deficiencies. There is evidence to suggest that zinc deficiency may occur after 3 months of age in some breastfed infants (Krebs et al., in press; Walravens et al., 1992). Deficiencies of other micronutrients may occur in the breastfed infant if there is a serious maternal deficiency of that nutrient. Causes of maternal deficiencies include very low intake of fruits and vegetables (folate), vegan diets (vitamins B12 and D), and alcoholism (thiamin). Osteopenia secondary to calcium deficiency may occur in premature infants, and decreased bone density attributable to inadequate calcium intake has been documented during the reproductive cycle in adolescents. Although the incidence of neural tube defects (spina bifida and anencephaly) can be reduced by approximately 50 percent by ensuring a folate intake of at least 400 µg/day in the periconceptional period (CDC, 1992), women are ordinarily not eligible for participation in the WIC program during this period. Many disease states increase the risk of clinically significant micronutrient deficiencies. For example, fat soluble vitamin deficiencies, including vitamin E deficiency, may occur in individuals who malabsorb nutrients because of cystic fibrosis or liver disease. Data on the prevalence of other nutrient deficiency diseases among the general and WIC populations were not available to the committee. Failure to Thrive and Other Nutrient Deficiency Diseases as Indicators of Nutrition and Health Risk The presence of clinical signs and symptoms of PEM or of specific micronutrient deficiencies indicates current nutrition and health risks. Persistent malnutrition may lead to elevated morbidity and mortality rates. Infants and children with FTT may remain developmentally delayed, despite weight gain (Drotar and Sturm, 1992; Wolke et al., 1990). Important functional disturbances may occur as a result of single or multiple nutrient deficiencies. Examples include

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 165 impaired cognitive function, impaired function of the immune system, and impaired function of skeletal muscle. Failure to Thrive and Other Nutrient Deficiency Diseases as Indicators of Nutrition and Health Benefit Participation in the WIC program provides key nutrients and education to help restore nutrition status and promote full rehabilitation of those with an overt nutrient deficiency. Infants and children with FTT can definitely benefit from nutrition and health interventions to improve weight gain. The benefit is so clear that a formal diagnosis of nonorganic FTT (FTT without a medical basis) must be based on a positive response of weight gain to nutrition rehabilitation (Lifshitz et al., 1991). Intervention promotes compensatory catch-up growth in weight and other dimensions of growth (Casey and Arnold, 1985); developmental delays may be less responsive to complete recovery (Frank and Zeisel, 1988). When clinically evident undernutrition is first identified in the WIC program setting, immediate referral for nutrition and health intervention is required. The supplemental food provided by the WIC program, as well as nutrition education and referrals for other health and social services, can benefit those at risk of nutrient deficiencies. Data on the benefit of participation in the WIC program for those identified as being at risk of nutrient deficiency diseases were not available to the committee. Use of Failure to Thrive and Other Nutrient Deficiency Diseases as Nutrition Risk Criteria in the WIC Setting The diagnosis of most nutrient deficiency diseases, including failure to thrive, is based on clinical evidence (including laboratory or radiological findings), performed by a health care provider, and reported to WIC program staff. See Table 5-1 for risk criteria used by states. Recommendations for Failure to Thrive and Other Nutrient Deficiency Diseases The risk of failure to thrive is well documented in infants and children, and the risk of other nutrient deficiency diseases is well documented in women as well. These diseases can be diagnosed clinically. There is a strong theoretical and empirical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of nutrient deficiency diseases as a nutrition risk criterion for women, infants, and children in the WIC program and it recommends use of diagnosis of failure to thrive as a nutrition risk criterion for

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 166 infants and children. The committee believes that these nutrition risk criteria deserve high priority for children because of the yield of benefit. MEDICAL CONDITIONS APPLICABLE TO THE ENTIRE WIC POPULATION Gastrointestinal Disorders For growth, development, or maintenance of normal nutrition status, food must be ingested, digested, and absorbed. Conditions associated with protracted vomiting, parasitic and bacterial infections of the gastrointestinal tract, malabsorption, and diarrhea interfere with those processes. Quality of the water supply, sanitation systems, and household food preparation habits are environmental factors associated with gastrointestinal disorders (Lutter et al., 1992). Prevalence of and Risks Associated with Specific Gastrointestinal Disorders Nausea and vomiting of pregnancy. Some degree of nausea is extremely common in early gestation, and at least half of normal pregnant women experience vomiting (Klebanoff et al., 1985). Vomiting severe enough to warrant a diagnosis of hyperemesis gravidarum is much less frequent. Inflammatory bowel disease. Inflammatory bowel disease occurs in two forms, ulcerative colitis and Crohn's disease. Pregnancy does not exert any consistent effect on the course of inflammatory bowel disease, but active disease at conception increases the risk of poor pregnancy outcome. Crohn's disease usually appears during the second and third decade of life; however, approximately 20 percent of cases occur during childhood or adolescence (Ekvall, 1993). It is estimated that there are approximately 800,000 individuals with inflammatory bowel disease in the United States. Women are more likely than men to develop Crohn's (Eisen and Sandler, 1994). The inflammatory process in Crohn's disease causes symptoms of diarrhea, blood and protein loss in the gastrointestinal tract, abdominal pain, weight loss, fever, anemia, and growth failure (Rosenberg and Mason, 1994). The cause of the growth failure is multi- factorial and includes enteric losses, malabsorption of fat and carbohydrates, and increased nutrient needs due to inflammatory processes. The major cause of poor growth is inadequate energy intake. Short bowel syndrome. Short bowel syndrome is most often seen as a result of surgical resections due to conditions such as necrotizing enterocolitis and

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 167 Crohn's disease. Loss of absorptive surface is the primary problem in short bowel syndrome, and the nutrition risk depends in large part on the extent and site of the resection. Motility disturbances, bile acid deficiency, and bacterial overgrowth are additional complications seen with this syndrome. Liver disease. Most liver diseases have a significant cholestatic component (Balistreri, 1985). Bile flow is obstructed from the hepatocyte into the biliary system and hence the intestine; there is a marked decrease in concentration of intraluminal bile acids, often below the concentration necessary for micelle formation and fat absorption. Growth failure is a frequent complication of liver disease. Vital hepatitis. Viral hepatitis exists in at least five forms, is highly infectious, can progress from acute to chronic disease, and can be transferred from mother to fetus. Cystic fibrosis. Cystic fibrosis is an inherited disorder in which there is a generalized dysfunction of the exocrine glands. This results in the production of abnormally thick, sticky mucus, and involves the lungs, pancreas, liver, and intestines (Ekvall, 1993). The most severe presentation of this disease is failure to thrive combined with respiratory distress and malabsorptive syndrome in infants. Cystic fibrosis occurs more in whites (1 in about 1,800 live births) than in blacks (1 in 17,000 live births), and is rare in Asians. Cystic fibrosis affected over 19,000 individuals in 1994, and 43 percent of cases were among females (Cystic Fibrosis Foundation, 1995). Data on the prevalence of specific gastrointestinal disorders among the WIC population were not available to the committee. Gastrointestinal Disorders as Indicators of Nutrition and Health Risk Gastrointestinal disorders increase nutrition risk through any of a variety of mechanisms: impaired food intake, abnormal deglutition, impaired digestion of food in the intestinal lumen, generalized or specific nutrient malabsorption, or excessive gastrointestinal losses of endogenous fluids and nutrients. Nutrient intake may need to be increased to correct existing deficiencies or to counterbalance excessive losses of nutrients or fluid. Because of frequent loss of nutrients through vomiting, diarrhea, malabsorption, or infections, individuals experiencing chronic symptoms are often malnourished. Chronic vomiting and diarrhea can lead to a rapid breakdown in body functions with such consequences as dehydration and malnutrition, resulting in lowered resistance to disease.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 168 Pregnant women with severe vomiting during pregnancy are at risk of weight loss, dehydration, and metabolic imbalances—particularly in severe cases of vomiting (hyperemesis gravidarum). Risk from mild forms of nausea and vomiting during pregnancy is low; the condition generally responds to small frequent feedings, usually of simple carbohydrates, and avoidance of any foods that cause nausea. More severe cases of vomiting require medical management to prevent serious complications. In rare cases, total parenteral nutrition may be necessary (Godsey and Newman, 1991). Gastrointestinal Disorders as Indicators of Nutrition and Health Benefit The goal of nutritional management of gastrointestinal disorders is to restore or preserve nutrition status. Treatment of any gastrointestinal disorder requires an appropriate source of nutrients. The WIC program provides nutritious supplemental foods or special dietary formulas, general nutrition education, and support for the initiation and maintenance of breastfeeding (which provides antimicrobial benefits as well as nutrients for infants (IOM, 1991; Lutter, 1992). The WIC program helps keep the family linked with health and social services. Ekvall (1993), Boyle (1995), and others discuss nutritional management of gastrointestinal disorders to restore or improve nutrition and health—a vital part of the medical management of the individual. Use of Gastrointestinal Disorders as Risk Criteria in the WIC Setting Diagnosis of gastrointestinal disorders or diseases by a health care provider is reported to the WIC agency staff. WIC program regulations allow for the provision of special dietary formulas indicated for many gastrointestinal disorders as part of the supplemental food package. Table 5-1 summarizes the extent to which various gastrointestinal disorders (including the category nausea and vomiting of pregnancy) are used as nutrition risk criteria by state WIC agencies. Recommendations for Gastrointestinal Disorders The risk of chronic gastrointestinal disorders is well documented among women, infants, and children, and clinical methods are available to identify these risk criteria. There is a theoretical basis for benefit from participation in the WIC program and empirical evidence of the importance of nutritious foods in restoring or maintaining satisfactory nutrition and health. Therefore, the committee recommends use of gastrointestinal disorders as nutrition risk criteria for women, infants, and children by the WIC agencies and with high priority.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 169 The committee cautions, however, that nutrition risk criteria for conditions such as vomiting and diarrhea be defined by state WIC agencies as chronic conditions, not single episodes. Diabetes Mellitus Diabetes mellitus results from an absolute insulin deficiency (Type I) or a functional insulin deficiency (Type II). Genetic and environmental factors are involved. Type I diabetes mellitus is associated with histocompatibility antigen, autoimmunity, and/or islet cell antibodies. Peak ages for presentation of absolute insulin deficiency are between 5 and 7 years of age and at puberty. There is a seasonal variability in onset and association with mumps, rubella, and cytomegalo viruses. Diabetes mellitus is the most common endocrine disorder to complicate pregnancy. Gestational diabetes refers to diabetes mellitus that is diagnosed during pregnancy; in most cases it is non-insulin-dependent. Prevalence of and Factors Associated with Diabetes Mellitus More than 13 million persons in the United States have diabetes mellitus, and 60 percent of newly diagnosed cases occur in women (Tinker, 1994). Estimates of the prevalence of diabetes mellitus during pregnancy depend on the diagnostic criteria employed; a rate of 2 to 3 percent is a reasonable conservative estimate. The occurrence of diabetes mellitus is more prevalent among overweight women (Colditz et al., 1995) and in certain American-Indian and Latino populations (Baxter et al., 1993; Valway et al., 1993). No information on the prevalence of diabetes mellitus or gestational diabetes among the WIC population was available to the committee. Diabetes Mellitus as an Indicator of Nutrition and Health Risk Insulin deficiency results in major disturbances of carbohydrate, protein, and lipid metabolism. With inadequate insulin, lipid metabolism increases. Insulin and growth hormone work synergistically to promote the movement of amino acids from the extracellular to the intracellular space, increase protein synthesis, and decrease protein degradation. Individuals with Type I diabetes mellitus nearly always require insulin and are at risk for developing ketoacidosis, hypoglycemic reactions, and such long- term serious complications as cardiovascular disease, renal disease, and loss of vision (Crofford, 1995; Shaughnessy and Slawson, 1994). Type I diabetes mellitus during pregnancy is associated with increased risk of preeclampsia, fetal malformation, macrosomia, fetal and neonatal death, and other complications.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 170 Women with gestational diabetes are at increased risk of developing Type II diabetes mellitus later in life (Coustan et al., 1993). Their infants are at increased risk of macrosomia. Breastfeeding women with diabetes mellitus are at risk for delayed lactogenesis, mastitis, and lower plasma glucose levels (Ferris et al., 1988; Neubauer et al., 1993). Diabetes Mellitus as an Indicator of Nutrition and Health Benefit The WIC program provides supplemental food, nutrition education, and access to health services that can benefit individuals with diabetes mellitus and women with gestational diabetes. Foods in the WIC package can help individuals to follow their diet plan. Individuals with diabetes mellitus benefit from referral for nutrition management (American Diabetes Association and American Dietetic Association, 1994, 1995; Bourgeosis and Duffer, 1990; Jovanovic-Peterson and Peterson, 1990). Dietary management and attention to exercise play a key role in maintaining euglycemia. There is ample evidence that normalization of maternal blood glucose diminishes the risk of virtually all complications in the mother, fetus, and newborn (Cunningham et al., 1993). Use of Diabetes Mellitus as a Nutrition Risk Criterion in the WIC Setting A health care provider reports the diagnosis of diabetes mellitus to WIC program staff. Table 5-1 lists the use of this nutrition risk criterion by state WIC programs. Recommendation for Diabetes Mellitus The risk of diabetes mellitus is well documented for women, infants, and children, and this condition can be diagnosed clinically. There is a theoretical basis for benefit from participation in the WIC program and empirical evidence that appropriate diet is a key to maintenance of euglycemia. Therefore, the committee recommends use of diabetes mellitus as a nutrition risk criterion for women, infants, and children and gestational diabetes for pregnant women in the WIC program. Thyroid Disorders Hypothyroidism results from deficient levels of production of thyroid hormone, or a defect in its receptor; hyperthyroidism results from excessive levels

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 171 of secretion of thyroid hormone (Behrman, 1992; Clugson and Hetzel, 1994). Hypothyroidism and hyperthyroidism may be associated with the autoimmune process. The drug thiourea has been associated with hypothyroidism and should be used with caution during pregnancy (ACOG, 1995). Prevalence of and Factors Associated with Thyroid Disorders Data on the prevalence of hypo- or hyperthyroidism among women, infants, or children in the United States or in WIC program participants were not available to the committee. Hyperthyroidism can occur in infants and children born to mothers with a history of hyperthyroidism. Thyroid Disorders as Indicators of Nutrition and Health Risk Congenital or neonatal hypothyroidism results in severe mental and physical retardation. Hyperthyroidism in infants may result in failure to thrive, cardiac failure, and a variety of other clinical abnormalities. The hypermetabolic state in individuals with hyperthyroidism is accompanied by increased caloric needs, and those affected may have a voracious appetite. On the other hand, hypothyroidism is accompanied by decreased metabolism and decreased caloric needs. Thyroid Disorders as Indicators of Nutrition and Health Benefit As part of the medical management of hypothyroidism, attention must be directed to anthropometric status. Nutrition education may help promote normal growth and development and avoidance of excessive weight gain. A low-fat version of the WIC food package would assist with weight management in hypothyroidism. The management of hyperthyroidism requires a diet high in energy, carbohydrates, and vitamins and minerals to maintain or achieve desirable weight, growth, and development. The WIC program provides supplemental food that helps achieve improved nutrient intake. Nutrition education and referrals to health care and social services may also assist individuals in managing their condition. Use of Thyroid Disorders as a Risk Criterion in the WIC Setting The diagnosis of hypo- or hyperthyroidism is performed by a health care provider, and the diagnosis is reported to WIC program staff.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 172 Recommendation for Thyroid Disorders The risk of hypo- and hyperthyroidism is well documented in women, infants, and children, and these conditions can be diagnosed clinically. There is a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends that the WIC program use hypo- and hyperthyroidism as nutrition risk criteria for women, infants, and children in the WIC program. Chronic Hypertension Hypertension is defined as elevated arterial blood pressure measured indirectly by an inflatable cuff and pressure manometer (NRC, 1989). The health risk of hypertension increases steadily with blood pressure level (either systolic or diastolic). Diastolic blood pressure is generally the value used to diagnose hypertension. Normotension in adults is defined as systolic blood pressure less than or equal to 140 mm Hg and diastolic blood pressure less than or equal to 90 mm Hg (in infants 80/60, and in children approximately 100/65 mm Hg) (WHO, 1978). Factors associated with hypertension include excessive body weight; intake of salt, fat, and perhaps other dietary components (e.g., potassium and calcium may be protective); alcohol consumption; race; and age (Kotchen et al., 1991; NRC, 1989). In children there is a strong correlation between obesity and blood pressure, and a direct association between changes in body weight and blood pressure (Kotchen et al., 1989). Prevalence of and Factors Associated with Chronic Hypertension Approximately 30 percent of adult Americans have definitive hypertension using criteria of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (NRC, 1989); and about 22 percent of women have hypertension (Burt et al., 1995). Using 1984 program data, USDA (1987) estimated that approximately 9 percent of women who are income-eligible for participation in the WIC program would present with hypertension as a nutrition risk. Hypertension is far less prevalent among infants and children and generally accompanies other chronic diseases (Pruitt, 1992). Data on the prevalence of hypertension among infants and children participating in the WIC program were not available to the committee.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 173 Chronic Hypertension as an Indicator of Nutrition and Health Risk Hypertension diagnosed through elevated diastolic blood pressure is a major risk factor for stroke, hypertensive heart disease, coronary heart disease, and kidney disease (Kotchen and Kotchen, 1994; NRC, 1989). Individuals with mild hypertension have twice the risk of cardiovascular disease than normotensive persons. Women with hypertension antedating pregnancy are at increased risk for several types of adverse pregnancy outcomes (IOM, 1990). Fetal growth restriction, presumably reflecting impairment of uteroplacental perfusion from vascular disease, is relatively common. Abruptio placentae occurs with increased frequency in women with chronic hypertension. There is also a tendency for women with chronic hypertension to experience an acute worsening of the condition, termed ''superimposed preeclampsia," or pregnancy-aggravated hypertension. These conditions account for a substantial proportion of perinatal morbidity and mortality in populations with a high baseline incidence of chronic hypertension. Chronic Hypertension as an Indicator of Nutrition and Health Benefit Evidence for the prevention and control of hypertension through altered dietary intake comes from many studies in adults and longitudinal studies that have followed blood pressures in children over time (NRC, 1989; Pruitt, 1992). Management of hypertension—either pharmacologic or nonpharmacologic—can reduce the development of serious conditions. Nonpharmacologic treatment for postpartum women includes a combined intervention of weight loss, sodium restriction, moderate alcohol restriction, and moderate isotonic physical activity. The WIC food package provides compatible foods. Nutrition education provided in the WIC setting can address topics pertinent to the prevention and management of hypertension in general and during pregnancy, the postpartum period, infancy, and childhood. Use of Chronic Hypertension as a Risk Criterion in the WIC Setting Diagnosis of hypertension can be reported to WIC program staff by health care providers. Trained health care staff can obtain blood pressure measurements in the WIC setting and refer for a confirming diagnosis and medical management. See Table 5-1 for the use of hypertension as a nutrition risk criterion in the WIC program.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 174 Recommendation for Chronic Hypertension The risk of chronic hypertension is well documented for women, infants, and children, and this condition can be diagnosed clinically. There is a theoretical and empirical basis for benefit from participation in the WIC program. Therefore, the committee recommends the use of chronic hypertension as a nutrition risk criterion for women, infants, and children in the WIC program. Renal Disease Either acute or chronic renal disease may complicate pregnancy. Urinary tract infections are the most common acute infection during pregnancy. However, most urinary tract infections involve the bladder; infection of the renal parenchyma (i.e., pyelonephritis) is less frequent. Nonetheless, acute pyelonephritis is the most common serious medical complication of pregnancy. Even though renal disease among infants and children has many etiologies (acute, chronic, or congenital), the rate of deterioration of nutrition status is fastest among infants and children with glomerulonephritis, followed by hereditary nephropathies and renal dysplasia, and then by urinary tract malformation (Gonzalez, 1992; Bergstein, 1992). Prevalence of and Factors Associated with Renal Disease Based on 1984 WIC program data, the expected frequency of renal disease (including chronic urinary tract infections) among women in the WIC program was estimated to be 19 percent (USDA, 1987). Estimates were not made for infants or children. Data on the prevalence of specific renal diseases or disorders among U.S. women, infants, and children were not available to the committee. Renal Disease as an Indicator of Nutrition and Health Risk With chronic renal disease in pregnant women, fetal growth is often restricted and there is a high likelihood of developing a preeclampsia-like syndrome superimposed on underlying vascular disease. The woman with chronic renal disease often has proteinuria, but is also at the risk of azotemia if she increases her dietary protein intake. Growth failure in children with renal disease can result from PEM, chronic acidosis, osteodystrophy, uremic conditions, and endocrine dysfunction (Bergstein, 1992). Uremia has a broad spectrum of neurologic, gastrointestinal, metabolic, hematologic, cardiovascular, and immunologic effects. Metabolic

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 175 changes in amino acid transport change peripheral insulin resistance and the process of glucose utilization. In renal insufficiency, a significant deficit in height is usually observed in infants and children. Renal Disease as an Indicator of Nutrition and Health Benefit The WIC program can benefit the nutrition and health of affected individuals by providing modified food packages, sometimes including special dietary formulas, and referrals to medical care that will include dietary counseling and management. Dietary management in renal disease helps to preserve renal function, treat symptoms, prevent states of nutrient deficiency or excess, and promote positive pregnancy outcomes and growth and development in infants and children. Use of Renal Disease as a Risk Criterion in the WIC Setting Renal disease is diagnosed by a medical care provider and reported to WIC agency staff. See Table 5-1 for the use of renal disease as a nutrition risk criterion in the WIC program. Recommendations for Renal Disease The risk of renal disease is well documented in women, infants, and children, and this condition can be diagnosed clinically. There is a theoretical and empirical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of renal disease (including chronic pyelonephritis with persistent proteinuria) as a nutrition risk criterion in the WIC program for women, infants, and children. However, the committee recommends that diagnosis of other chronic urinary tract infections not be used as a nutrition risk criterion. Cancer An individual's nutrition status at the time of diagnosis of cancer (populations of cells that have acquired the ability to multiply and spread without the usual biologic restraints; NRC, 1982) is associated with the outcome of treatment (Shils et al., 1994). The type of cancer and stage of disease progression determines the type of medical treatment, and, if indicated, nutrition management.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 176 Prevalence of and Factors Associated with Cancer The incidence of cancer in 1995 was estimated to be 575,000 new cases among women, and 8,000 new cases among children (American Cancer Society, 1995). Data on the prevalence of cancer among the WIC population were not available to the committee. Cancer as an Indicator of Nutrition and Health Risk Individuals with a diagnosis of cancer are at significant health risk and under specific circumstances may be at increased nutrition risk, depending upon the stage of disease progression or type of ongoing cancer treatment. The most common nutritional risk for individuals with cancer is PEM and wasting (Shils et al., 1994). Energy and protein needs are often increased as a result of the disease or its therapy. Cancer treatment interventions that promote the development of PEM are irradiation to the head, neck, esophagus, abdomen, or pelvis, or intense or frequent use of corticosteroid therapy. PEM is associated with impaired immune competence, increased susceptibility to infections, major organ dysfunction, and increased morbidity and mortality. Hematopoietic, gastrointestinal, and immunologic systems are most affected by PEM. Some chemotherapy drugs (e.g., cytosine arabinoside) are toxic to the gastrointestinal tract and, thus, pose additional nutrition risks. Cancer as an Indicator of Nutrition and Health Benefit Individuals with cancer should maintain adequate nutrition status to promote normal growth patterns in infants and children and to maintain weight in women. The food package, in conjunction with nutrition education and referrals, may help prevent the development of nutrition problems that are secondary to the disease or its therapy. Use of Cancer as a Risk Criterion in the WIC Setting A diagnosis of cancer is made by a health care provider and reported to WIC agency staff. See Table 5-1 for use of this criterion by state WIC programs. Recommendation for Cancer The risk of cancer is well documented for women, infants, and children, and a clinical method is available to identify this condition. There is a theoretical

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 177 basis for benefit from participation in the WIC program. Therefore, the committee recommends the use of cancer or ongoing chemotherapy as a nutrition risk criterion in the WIC program for women, infants, and children. Central Nervous System Disorders Central nervous system (CNS) disorders can be categorized as conditions that alter nutrition status metabolically, mechanically, or both. CNS disorders such as cerebral palsy (CP) and neural tube defects (NTD; e.g., spina bifida or myelomeningocele) affect energy requirements and may affect the individual's ability to feed himself. Prevalence of and Factors Associated with Central Nervous System Disorders Epilepsy is a symptom of brain dysfunction characterized by excessive fluctuations in electromechanical balance that may be expressed in spontaneous recurring seizures (Ekvall, 1993). Epilepsy affects 2.5 million individuals in the Unites States, with 30 percent of cases in children under 18 years of age (approximately 5 per 1,000) (Epilepsy Foundation of America, 1993). Data on the prevalence of epilepsy among the WIC population were not available to the committee. Cerebral palsy in infants and children is a group of chronic, nonprogressive disorders of the brain that produce abnormalities of posture, muscle tone, and motor coordination (Ekvall, 1993). The prevalence of cerebral palsy is approximately 2 per 1,000 live births, with cases occurring more than twice as often in whites as in blacks. Factors associated with CP are LBW and birth asphyxia. NTDs account for most congenital anomalies of the CNS; they are estimated to occur in approximately 5 in 10,000 live births (approximately 2,500 to 3,000/ yr), with cases occurring more than twice as often in whites as in blacks. NTDs result from the failure of the neural tube to close between the third and fourth week of gestation. Maternal intake of at least 400 µg of folic acid daily (4 mg daily by women who have had an affected infant previously) in the periconceptional period is believed to greatly reduce the risk of having an infant with NTD (MMWR, 1992; MRC Vitamin Study Research Group, 1991). Infants born with an NTD exhibit high infant mortality; but over the past several decades, survival has dramatically increased with prompt correction of the tube defect and multidisciplinary management of the infant's condition. Data on the prevalence of CNS disorders among the WIC population were not available to the committee.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 178 Central Nervous System Disorders as an Indicator of Nutrition and Health Risk Individuals with epilepsy are at risk of physical injury resulting from seizures, inadequate growth, and alteration in nutrient status from prolonged anticonvulsant therapy (e.g., hydantoins alter folate metabolism) (Ekvall, 1993). Infants and children with cerebral palsy often grow poorly and have decreased energy and nutrient intake, primarily because of poor motor skills. Infants with NTDs may be at increased risk of abnormal growth and development because of limited mobility or paralysis, hydrocephalus, limited feeding skills, and genitourinary problems. Because of immobility, reduced respiratory capacity, or other physical problems, women with cerebral palsy, or neural tube defects who become pregnant may find it very difficult to meet their increased nutrient requirements. Central Nervous System Disorders as an Indicator of Nutrition and Health Benefit Individuals with CNS disorders need adequate nutrients and sometimes feeding assistance for proper growth and development (Ekvall, 1993). Women, infants, and children with epilepsy, cerebral palsy, or NTDs can benefit from participation in the WIC program by the provision of nutritious supplemental food, nutrition education, and referrals to health care and social services. Use of Central Nervous System Disorders as a Risk Criterion in the WIC Setting CNS disorders are diagnosed by a health care provider and reported to WIC agency staff. Table 5-1 summarizes how many states use these risk indicators in the WIC setting. Recommendation for Central Nervous System Disorders The risk of central nervous system disorders is well documented in women, infants, and children, and clinical methods are available to identify these risks. There is a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of central nervous system disorders as nutrition risk criteria for women, infants, and children in the WIC program. This includes diagnosis of epilepsy, cerebral palsy, and neural tube defects (spina bifida or myelomeningocele).

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 179 Genetic and Congenital Disorders Genetic abnormalities and congenital malformations are common causes of disease, disability, or death among infants, and their complications can persist throughout life (Holmes, 1992). Many genetic alterations are associated with congenital heart or kidney disease (see the section on renal disease). Prevalence of and Factors Associated with Genetic and Congenital Disorders Approximately 0.5 to 1 percent of infants have a hereditary malformation at birth that causes no physical or metabolic abnormality. Approximately 2 percent of newborns have a major congenital malformation. Genetic and congenital disorders affect nutrition if they cause problems with self-feeding, digestion, absorption or utilization of nutrients, and/or hypoxia. Cleft lip or palate reflects a failure of the palate shelves to meet and fuse. The prevalence of cleft lip or palate in the general population ranges from 0.03 to 0.2 percent (Behrman, 1992). Populations at greater risk for cleft lip or palate are white, Asian, some tribes of American Indians, or infants delivered postterm. The condition occurs more in males than in females, and more frequently in children born subsequent to a previous child with cleft lip or palate. Down syndrome results from the presence of an extra 21st chromosome, and is the most common chromosomal abnormality associated with mental retardation (Ekvall, 1993). Down syndrome occurs in approximately 1 in 800 live births, and occurrence increases with advancing maternal age. Over 50 percent of individuals with Down syndrome have congenital heart disease. Children with Down syndrome also have an increased incidence of duodenal atresia and imperforate anus. Pyloric stenosis and other gastrointestinal obstructive processes have multifactorial inheritance (Shandling, 1992). Pyloric stenosis is more prevalent in first-born male infants (1:150 live male births compared to 1:750 live female births) and males born to mothers who had pyloric stenosis. The condition is generally corrected surgically within the first month of life. Thalassemia major is a severe, progressive hemolytic anemia usually presenting during the infant's second 6 months (Holmes, 1992). Higher prevalence of thalassemia major occurs in ethnic groups from Mediterranean countries, Africa, the Middle East, and India. In the United States, Berini and Kahn (1987) reported that blacks have a higher incidence of the thalassemia gene than the general population. Sickle cell anemia is an inherited disorder in which the sickle gene is obtained from each parent (Hb SS) (Ekvall, 1993). Sickle cell anemia occurs in approximately 1 in 625 U.S. blacks (1 in 12 are carriers [Hb AS]), but it is also

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 180 observed in individuals of Italian, Sicilian, Egyptian, Turkish, Arabic, and Asian ancestry. Data on the prevalence of specific genetic and congenital disorders among women, infants, and children participating in the WIC program were not available to the committee. Genetic and Congenital Disorders as Indicators of Nutrition and Health Risk Genetic and congenital disorders often adversely affect the metabolism of nutrients or normal physiological processes, or cause mechanical barriers to adequate nutrition—resulting in severe health or nutrition problems. Even though the nutritional needs of infants and children with cleft lip or palate are the same as those of other children, mechanical difficulties in feeding may exist. Infants may have insufficient suction when sucking, swallowing problems, and slow weight gain during their first few months. Bowers (1987) found that those with unilateral clefts and isolated clefts of the lip and palates were significantly shorter that their unaffected peers and boys were thinner. Infants and children with Down syndrome often have feeding problems, growth retardation, dental problems, and changes in nutrient metabolism (Ekvall, 1993). Additional physical factors contributing to nutrient inadequacies include increased mucus production, late appearance of the chewing reflex and of teeth, other dental problems, storage of food in the high-arched palate, and/or thrusting of food out of the mouth with the tongue. Children with congenital heart disease often experience delayed growth and developmental delay. Hypoxia retards cell growth and multiplication. Impaired energy intake and hypermetabolism may both contribute to malnutrition. Individuals with thalassemia major have severe anemia, spleen and liver enlargement, impaired growth, and endocrine and cardiac problems (Holmes, 1992). Virtually every organ in the body can be affected by the two primary manifestations of sickle cell anemia: severe hemolytic anemia and vaso-occlusion and infarction of organs and tissues. Genetic and Congenital Disorders as Indicators of Nutrition and Health Benefit For infants and children with these disorders, special attention to nutrition may be essential to achieve adequate growth and development and to maintain their health. The WIC program can provide supplemental food, special formula as appropriate, general nutrition and health education, and improved linkages with health care and social services. It does not provide counseling about therapeutic diets. Affected infants, children, and women need dietary management as part of the overall medical management of their conditions.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 181 Use of Genetic and Congenital Disorders as Nutrition Risk Criteria in the WIC Setting Genetic and congenital disorders are diagnosed by a medical care provider and reported to WIC program staff. Table 5-1 summarizes the use of various types of genetic or congenital disorders as nutrition risk criteria by state WIC agencies. Recommendations for Genetic and Congenital Disorders The risk of genetic or congenital disorders is well documented in women, infants, and children, and clinical methods are available to identify these disorders. There is a theoretical and empirical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of genetic or congenital disorders as nutrition risk criteria for women, infants, and children in the WIC program. This includes the use of specific disorders discussed in this section, except for pyloric stenosis. Pyloric stenosis is usually repaired within the first month of life. After the infant has recovered from the surgery, gastrointestinal function returns to normal and health and nutrition risk is eliminated. Inborn Errors of Metabolism Inborn errors of metabolism include phenylketonuria (PKU), maple syrup urine disease, galactosemia, hyperlipoproteinuria, homocystinuria, tyrosinemia, histidinemia, urea cycle disorders, glutaric aciduria, methylmalonic acidemia, glycogen storage disease, galactokinase deficiency, fructoaldolase deficiency, propionic acidemia, and hypermethioninemia. These and the many other inborn errors of metabolism are either gene mutations or gene deletions that translate into altered metabolism in the body. They can be identified through metabolic assessment performed prenatally or at birth. Prevalence of and Factors Associated with Inborn Errors of Metabolism The occurrence of many inborn errors of metabolism is concentrated among individuals of specific ethnic origins (e.g., tyrosinemia type I is seen most often in persons having a French-Canadian ancestry, and glutaric aciduria is most prevalent among Swedish and Pennsylvania Amish populations). The prevalence of inborn errors of metabolism ranges from extremely rare (1 in more than 200,000 live births) to approximately 1 in 10,000 live births (USDA, Report on Ad Hoc Task 1.3. Estimated Demand and Cost of WIC Food Package III, USDA, Food and Nutrition Service, Washington, D.C., unpublished information).

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 182 No prevalence estimates on the number of WIC participants with inborn errors of metabolism were available to the committee. Inborn Errors of Metabolism as Indicators of Nutrition and Health Risk Untreated pregnant women with certain inborn errors of metabolism have a higher risk of spontaneous abortion or other health or nutrition risks. Infants born to mothers with untreated PKU may show fetal growth restriction, microcephaly, LBW, and congenital heart disease (Barness, 1993; Rohr et al., 1985). If inborn errors of metabolism are not detected and treated soon after birth, infants accumulate abnormal metabolites in their blood, resulting in a spectrum of clinical presentations such as mental retardation, seizures, microcephaly, eczema, growth retardation, speech defects, developmental delay, and abnormal eye and bone formation. Inborn Errors of Metabolism as Indicators of Nutrition and Health Benefit For many inborn errors of metabolism, appropriate dietary management, which includes the use of special formulas, can minimize the medical risk to affected individuals (COG-AAP, 1991). The benefit of nutrition and medical intervention is illustrated through the example of PKU, which is the most prevalent inborn error in the United States for which dietary management has been provided over an extended period (since the mid-1960s). Such dietary management is not provided by the WIC program, but the special formulas may be. Individuals with PKU lack the enzyme to convert phenylalanine to tyrosine, and high levels of phenylalanine and its metabolites are toxic to the developing central nervous system. Therefore, restricting intake of phenylalanine reduces the risk of damage to the fetus or the newborn. Early results from a large collaborative study indicate that a phenylalanine-restricted diet, if instituted early in gestation, can result in apparently normal outcome (Platt et al., 1992). Recently, it has been shown that children with PKU who receive early and continuous dietary treatment with a phenylalanine-free amino acid mixture have only mildly elevated levels of phenylalanine and reduced levels of tyrosine. Children whose phenylalanine levels were three to five times normal (6–10 mg/ dl) showed signs of poor performance in tests of object retrieval, attention control, and motor tapping but no signs of deficits in other functions. The nature of the selective deficits observed indicated an impairment in the dorsolateral prefrontal cortex (Diamond, 1995). Infants with PKU would receive excessive phenylalanine if breastfed exclusively. Therefore, all mothers, whether breastfeeding or not, should be referred

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 183 for dietary treatment of the infant, which includes use of low phenylalanine or phenylalanine-free formula. Such special formulas may be provided by the WIC program. A phenylalanine-restricted diet during infancy and early childhood normalizes blood phenylalanine levels, permitting normal mental development. Similar dietary management is indicated for individuals with other inborn errors of metabolism. Use of Inborn Errors of Metabolism as Risk Criteria in the WIC Setting Inborn errors of metabolism are reported to WIC programs from diagnosis by a medical care provider. Table 5-1 summarizes how many states use these risk criteria in the WIC setting. Recommendations for Inborn Errors of Metabolism The risks of PKU and other inborn errors of metabolism are well documented in women, infants, and children, and these risks can be identified clinically. The benefit of use of special formulas is well established. Therefore, the committee recommends use of PKU and other inborn errors of metabolism as nutrition risk criteria for women, infants, and children in the WIC program. Chronic or Recurrent Infections The relationship between nutrition and infection has been appreciated for centuries: tuberculosis was known as ''consumption," and HIV/AIDS was categorized as "slim disease" when first discovered in East Africa (Keusch, 1994). Individuals with chronic or recurrent infections such as tuberculosis, pneumonia, bronchitis, upper respiratory infections, otitis media, meningitis, and hepatitis may have increased nutrition needs. Nutrition deficits can impair the host's ability to sustain cellular proliferation and other defense mechanisms. HIV/AIDS is covered separately in the next section. Prevalence of and Factors Associated with Chronic or Recurrent Infections Data on prevalence of chronic or recurrent infections among the U.S. or the WIC population were not available to the committee. In the United States, the probability of children developing acute otitis media is understood to be very high (Infante-Rivard and Fernandez, 1993).

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 184 Chronic or Recurrent Infections as Indicators of Nutrition and Health Risk Catabolic responses to infection increase energy and nutrient requirements and may exacerbate medical conditions associated with infection (Keusch, 1994). Iron, zinc, vitamin A, and other nutrients are associated with the host's ability to fight infection, and deficiencies of these nutrients are associated with negative health outcomes with chronic or recurrent infections. Hepatitis increases risk for nutrient imbalances, anorexia, and emesis (Brunell, 1992). Infants and children with otitis media in the first year of life have an increased risk of recurrent acute or chronic disease (Bluestone and Nozza, 1992). The committee did not find any research studies indicating nutrition risk resulting from upper respiratory infections, bronchitis, or otitis media. Chronic or Recurrent Infections as Indicators of Nutrition and Health Benefit The relationship between nutrition, the immune system, and health is very complex. The supplemental food provided through the WIC program provides nutrients that may be needed to maintain an individual's ability to fight chronic or recurrent infections. The WIC program's role in referring participants to health services provides additional benefits. The committee found no studies that indicated that supplemental food or nutrition education would improve the health of women, infants, or children with chronic or recurrent upper respiratory infections, bronchitis, or otitis media. Use of Chronic or Recurrent Infections as Risk Criteria in the WIC Setting Diagnosis of chronic or recurrent infections is made by a medical care provider and reported to WIC program staff. State WIC agency plans generally define "chronic" as a persistent condition present at the time of certification for the program, and "recurrent" as a condition that must have occurred more than 2 times over the past 12 months (USDA, 1994). Table 5-1 summarizes use of this risk indicator by state WIC agencies. Recommendations for Chronic or Recurrent Infections The risk of certain chronic or recurrent infections has been well documented for women, infants, and children. There is a theoretical and empirical basis for benefit from participation in the WIC program for individuals with serious infections such as tuberculosis. The committee recommends use of selected chronic or recurrent infections as a nutrition risk criterion for women,

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 185 infants, and children in the WIC program. However, the committee cautions that state WIC agency program plans should clearly define chronic or recurrent with each condition in its listing of nutrition risk criteria. The committee recommends discontinuation of chronic upper respiratory infections, bronchitis, otitis media, and chronic urinary tract infection (see earlier section) as nutrition risk criteria in the WIC program because of lack of scientific evidence to support nutrition benefit. HIV Infection and AIDS Prevalence of and Factors Associated with HIV Infection and AIDS The growing prevalence of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) among women (CDC, 1995b) has been accompanied by an increase in the number of children who have been infected perinatally. Mother-to-infant transmission cumulatively accounts for about 90 percent of all pediatric cases (CDC, 1994a). The CDC estimates that 1.6 to 1.7 of every 1,000 women tested in 1992 were HIV seropositive (CDC, 1994b). The prevalence of seropositive infants is much lower. Women made up 18 percent of adults and adolescents with AIDS reported in 1994. In 1994, CDC estimated that black women made up more than half of all reported cases of HIV/AIDS among women older than 13 years of age, and Hispanic women were also heavily overrepresented. The racial/ethnic distribution was similar for infants and children (CDC, 1994b). No data on the prevalence of HIV/AIDS in the WIC program population were available to the committee. The strikingly higher rates of HIV/AIDS in blacks and Hispanics are closely linked to poverty; and the ethnic distribution of Americans living in poverty closely resembles the distribution of AIDS cases (National Commission on AIDS, 1992). Populations living in poverty tend to have unequal access to preventive and medical care, lower standards of living, higher levels of unemployment, and higher rates of drug use and alcoholism. A study in Seattle, Washington, found that after controlling for other demographic and behavioral risk, income level was independently associated with HIV infection (Krueger et al., 1990). Risk indicators for HIV/AIDS include unprotected maternal or paternal sexual activity, maternal or paternal injection of illegal drugs, sexual abuse, bisexuality, exposure to HIV-contaminated blood or blood products, and consumption of HIV-contaminated breast milk (infants only).

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 186 HIV/AIDS as an Indicator of Nutrition and Health Risk As a member of the retrovirus family, HIV enters the cell and causes cell dysfunction or death. Since this virus primarily affects cells of the immune system, immunodeficiency results. HIV can replicate in T cells, B cells, monocytes, and macrophages. Recent evidence suggests that monocytes and macrophages may be the most important target cells and indicates that HIV can infect bone marrow stem cells. The leading indicators of AIDS are HIV-related immunosuppression (81 percent) and Pneumocystis carinii pneumonia (12 percent) in adults, and bacterial infections (19 percent) and P. carinii pneumonia (18 percent) in infants and children (CDC, 1994b). HIV wasting syndrome accounted for 10 percent of all conditions that are indicators of AIDS for adults and 17 percent for infants and children. Other major clinical findings associated with HIV infection (Chachoua et al., 1989) are failure to thrive, poor growth (McKinney and Robertson, 1993; Saavedra et al., 1995), oral candidiasis, parotitis, chronic or recurrent diarrhea, malabsorption, lymphoid interstitial pneumonitis, bacterial and viral infections, opportunistic infections, hepatomegaly, splenomegaly, encephalopathy, developmental delay, loss of developmental milestones, cardiomyopathy, and nephropathy. In addition to all the clinical findings presented above, other clinical symptoms associated with HIV infection in adults include such conditions as Kaposi's sarcoma, B-cell lymphoma, and lymphopenia (Chachoua et al., 1989). HIV infection is associated with the risk of malnutrition at all stages of infection. In the early stages, malnutrition may result from lifestyle factors such as drug abuse. As the disease process progresses, anorexia, intestinal malabsorption, diarrhea, drug-nutrient interactions, fever, secondary infection, and increased cytokine production may all contribute to PEM, the wasting syndrome, and to specific micronutrient deficiencies (Baum et al., 1994). PEM and specific micronutrient deficiencies have adverse effects on the immune system, pregnancy outcome, growth and development of infants and young children, organ (e.g., cardiac) function, and tolerance to treatment. HIV has been reported in human milk and has been documented to be passed from mother to infant by breastfeeding (Newell and Peckham, 1994; Ruff, 1994). A separate study by Semba et al. (1994) reported an increased risk of mother-to- child transmission of HIV among vitamin A deficient mothers. HIV/AIDS as an Indicator of Nutrition and Health Benefit Some prospective, observational evidence, mainly obtained from studies on homosexual men, indicates that optimizing nutrition among individuals with

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 187 HIV infection may retard disease progression (Abrams et al., 1993; LSRO/ FASEB, 1990; Semba et al., 1995; Tang et al., 1993). The observational study by Semba et al. (1994) indicates that optimal vitamin A status may have a protective effect on mother-to-child transmission of HIV, but this finding needs to be tested in an intervention study. A recent study of 118 vitamin A supplemented children of HIV-infected women in Durban, South Africa, found that these children had lower overall morbidity than the control group and that morbidity associated with diarrhea was significantly reduced in the supplemented infected children (Coutsoudis et al., 1995). HIV-infected women in the United States need to be advised against breastfeeding because of the risk of the vertical transmission of maternal virus to the infant (IOM, 1991), and their infants are likely to benefit from the formula WIC provides. Special interventions (e.g., special infant or enteral formula) may be necessary in infants and children with clinical evidence of HIV/AIDS. The potential benefits of ensuring optimal nutrition for HIV-infected women (during pregnancy and the postpartum period), infants, and children include improved maternal nutrition and health, improved infant and child growth and development, and, possibly, a slowing of disease progression. At present, there is a paucity of studies to demonstrate clear benefits of WIC program interventions for those with HIV/AIDS. However, the American and Canadian Dietetic Associations have taken the position that therapeutic and educational nutrition interventions should be components of care provided to HIV-infected individuals (American Dietetic Association, 1994). WIC program-related referrals to health care and social services may benefit those with HIV/AIDS and uninfected infants of infected mothers. Use of HIV/AIDS as a Nutrition Risk Criterion in the WIC Setting Health care providers report diagnoses of HIV infection or AIDS to WIC program staff. Table 5-1 lists the numbers of states using this diagnosis as a nutrition risk criterion. Recommendation for HIV/AIDS The risk of HIV/AIDS is well documented in women, infants, and children, and can be identified by clinical diagnosis. There is a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of HIV/AIDS as a nutrition risk criterion for women, infants, and children in the WIC program.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 188 Recent Major Surgery, Trauma, Burns, or Severe Acute Infections Most patients having major surgery do not experience serious malnutrition. However, the disease process or metabolic response to recent major surgery, trauma, burns, or severe acute infection can increase the risk of malnutrition and affect subsequent nutrient requirements for rehabilitation and recovery (Souba and Wilmore, 1994). The variability in the metabolic and physiologic responses to major surgery, trauma, burns, and severe acute infections is related in part to the patient's age, previous state of health, preexisting disease, previous stress, and specific pathogens. Prevalence of and Factors Associated with Recent Major Surgery, Trauma, Burns, or Severe Acute Infections Data on the prevalence of recent major surgery, trauma, burns, or severe acute infections among women, infants, and children in the U.S. population or participating in the WIC program were not available to the committee. Chronic and recurrent infections and HIV infection are discussed in previous sections of this chapter. Recent Major Surgery, Trauma, Burns, or Severe Acute Infections as Indicators of Nutrition or Health Risk The catabolic response to surgery occurs as a result of the traumatic insult of surgery and other complications of both preexisting disease and gastrointestinal function that diminish food intake (Souba and Wilmore, 1994). Persons experiencing severe trauma such as automobile accidents or burns exhibit a hypermetabolic state that may reach twice the basal levels and persist for 2 months or longer (Wilmore, 1977). Alterations in the metabolism of glucose, protein, and fat occur following injury. There is a marked rise in the regulatory hormones (glucagon, glucocorticoids, and catecholamines) in all phases of injury or after severe burn. The gut functions as a central organ of amino acid metabolism, a role that becomes more pronounced during a critical illness. Disuse of the gastrointestinal tract during major illnesses may lead to numerous physiologic derangements, changes in the microflora, impaired immune function in the gut, and disruption of the integrity of the mucosal barrier. Severe infections are characterized by prolonged fever, hypermetabolism, diminished protein economy, altered glucose dynamics, and accelerated lipolysis. Anorexia associated with severe infections contributes to the loss of lean body mass. Multiorgan and system involvement surrounding surgery, trauma, or

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 189 burns compound these metabolic effects and often affect function of the gastrointestinal tract, liver, heart, and lungs. Women who conceive during recovery from recent surgery, trauma, or burns may be at increased nutrition risk because the special nutritional needs of pregnancy are superimposed on those related to the metabolic response to trauma. Recent Major Surgery, Trauma, Burns, or Severe Acute Infections as Indicators of Nutrition or Health Benefit In part because of technologic and scientific advances in nutritional support, individuals who would have died in the past are now surviving complex surgical procedures, major trauma, burns, and sepsis (Souba and Wilmore, 1994). After discharge, there may be a continued need for high nutrient intake to promote completion of healing and to return to optimal weight and nutrition status. Supplemental food supplied by the WIC program is a source of key nutrients. Use of Recent Major Surger, Trauma, Burns, or Severe Acute Infections as Nutrition Risk Criteria in the WIC Setting Recent major surgery, trauma, burns, or severe acute infections are diagnosed by a health care provider and reported to WIC program staff or are self-reported during the certification process for participation in the WIC program, or at follow-up visits. See Table 5-1 for a summary of use of these specific nutrition risk criteria by WIC state agencies. In many cases, the recency of the condition is not specified. Recommendation for Recent Major Surgery, Trauma, Burns, or Severe Acute Infections The risk of recent major surgery, trauma, burns, or severe acute infections is well documented for women, infants, and children, and these conditions are identified easily. There is a theoretical and empirical basis for benefit from participation in the WIC program. Therefore, the committee recommends the use of recent major surgery, trauma, burns, or severe acute infections as nutrition risk criteria by the WIC program for women, infants, and children. If self-report is used as the basis for certification, a cutoff point of 2 months (Wilmore, 1977) is recommended.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 190 Other Medical Conditions There are other medical conditions with nutrition implications that are used as nutrition risk indicators in the WIC program that do not fit into the categories previously discussed in this chapter. This section covers the conditions of juvenile rheumatoid arthritis, lupus erythematosus, and cardiorespiratory disorders. Prevalence of and Factors Associated with Other Medical Conditions Juvenile rheumatoid arthritis. Juvenile rheumatoid arthritis (JRA) is the most common pediatric rheumatic disease and is the most common cause of chronic arthritis among children, occurring in approximately 0.01 percent of infants and children (Ekvall, 1993). JRA is thought to result from infection with unidentified microorganisms or an autoimmune reaction (Schaller, 1992). The disease persists throughout life. Individuals with JRA are at risk of joint stiffness, fever, anorexia, weight loss, failure to grow, and fatigue (Ekvall, 1993). Approximately 36 percent of these individuals experience PEM and have lower than recommended intakes of energy, vitamin E, calcium, and iron. Serum vitamin C is often low among patients who receive high dosages of aspirin. Lupus erythematosus. Lupus erythematosus is also an autoimmune disorder —one that affects multiple organ systems. Lupus erythematosus is more common in dark-skinned ethnic groups including blacks, Hispanics, Asians, and some American-Indian tribes, and is estimated to occur in 1 in 700 women between 15 and 65 years of age (Ferris and Reece, 1994). Lupus erythematosus increases risk of infections, malaise, anorexia, and weight loss (Schaller, 1992). Pregnant women with lupus erythematosus are at increased risk of late pregnancy losses (after 28 weeks gestation) secondary to hypertension and renal failure, of cardiac defects or heart block in the fetus, and spontaneous abortion (Ferris and Reece, 1994). Little is known about nutrient metabolism or requirements of pregnant or breastfeeding women with lupus erythematosus. Cardiorespiratory diseases. Cardiorespiratory diseases interfere with the normal physiological process. Congestive heart failure in infants and children is often accompanied by failure to thrive and malnutrition. Prevalence estimates on cardiorespiratory diseases in the U.S. population were not available to the committee. Growth failure can be present in individuals with cardiorespiratory disease and can be aggravated because of increased metabolic requirements and difficulty in sucking and swallowing (Ekvall, 1993). Salt intake must be limited for

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 191 persons having congestive heart failure. Low calorie intake and hypermetabolism are both postulated as causes of malnutrition among individuals with cardiorespiratory diseases. Data on the prevalence of the above disorders among women, infants, and children participating in the WIC program were not available to the committee. Other Medical Risks as Indicators of Nutrition and Health Benefit The WIC program can benefit individuals with medical risks through the provision of supplemental food, special dietary formulas as indicated, and referrals for health care services. WIC provides general nutrition and health education that focuses on maintaining dietary intake to meet the Recommended Dietary Allowance for age and the promotion of optimal growth or the prevention of obesity (Ekvall, 1993). Nutrition-related interventions as a part of medical management help correct growth and weight problems in children with JRA and lupus erythematosus (Schaller, 1992). Use of Other Medical Risks as Risk Indicators in the WIC Setting Other medical risks are diagnosed by a health care provider and reported to WIC staff. See Table 5-1 for a summary of use of these specific nutrition risk indicators by WIC state agencies. Note that JRA has not been used as a nutrition risk criterion in the WIC by state WIC agencies for infants or children (USDA, 1994). Recommendations for Other Medical Conditions The risks of juvenile rheumatoid arthritis, lupus erythematosus, and cardiorespiratory disorders are documented in women, infants, and children, and they can be identified by a clinical diagnosis. There is a theoretical and empirical basis for benefit from participation in the WIC program. Therefore, the committee recommends the use of juvenile rheumatoid arthritis, lupus erythematosus, and cardiorespiratory disorders as nutrition risk criteria for women, infants, and children in the WIC program. The committee recommends deletion of general diagnosis of arthritis as a nutrition risk criterion in the WIC program for women.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 192 CONDITIONS RELATED TO THE INTAKE OF SPECIFIC FOODS Food Alergies Food represents the largest antigenic challenge confronting the human immune system. Food allergies are illnesses that affect only part of the population. True food allergies involve abnormal immunologic responses to food-borne substances. With true food allergy, even minute amounts of the offending food can cause potentially life-threatening reactions. Two types of true food allergies occur: antibody-mediated and cell-mediated (Sampson, 1994). Allergens are typically naturally occurring proteins from the implicated food. Those proteins that are resistant to digestion can elicit the formation of antibodies, but only the formation of allergen-specific immunoglobulin E (IgE) elicits allergic sensitization. The antibody-mediated allergies (also known as atopy or immediate hypersensitivity) occur immediately after consumption of the offending food. The foods most commonly involved in IgE-mediated food allergies are peanuts, cow milk, eggs, soybeans, nuts from trees, wheat, and seafood. The sole known example of a cell-mediated food allergy is celiac disease, also known as gluten-sensitive enteropathy. This is a delayed hypersensitivity reaction because the onset time between ingestion of the offending food and development of symptoms can be from 24 to 72 hours later. Signs and symptoms of celiac disease result from the ingestion of the gluten protein fraction of wheat, rye, barley, triticale, and oats. Prevalence of and Factors Associated with Food Allergies The prevalence of IgE-mediated food allergies in the population is estimated to be between 4 and 8 percent of young infants, 1 and 2 percent of children, and less than 1 percent of adults (Sloan and Powers, 1986). The prevalence of celiac disease has been estimated at 1 in every 3,000 individuals in the United States (Ekvall, 1993). The prevalence of food allergies among the WIC population was not available to the committee. Food Allergies as Indicators of Nutrition and Health Risk Atopic diseases such as asthma, allergic rhinitis, and atopic dermatitis can all be precipitated by antigenic foods. Both upper and lower respiratory symptoms have been demonstrated as a result of food allergy; however, the role of nutrition part from avoidance of the allergenic food could not be documented.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 193 Infants are more susceptible to the development of food allergies than are adults: their digestive system may not yet be fully functional and the intestinal mucosa may be more permeable to proteins. Infants born to parents with histories of IgE-mediated allergies are most at risk for the development of food allergies. Many infants outgrow allergies to milk within a few months or years, but some food allergies, such as peanut allergy, may be more intransigent. Individuals with IgE-mediated food allergies are at risk of gastrointestinal disorders (e.g., nausea, vomiting, diarrhea, colic), atopic dermatitis, urticaria, angioedema, rhinitis, and the potentially life-threatening conditions anaphylactic shock and asthma. Celiac disease is a malabsorption syndrome that primarily affects the absorptive functions of the small intestine. The primary symptoms are body wasting, diarrhea, anemia, and bone pain. Food Allergies as Indicators of Nutrition and Health Benefit The avoidance of the offending food is the primary method of treatment for food allergies. Referral for dietary management is indicated for those with true food allergy. Exclusive breastfeeding for several months appears to reduce severe allergic disease in high-risk infants, but debate continues over whether restricting the mother's diet during lactation to avoid the common antigens (cow milk, seafood, soy, nuts, and eggs) confers additional benefit (Harrison, 1994). A prospective, randomized, controlled study of food allergen avoidance in infancy by Zeiger and Heller (1995) confirms benefit of nutrition intervention to reduce risk of severe food allergy but reports no benefit from third trimester food restrictions. Breastfeeding for 1 year may delay the onset of food allergies, but it does not decrease the likelihood of their development by 7 years of age. For allergic infants who are formula fed, WIC may provide special milk-free formula. A modified food package may be needed for maximum benefit. Use of Risk of Food Allergies as Nutrition Risk Criteria in the WIC Setting Food allergies are diagnosed by a physician and reported to the WIC program. Table 5-1 lists the use of food allergies as a nutrition risk criterion by state WIC agencies.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 194 Recommendation for Food Allergies The risk of food allergies is well documented for women, infants, and children, and this condition can be identified clinically. There is a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of food allergy and celiac disease as nutrition risk criteria for women, infants, and children in the WIC program. Food Intolerances Food intolerances occur through many different mechanisms. The primary categories of food intolerance include enzyme deficiencies, pharmacologic reactions, and idiosyncratic reactions with unknown mechanisms. These illnesses are of lesser importance than allergy because of finite tolerance levels for the offending foods among affected individuals. Also, the link between specific foods or food additives and food intolerances has not been proven in many cases. The best examples of food intolerances are lactose intolerance and sulfite-induced asthma. Lactose intolerance is a disorder in which a deficiency of -galactosidase in the small intestine results in reduced ability to digest and absorb lactose. Sulfite- induced asthma is an idiosyncratic illness—the mechanism of this reaction is not known. Prevalence of and Factors Associated with Food Intolerances The prevalence of lactose intolerance varies from 6 to 12 percent in northern European Caucasians to 60 to 80 percent in most other ethics groups (Rohr et al., 1985). The prevalence of noticeable lactose intolerance increases with advancing age; it is rare in otherwise healthy young infants but is a frequent occurrence following infectious diarrhea. In these individuals, recovery can be anticipated within a few weeks. Sulfites are a comparatively minor cause of asthma, affecting perhaps 1 to 2 percent of all asthmatic individuals. The prevalence of food intolerances among the WIC population was not available to the committee. Food Intolerances as Indicators of Nutrition and Health Risk The symptoms of lactose intolerance include abdominal cramps, flatulence, and frothy diarrhea. However, many individuals with lactose intolerance can tolerate the ingestion of small amounts of dairy products at any one time and a

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 195 number of small servings over the course of a day. Asthma is the only well- documented adverse effect of sulfite ingestion. Food Intolerances as Indicators of Nutrition and Health Benefit The committee found no empirical evidence of direct benefit of the WIC program for individuals with food intolerances other than lactose intolerance. Participation in the WIC program can provide special formula for affected infants; cheese, which is low in lactose, for women and children; and education about food sources of lactose and foods that can be substituted for milk to maintain a nutritionally balanced diet. Use of Food Intolerances as Nutrition Risk Criteria in the WIC Setting Diagnosis of food intolerance is reported to the WIC agency by a health care provider. Table 5-1 lists use of food intolerance as a nutrition risk criterion by WIC state agencies. Recommendations for Food Intolerances The risk of food intolerances other than lactose intolerance is not well documented in women, infants, and children. For lactose intolerance, there is a theoretical and empirical basis for benefit from participation in the WIC program, especially when lactose-reduced milk products are part of the food package. Therefore, the committee recommends use of well-documented symptomatic lactose intolerance as a risk criterion for women, infants, and children. However, the committee recommends discontinuation of nonspecific and poorly identified food intolerances. Given the lack of evidence to support the role of nutrition as an indicator of benefit for asthma, the committee recommends discontinuation of use of diagnosis of asthma as a nutrition risk criterion for women, infants, and children in the WIC program. CONDITIONS SPECIFIC TO PREGNANCY Pregnancy at a Young Age Pregnancy at young ages (i.e., before growth is complete) carries particular nutritional risk because of the potential for competition for nutrients between the needs for pregnancy and those for the woman's own growth. Adolescent pregnancy is generally regarded as conception before the 18th birthday, but postmenarchal age may be more important than chronologic age in quantifying risk,

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 196 with the first 2 years after menarche the most critical time (Zlatnik and Burmeister, 1977). Prevalence of and Factors Associated with Pregnancy at a Young Age The rate of births to teens ages 15 to 19 increased 24 percent between 1986 and 1991, from 50 to 62 births per 1,000 females (IOM, 1995). Low-income, minority status, and disadvantaged backgrounds are common scenarios among pregnant teenagers. Pregnancy at a Young Age as an Indicator of Nutrition and Health Risk Weight gain during pregnancy is more likely to be low in very young mothers, and adolescents often follow dietary practices that lead to low intakes of a variety of nutrients (IOM, 1990). Maternal age less than 15 years has been identified as a risk factor for LBW (IOM, 1995). Pregnancy at a Young Age as an Indicator of Nutrition and Health Benefit In one study of pregnant teens who participated in the WIC program, mean birth weight appeared to be increased, and the percentage of mothers delivering LBW infants decreased (Kennedy and Kotelchuck, 1984), but confirmation of these findings is needed. Since pregnant adolescents are likely to have many risk factors, they have substantial potential to benefit from the food package, nutrition education, and referral to health and social services. Use of Pregnancy at a Young Age as a Risk Criterion in the WIC Setting Table 5-1 lists the use of pregnancy at a young age as a nutrition risk criterion by state WIC programs. Cutoff points in use include conception at a specified number of years postmenarche and specific actual ages at conception. Recommendation for Pregnancy at a Young Age The risk of pregnancy at a young age is well documented in women, and it is easy to identify this condition. There is empirical evidence and a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of pregnancy at a young age as a nutrition risk for women in all state WIC programs, with a cutoff value of 2 years postmenarche.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 197 Pregnancy Age Older than 35 Years Prevalence of and Factors Associated with Pregnancy Age Older than 35 Years In the United States, the prevalence of women delaying childbearing continues to increase; from 1976 to 1986 the rate of first births among women 40 years of age or older doubled (NCHS and Ventura, 1989). Data on the prevalence of pregnancy above 35 years of age among the WIC population were not available to the committee. Pregnancy Age Older than 35 Years as an Indicator of Nutrition and Health Risk With advancing age, especially after age 35, risks associated with pregnancy increase. Most or all of this is due to the increasing likelihood of medical illnesses in the mother and congenital defects (i.e., chromosomal abnormalities) in the fetus (Berkowitz et al., 1990; Cefalo and Moos, 1988; Fretts et al., 1995). The extent of risk attributable specifically to nutrition in older mothers is highly questionable. Pregnancy Age Older than 35 Years as an Indicator of Nutrition and Health Benefit Although medical complications of pregnancy increase with increased age, and yield of risk would be high, there is little evidence of nutrition benefit from WIC participation and the services offered by the program. Recommendation for Pregnancy Age Older than 35 Years The risk of pregnancy age older than 35 years is well documented in women, and this condition can be identified easily. However, there is no theoretical or empirical basis for benefit from participation in the WIC program. Therefore, the committee recommends discontinuation of use of pregnancy age older than 35 years as a nutrition risk criterion for women in the WIC program. Closely Spaced Pregnancies Closely spaced pregnancies are commonly defined using either of two indicators: short interpregnancy interval (birth to conception interval), or short birth interval (the interval between the previous and sampled births). The interpregnancy interval is not affected by the length of gestation of the second pregnancy.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 198 Prevalence of and Factors Associated with Closely Spaced Pregnancies In 1991, 14 percent of all second- and higher-order U.S. births occurred within 18 months of the mother's previous birth, 28 percent within 2 years, and 52 percent within 3 years (CDC/NCHS, 1993). Black women are more likely than white women to have closely spaced pregnancies, regardless of the definition used (CDC/NCHS, 1993; Kalmuss and Namerow, 1994; Rawlings et al., 1995). For WIC program participants, over 30 percent had an interpregnancy interval of 23 months or less (Gordon and Nelson, 1995); only about 3 percent had intervals of 11 months or less. No data were found for the prevalence of shorter interpregnancy intervals. In a study of adolescent mothers, Kalmuss and Namerow (1994) reported that approximately 25 percent of adolescent mothers have a second child within 24 months of their first birth. The percentage is even higher (31 percent) for those age 17 years or less at the time of the first birth. Poverty is associated with closely spaced births among adolescents, while higher educational level of the parents is associated with longer intervals between births. Closely Spaced Pregnancies as an Indicator of Nutrition and Health Risk Mothers with closely spaced pregnancies have little time to recover from the physiologic and nutrition demands of the previous pregnancy. If such women are also breastfeeding, any negative effects of lactation on maternal nutritional status may further increase the risks of adverse outcomes of pregnancy, such as prematurity or fetal growth restriction (Cleland and Sathar, 1984; Hobcraft et al., 1985). This may occur because both the last portion of pregnancy and full lactation are periods of potential nutritional depletion for the mother (Winkvist et al., 1992). Becoming pregnant soon after the end of this period of depletion allows the mother little or no time for nutritional repletion. Prematurity leading to shorter birth intervals has also been suggested as an explanation for the relationship of closely spaced pregnancies with prematurity and fetal growth restriction. Where investigated (DaVanzo, 1984), both maternal depletion and prematurity seemed to play an equally important role. Studies of lactating women indicate that their nutrient or energy stores may be depleted if nutrient and energy intake are marginal, while milk tends to remain adequate in nutrient content (IOM, 1991). Although overlapping of lactation with pregnancy is uncommon in the United States, when it does occur, it can increase the risk of nutrient depletion. Using data from Guatemala, Merchant and colleagues (1990) found evidence of depletion of maternal nutrient stores caused by substantial overlapping of pregnancy and lactation.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 199 In studies using multivariate analysis, an interpregnancy interval of 3 months (or a comparable birth interval of 12 months) is reported to increase the risk of delivering an infant born preterm and with low birth weight (Rawlings et al., 1995), delivering an infant small for gestational age (SGA) (Miller, 1989), and neonatal death (Miller, 1989). None of these studies focused on low-income populations. In a study by Lang and co-workers (1990), the risk of preterm labor was increased twofold but was not statistically significant. In the Rawlings et al. (1995) study of 1,922 U.S. military families who have health care available without charge, the increased risk of delivering a preterm, low-birth-weight infant was seen for whites only for interpregnancy intervals of less than 3 months, while for blacks the cutoff was less than 9 months. Lieberman and colleagues (1989), in a study of nearly 4,500 women in Boston, found that women with interpregnancy intervals of 18 months or fewer were at twice the risk of giving birth to a full-term SGA infant when compared with women with interpregnancy intervals of 24 to 36 months. These results were obtained after adjusting for multiple confounding factors. The risk was lowest (2.4 percent) at interpregnancy intervals of 24 to 36 months. In contrast, for more than 2,000 low-income women with a birth interval of 2 years or less (which approximates a 15-month interpregnancy interval), multivariate analyses indicated an increased risk of spontaneous preterm delivery (Abrams et al., 1989) but not SGA (Abrams et al., 1991). In a much smaller study of healthy, nonsmoking women from private obstetric practices in Chicago, differences in interpregnancy interval were not associated with higher postpartum weight, subsequent pregravid weight, birth weight, or length of gestation (Farahati et al., 1993). A number of U.S. studies showed that closely spaced pregnancies increase the risk of the low birth weight (e.g., Brody and Bracken, 1987; Eisner et al., 1979; Spiers and Wang, 1976) without differentiating whether the low birth weight was a result of preterm birth or intrauterine growth retardation. In a multivariate analysis that used data from Hungary, Sweden, and the United States, Miller (1989) reported that maternal depletion did not explain the association of closely spaced pregnancies with SGA because the risk did not decrease with increasing length of the birth interval in the under-18-months range; however, in the Lieberman (1989) study, it did. Closely Spaced Pregnancies as an Indicator of Nutrition and Health Benefit The shorter the time between pregnancies, the shorter the time for repletion of nutrient stores. As reported in Chapter 4, women who received postpartum WIC program benefits for 5 to 7 months delivered infants with higher mean birth weights and birth lengths and a lower risk of low birth weight (Caan et al., 1987) than did women who received supplements for 2 months or less. Moreover,

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 200 the women who were supplemented longer had higher mean hemoglobin values and lower risk of maternal obesity at the beginning of their subsequent pregnancies. These results suggest that more repletion occurred in the women who received WIC program benefits for the longer period and suggests that WIC program participation may be beneficial to postpartum women with closely spaced pregnancies. Use of Closely Spaced Pregnancies in the WIC Setting Interpregnancy interval is the most practical and informative definition of closely spaced pregnancies to use in the WIC setting. Health care providers in the WIC setting can obtain the date of the previous delivery from self-report and the estimated date of conception from the patient's record. Table 5-1 shows that 52 states use closely spaced pregnancies as a risk criterion for pregnant women. The cutoff point varies widely, from three births in 24 months to intervals of &le; 25 months, and two states do not give a cutoff point. Recommendations for Closely Spaced Pregnancies Health risks of closely spaced pregnancies are reasonably well documented for pregnancy outcomes, especially those of women who have low-incomes and for interpregnancy intervals of 3 months or less. There is a theoretical basis for nutrition risk during the subsequent pregnancy and period of lactation, but information linking nutrition to the health risks is equivocal. Closely spaced pregnancies can be identified using information easily available through self- report and the patient's record. The committee recommends use of closely spaced pregnancies as a nutrition risk criterion for pregnant women, using a 6-month interpregnancy interval as the usual cutoff point, but increasing the cutoff point to a 9-month interpregnancy interval for women who are concurrently pregnant and lactating. The committee assumes that a postpartum women with a previous short interpregnancy interval will quality under another risk criterion. The committee recommends research on the associations of short interpregnancy intervals and such nutritional risk factors as prepregnancy weight, weight gain, and diet. High Parity Parity refers to the number of a woman's completed pregnancies that have reached the stage of viability. The cutoff values defining different parity groups

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 201 are usually first-order births or first pregnancy, first- and second-order births, and births of higher orders. Often, studies examine very high parity births, defined variously as four, five, or more previous pregnancies. High parity is closely related to other risk criteria, especially prior miscarriages and abortions, closely spaced pregnancies, and high age at conception. Prevalence of and Factors Associated with High Parity Estimates of the prevalence of high parity vary because of differences in the definition of high parity and the data source used. Population-based data generally use natality data from birth certificates for live-born U.S. infants and refer to the number of previous births since the number of previous viable pregnancies is not available. In 1993, 11 percent of all live births were fourth- and high-order births (Ventura et al., 1995). Black women giving birth are more likely than white women to be at higher parity; 16 percent of all births to black women were fourth- or higher-order births compared with 10 percent of all births to white women (Ventura et al., 1995; Cogswell and Yip, 1995). Among women of Hispanic origin, 15 percent of all live births in 1993 were fourth- or higher-order births, and among American-Indian women, 22 percent of all births were fourth- or higher-order births. Data from the 1988 National Maternal and Infant Health Survey (NMIHS) indicate that 16 percent of low-income pregnant women who were income- eligible for the WIC program had four or more previous pregnancies and 32 percent had three or more previous pregnancies (Gordon and Nelson, 1995). The percentage of prenatal WIC participants with three or more pregnancies was higher than this percentage among income-eligible nonparticipants (34 percent versus 29 percent). High Parity as an Indicator of Nutrition and Health Risk Empirical evidence points to two main risks of high parity: (1) poor pregnancy outcomes and infant growth and (2) long-term health risks to women. The rationale typically offered for expecting poorer pregnancy outcomes for women of high parity is maternal depletion (Merchant and Martorell, 1988). High parity implies frequent, and often closely-spaced, pregnancies, which could result in a deterioration in maternal nutrition status and increased risks of intrauterine growth retardation, low birth weight, and poor lactation performance. However, the relationship between maternal depletion and parity may be more complicated. Women of high parity may be those who are most fecund. If a woman's nutritional status deteriorates, her fecundity may decrease, resulting in lower parity (Winkvist et al., 1992).

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 202 In a comprehensive review of numerous studies of the determinants of low birth weight, Kramer (1987) concluded that, although lower mean birth weight is frequently observed for women of very high parity, few studies have adequately controlled for important confounding factors such as age, socioeconomic status, cigarette and alcohol use, genital infection, and interpregnancy intervals. Moreover, the few studies with adequate controls found either no significant effects of parity on mean birth weight or negative effects that only occurred at parity 14 or 15 (Kramer, 1987). Some recent studies also find no significant effects of high parity on the risk of intrauterine growth retardation (Miller, 1989; Springer et al., 1992). In contrast, an analysis of trends in low birth weight in the United States from 1975 through 1985 reported that, within each age group, the rates of low birth weight were higher for third- and higher-order births than for second-order births (Taffel, 1989). A study of the effects of maternal age and parity on birth weight in New York City reported significant increases in mean birth weight from parity 1 to parity 3, but marked declines in mean birth weight among higher parity groups (MacLeod and Kiely, 1988). Neither of these studies had adequate controls for socioeconomic status. An analysis of the determinants of infant and child mortality also found that higher-order births were at higher risk of poor birth outcomes, although the authors hypothesized that this increased risk could reflect the risks of advanced maternal age and close birth spacing (Hobcraft et al., 1985). Many studies find interaction effects of parity and age and parity and short interpregnancy birth interval on birth weight. In particular, multiparity increases the risk of low birth weight for women under age 20, although the independent effects of parity and short interpregnancy intervals for young women are difficult to disentangle (Kramer, 1987; MacLeod and Kiely, 1988). Kramer (1987) concluded that multiparity increases the risk of low birth weight for women under age 20, has little effect for women ages 20 to 34 years, and decreases the risk for women over age 35. High parity is also thought to be related to the long-term health status of women. Studies of the long-term effects of childbearing found that parous women had lower mortality from breast, ovarian, and endometrial cancer than did nulliparous women but a higher mortality from diabetes mellitus, gallbladder disease, cancer of the uterine cervix, nephritis and nephrosis, hypertension, ischemic and degenerative heart disease, cerebrovascular disease, and all causes of death (Beral, 1985). Focusing on specific health problems, high parity is associated with significantly increased risks of both non-insulin-dependent diabetes mellitus and impaired glucose tolerance, after controlling for age, obesity, and family history (Kritz-Silverstein et al., 1989). High parity has also been found to be associated

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 203 with increased risks of obesity and excessive weight gain, which in turn are risk factors for cardiovascular disease (Brown et al., 1992; Williamson et al., 1994). The weight gain associated with increased parity is generally thought to be modest. A prospective study of childbearing and 10-year weight gain in U.S. white women found an average weight gain of 1.7 kg associated with having one additional live birth after age 25. Nonetheless, the modest effect of each additional birth on weight gain shows potentially strong effects of very high parity on the risk of excessive weight gain and obesity. Specifically, the risk of gaining more than 13 kg and of becoming overweight was increased by 60 to 110 percent in women having live births during the 10-year study period (Williamson et al., 1994). Moreover, multivariate analysis of the participants in the 1988 NIMHS who began pregnancy with normal body mass index suggests that high multiparity1 was significantly associated with excessive maternal postpartum weight retention (> 20 lb) in black but not white mothers (Parker and Abrams, 1993). Overall, studies of the nutrition and health risks of high parity report mixed findings and often suffer from incomplete controls for potential confounding factors. High Parity as an Indicator of Nutrition and Health Benefit The equivocal evidence on the risks associated with high parity suggests that high parity is likely to be a poor indicator of nutrition and health benefit. Since the effects of high parity on mean birth weight and the risk of low birth weight are modest, at best, prenatal WIC participation by women at high parity is unlikely to influence birth outcomes. Finally, although there are some important long-term effects of high parity on women's health status, WIC participation is only likely to modify these effects through nutrition education and, perhaps, health care referrals. The WIC food package for women at high parity would not be expected to influence these long-term health impacts. No studies were identified that examined the effects of WIC participation for women at high parity. Use of High Parity in the WIC Setting State WIC agencies typically define high parity on the basis of the number of previous pregnancies and rely on self-report. Table 5-1 indicates the extent to which state WIC agencies use high parity as a risk criterion. In 1992, the cutoff 1 High multiparity was defined as more than three births if older than 25 years or more than two births if younger than 25 years; the reference group was other multiparous women.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 204 for high parity ranged from more than three to more than five pregnancies, and one state that used high parity as a risk indicator did not indicate a cutoff value. Recommendations for High Parity Studies of the nutrition and health risks of high parity are inconclusive and suggest few significant effects on birth outcomes that can be attributed specifically to high parity. While there is some evidence of long-term health risks of high parity, WIC participation is not likely to modify these long-term effects. Therefore, the committee recommends that high parity be discontinued as a nutrition risk criterion. Empirical evidence on the interactions of high parity with both age and short interpregnancy interval does suggest significant risks associated with high parity at young ages and high parity with short interpregnancy intervals. The committee recommends that consideration be given to the development of a nutrition risk criterion that reflects the combination of high parity and other nutrition risk criteria, such as age and interpregnancy interval. In addition, during the review of high parity as a risk criterion, it became clear that the highest parity-related risk is for first-order births. Specifically, first-borns have lower mean birth weight and a higher risk of low birth weight than subsequent births (Kramer, 1987; Cogswell and Yip, 1995; Macleod and Kiely, 1988; Miller, 1989; IOM, 1985; Taffel, 1989). An obstetrical risk screening system developed and used in a community-based setting in Massachusetts weighted the risks of parity 0 and parity 5+ equally, while parity 1-5 was considered to be the lowest risk (Kennedy, 1986). Current WIC nutrition risk criteria do not include a criterion for parity 0 (nulliparous women). While parity 0 is likely to be closely related to young age at conception, it is not perfectly correlated, and adverse outcomes have been documented for nulliparous women at older ages. Parity 0 may also be a maker for several important perinatal risk factors: a low level of knowledge about nutrition and the importance of health care, inadequate social support, and a lack of knowledge about eligibility for public assistance. The committee recommends that further research be conducted on the nutrition and health risks of parity 0 and on the effects of WIC participation on birth outcomes for women pregnant for the first time. History of Preterm Delivery Prevalence of and Factors Associated with History of Preterm Delivery Preterm birth (delivery before 37 completed weeks of gestation) is generally acknowledged to represent the predominant problem in obstetrics, in both

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 205 industrialized and developing societies. In 1991, approximately 11 percent of pregnancies in the United States ended early (Paneth, 1995); this was about 15 percent higher than in 1981. The prevalence of history of preterm delivery in the WIC program was not known to the committee. Maternal factors associated with history of preterm delivery or shortened gestational duration are low-income, ethnic background (blacks at higher risk), young age, smoking, poor nutrition, and low educational attainment (IOM, 1990; Paneth, 1995). History of Preterm Delivery as an Indicator of Nutrition and Health Risk Preterm delivery itself is the largest contributor to neonatal, infant, and perinatal mortality in the United States (IOM, 1990). History of preterm delivery is a major risk factor for preterm delivery in industrialized countries (Shoino and Behrman, 1995). History of Preterm Delivery as an Indicator of Nutrition and Health Benefit Nutrition interventions play a role in the prevention of preterm delivery by minimizing preventable factors such as anemia and inappropriate weight gain. While there are few published reports on nutrition intervention and gestational duration, low weight gain during pregnancy may increase risk of reduced gestational duration (see Chapter 4). Through the provision of supplemental foods, nutrition education, and referrals for health and social services the WIC program supports desirable weight gain during pregnancy and thus the potential to improve gestational duration. WIC program evaluations reported longer duration of gestation for WIC participants than for nonparticipants (Edozien et al., 1979; Rush et al., 1988b), although with uncertain statistical significance. Use of History of Preterm Delivery as a Nutrition Risk Criterion in the WIC Setting Table 5-1 lists the use of history of preterm delivery by state WIC programs. Recommendation for History of Preterm Delivery The risk of history of preterm delivery is well documented in women, and it can be identified from medical records or self-report. There is a theoretical basis for benefit from participation in the WIC program. The committee recommends use of history of preterm delivery as a nutrition risk criterion for women in the

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 206 WIC program, using the IOM (1990) cutoff value of 37 weeks' gestation for the previous occurrence. History of Postterm Delivery Prevalence of and Factors Associated with Postterm Delivery Postterm delivery (typically defined as pregnancy extending beyond 42 weeks from the onset of the last menstruation) is a fairly frequent occurrence. The prevalence of history of postterm delivery is difficult to ascertain because of uncertainties that typically surround estimation of gestational age. The prevalence of history of postterm delivery among WIC participants was not available to the committee. History of Postterm Delivery as an Indicator of Nutrition and Health Risk History of postterm delivery is associated with increased risks for the fetus, such as hypoxia, meconium aspiration, and macrosomia (ACOG, 1989). History of Postterm Delivery as an Indicator of Nutrition and Health Benefit The committee finds no evidence of benefit to support retaining history of postterm delivery as a nutrition risk criterion in the WIC program. Recommendation for History of Postterm Delivery The risk of history of postterm delivery is not well documented in women, and it is difficult to identify this because of uncertainties that typically surround estimation of gestation age. There is no theoretical or empirical basis for benefit from participation in the WIC program. Therefore, the committee recommends discontinuation of use of history of postterm delivery as a nutrition risk criterion for women by state WIC programs. History of Low Birth Weight Low birth weight (see section ''Low Birth Weight" in Chapter 4) occurs because of either preterm birth or fetal growth restriction. As discussed above, women who have delivered early are at increased risk of repeat preterm birth in a subsequent pregnancy, and those who have delivered an infant who is small

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 207 for gestational age are also at increased risk to repeat, especially if fetal growth was restricted because of a persistent condition such as maternal hypertensive disease. Thus, a history of LBW identifies a cohort of women at increased risk of delivering another LBW infant. There is some basis for anticipating benefit from nutritional intervention in case of preterm birth and fetal growth restriction. Since a history of LBW identifies women at increased risk for either of these two conditions, the committee recommends use of a history of LBW as a nutrition risk criterion. History of Neonatal Loss Neonatal loss is a vague term that encompasses death of the neonate from any cause. As such, it is not a useful nutritional risk criterion for the WIC program. History of LBW already encompasses a major contributing factor to neonatal death. History of Previous Birth of an Infant with a Congenital or Birth Defect Prevalence of and Factors Associated with a History of Previous Birth of an Infant with a Congenital or Birth Defect See the section "Genetic and Congenital Disorders" for information. History of Previous Birth of an Infant with a Congenital or Birth Defect as an Indicator of Nutrition and Health Risk Women who have previously had an infant affected by a neural tube defect are at increased risk of a recurrence (MRC Vitamin Study Research Group, 1991). Recent studies suggest that intake of folic acid may also be inversely related to the occurrence of cleft lip or cleft palate (Shaw et al., 1995). History of Previous Birth of an Infant with a Congenital or Birth Defect as an Indicator of Nutrition and Health Benefit For improved nutrition to reduce risk of recurrence of birth defects, the woman's increased nutrient intake needs to occur prior to and in the early weeks of pregnancy. Except in the case of closely spaced pregnancies, this is not ordinarily a period when women are served by the WIC program. It is not known if improved nutrient intake will lead to other improvements in pregnancy outcome.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 208 Use of History of Previous Birth of an Infant with a Congenital or Birth Defect in the WIC Setting In 1992, at least 32 states used this criterion (Table 5-1). Recommendation for History of Previous Birth of an Infant with a Congenital or Birth Defect The risk of history of previous birth of an infant with a congenital or birth defect is well documented. The potential to benefit from WIC program participation is uncertain. The committee recommends use of history of a previous birth of an infant with a congenital or birth defect, particularly a neural tube defect, as a nutrition risk criterion for pregnant women. Lack of Prenatal Care Prenatal care is defined in Standards for Obstetric-Gynecologic Services (ACOG, 1985) and Guidelines for Perinatal Care (AAP-ACOG, 1992). Prenatal care serves as a means to monitor the progress of the mother and the developing fetus. The components of prenatal care include pregnancy dating, establishing goals, risk assessment, education, and clinical and laboratory tests. As risks are identified, referrals should be made to appropriate medical and social services, including referrals to the WIC program (IOM, 1985). Prevalence of and Factors Associated with Lack of Prenatal Care Lack of or inadequate prenatal care is defined as lack of entry into prenatal care by a specified number of weeks' gestation or fewer than a specified number of prenatal care visits for stage of gestation as recognized by the American College of Obstetricians and Gynecologists (ACOG) (Witwer, 1990). Although recent surveys report that 98 percent of American women receive some form of prenatal care, in 1992, 22 percent of all women did not begin prenatal care during the first trimester (Shiono and Behrman, 1995). A study by the U.S. General Accounting Office (1987) reported 71 percent of low-income women experienced problems obtaining prenatal care because of inadequate financial resources and barriers to transportation and health care services. Data on the lack of prenatal care among WIC participants were not available to the committee. Documented risk factors for lack of or inadequate prenatal care include young maternal age, nonwhite ethnic background, and low maternal education

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 209 (Curry, 1990). In addition, poverty, unemployment, other socioeconomic factors, and single marital status have been reported as risk factors (IOM, 1990). Lack of Prenatal Care as an Indicator of Nutrition and Health Risk Women who do not receive early and adequate prenatal care are more likely to deliver premature, growth-retarded, or low-birth-weight infants and to gain too little weight during pregnancy (Alexander and Korenbrot, 1995; IOM, 1990; USDA, 1991a). Lack of Prenatal Care as an Indicator of Nutrition and Health Benefit Several studies have reported significant nutrition and health benefits for pregnant women through early enrollment in the WIC program (Rush et al., 1988b). Other studies have reported improved birth outcomes and associated savings in health care expenditures in pregnant women enrolled early in the WIC program (Buescher et al., 1993; Devaney et al., 1990). However, there were not any studies available to the committee to evaluate definitively the effects of timing of prenatal care in relation to WIC services on pregnancy outcome, and most studies treated prenatal care as the presence or absence of care, not number of visits or timing of care (USDA, 1991a). Many studies predict improved birth outcomes through participation in the WIC program, but the results cannot be considered conclusive because of methodological problems (Rush et al., 1988a). However, Alexander and Korenbrot (1995) report that the interventions of most benefit to the mother and fetus include nutrition (to improve prepregnancy weight or gestational weight gain and reduce risk of low-birth-weight infants), smoking cessation (to prevent low-birth-weight infants), and medical care (to improve general morbidity). The review concludes that access to and utilization of prenatal care services reduces risk factors for poor pregnancy outcomes and must be part of a broad, unified approach to public health that includes nutrition interventions. Use of Lack of Prenatal Care as a Nutrition Risk Criterion in the WIC Setting According to 1992 state plans, lack of prenatal care or inadequate prenatal care is used as a risk criterion in 18 state WIC agencies (USDA, 1994). Cutoffs for establishing the presence of this risk criterion in the WIC program are generally based on the interval between conception and initiation of prenatal care or less than a specified number of prenatal care visits at a stated length of gestation.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 210 Recommendations for Lack of Prenatal Care The nutritional risk of lack of prenatal care is documented in women, and this can be identified readily. There is empirical evidence and a theoretical basis for benefit from WIC program participation. Therefore, the committee recommends use of lack of prenatal care or inadequate prenatal care as a nutrition risk criterion for women in the WIC program, with a cutoff value of care beginning after the first trimester or long intervals between additional visits (see AAP-ACOG, 1992). In addition, the committee recommends that its relative priority be reduced to priority level VII. Multifetal Gestation Prevalence of and Factors Associated with Multifetal Gestation The prevalence of multifetal gestation is considerably higher than the traditional estimate of one in 75 conceptions. Part of this increase reflects improved methods of early diagnosis with sonography, and part reflects the use of ovulation-inducing agents in assisted reproductive technologies. Older maternal age, black race, and previous family history are also associated with increased prevalence of multifetal gestation. Although less than 2 percent of all births are twin births, twins accounted for 16 percent of LBW infants (IOM, 1990). Data on the prevalence of multifetal gestation in the WIC program are not available. Multifetal Gestation as an Indicator of Nutrition and Health Risk The women carrying more than one fetus presents a high-risk situation, with increased risk of preterm labor, impaired fetal growth, placental and cord accidents, and preeclampsia. The risk increases markedly as the number of fetuses increases, but even with twins the incidence of complications is substantial. There is considerable reason to believe that nutrition is involved. Based on a review of evidence regarding weight gain in women carrying twins, the IOM (1990) concluded that a total gain of 16 to 20.5 kg (35–45 lb) is consistent with a favorable outcome in a full-term twin pregnancy. This range, which represents the first weight gain recommendation for twins, translates to a weekly gain of about 750 g during the second and third trimesters. Women pregnant or breast-feeding with twins have greater requirements for all nutrients than those with only one infant.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 211 Multifetal Gestation as an Indicator of Nutrition and Health Benefit The need for increased weight gain associated with multifetal gestation and the increased nutrient needs mentioned above suggest that this nutrition risk criterion is a good predictor of benefit from the supplemental food, nutrition education, and health and social service referrals provided by the WIC program. No empirical evidence of this relationship was available to the committee. Use of Multifetal Gestation in the WIC Setting Multifetal gestation is generally determined via sonography and reported to WIC by the health care provider. Multifetal gestation is used as a nutrition risk criterion in the WIC by 51 state WIC agencies (USDA, 1994). Recommendation for Multifetal Gestation The risk of multifetal gestation is well documented in women, and this condition can be identified by a clinical diagnosis. There is a theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of multifetal gestation as a nutrition risk criterion for pregnant, breastfeeding, and postpartum women in the WIC program. Fetal Growth Restriction Physical examination of the pregnant woman by a health care provider may allow diagnosis of fetal growth restriction. The many causes of fetal growth restriction (this term replaces intrauterine growth retardation) can be conveniently grouped as intrinsic or extrinsic to the fetus. Intrinsic causes include fetal infections and chromosomal and other congenital anomalies; extrinsic causes include maternal dietary inadequacy, vascular disease, and placental and cord abnormalities. Whenever fetal growth restriction is suspected, a careful dietary assessment of the mother is advised (Luke et al., 1993). Although inadequate maternal nutrition is but one cause of fetal growth restriction, it is one of the few causes that are responsive to remedial therapy. Prevalence of and Factors Associated with Fetal Growth Restriction Data on the prevalence of fetal growth restriction among WIC participants or in the U.S. population were not available to the committee. Restricted fetal growth usually results in an infant who is small for gestational age, discussed in Chapter 4.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 212 Fetal Growth Restriction as an Indicator of Nutrition and Health Risk Infant size at birth is a critical determinant of long-term child health outcomes (see review by McCormick, 1985). Newborn infants whose growth was restricted during gestation are at risk of respiratory distress, hypoglycemia, hypocalcemia, polycythemia, birth asphyxia, intracranial hemorrhage, and long- term cognitive delays (IOM, 1990). Fetal Growth Restriction as an Indicator of Nutrition and Health Benefit Decreased cigarette smoking, improved diets, and improved utilization of early prenatal care during the 1970s may have contributed to the observed improvement in birth weights. Energy supplementation during pregnancy may decrease the incidence of fetal growth restriction with or without concurrent increases in gestational weight gain (IOM, 1990). Studies have shown that food supplementation during pregnancy to improve weight gain reduces the risk of fetal growth restriction (IOM, 1990). The WIC program holds potential to reduce fetal growth restriction by providing supplemental foods and nutrition education to improve weight gain. Use of Fetal Growth Restriction as a Risk Criterion in the WIC Setting Fetal growth restriction is a diagnosis reported to WIC programs by a health care provider. An abnormally slow rate of intrauterine growth may be detected by careful serial measurements of uterine fundal height and abdominal girth and confirmed by ultrasonography. Fetal growth restriction is usually defined as a fetal weight below the 10th percentile for gestational age. Fetal growth restriction is used as a risk indicator for pregnant women in 17 state WIC agencies (USDA, 1994). Recommendation for Fetal Growth Restriction The risk of fetal growth restriction is well documented in women, and a suitable method for identifying this condition is available. There is a theoretical and empirical basis for benefit from participation in the WIC program. Therefore, the committee recommends use of fetal growth restriction as a nutrition risk criterion for pregnant women in the WIC program.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 213 Preeclampsia and Eclampsia Preeclampsia is diagnosed when a previously normal gravida develops hypertension and proteinuria in late gestation, and eclampsia refers to preeclampsia plus either convulsions or coma. Both conditions are limited largely to women in their first pregnancy, and they are strongly associated with low- income, low educational attainment, and poor nutrition (Henderson and Little, 1990). Prevalence of and Factors Associated with Preeclampsia and Eclampsia Preeclampsia occurs in approximately 6 to 8 percent of all pregnancies. Data on the prevalence of preeclampsia or eclampsia among the WIC population were not available to the committee. Preeclampsia and Eclampsia as Indicators of Nutrition and Health Risk Preeclampsia is strongly associated with an increased risk of LBW in infants (Henderson and Little, 1990). It is also associated with fetal growth restriction resulting from decreased delivery of nutrients or oxygen through the uteroplacental circulation (Henderson and Little, 1990), and with preterm delivery (IOM, 1985). Preeclampsia and Eclampsia as Indicators of Nutrition and Health Benefit Although high calcium intake may reduce the risk of developing preeclampsia (IOM, 1990; Ito et al., 1994; Repke, 1994; van den Elzen et al., 1995), the committee could find no theoretical or empirical basis for expecting those with a diagnosis of preeclampsia or eclampsia to benefit from participation in the WIC Program. Use of Preeclampsia and Eclampsia as Risk Criteria in the WIC Setting Preeclampsia or eclampsia are diagnosed by a health care provider. As a risk criterion for pregnant women in the WIC program, preeclampsia or eclampsia is used by all state WIC agencies (USDA, 1994).

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 214 Recommendation for Preeclampsia and Eclampsia The risk of preeclampsia or eclampsia is well documented in pregnant women, and this condition can be identified by a clinical diagnosis. There is no theoretical basis or scientific evidence for nutrition benefit from participation in the WIC program. Therefore, the committee recommends discontinuation of use of preeclampsia or eclampsia as a nutrition risk criterion for pregnant women in the WIC program. Placental Abnormalities Prevalence of and Factors Associated with Placental Abnormalities The placenta normally implants in the uterine fundus and remains attached until after delivery of the infant. Occasionally, the placenta may be found in the lower portion of the uterus, near or over the cervix, where the normal prelabor changes of late gestation can lead to premature separation of a portion. This condition is called placenta previa. In addition, the normally implanted placenta can separate prematurely, a condition known as abruptio placentae or abruption. Placental Abnormalities as an Indicator of Nutrition and Health Risk Extreme and acute placental separation interferes with fetal oxygenation and can lead to fetal death, but small and gradual separation may be tolerated reasonably well. If continued over long periods, such a case of chronic separation can lead to blood loss anemia in the pregnant woman. Medical care and monitoring is indicated in the case of placental separation. The committee found no evidence of nutrition-related risks in placental abnormalities, except for the occasional case of anemia due to chronic blood loss. Placental Abnormalities as an Indicator of Nutrition and Health Benefit No theoretical base or studies were identified by the committee related to the benefits of nutrition intervention for pregnant women with placental abnormalities or with a history of placental abnormalities. Use of Placental Abnormalities in the WIC Setting Presence of placental abnormalities are diagnosed and reported by a health care provider. According to 1992 state WIC plans, diagnosis of a placental abnormality

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 215 (abruptio placentae) is used as a nutrition risk criterion by 15 state WIC agencies (USDA, 1994) (see Table 5-1). Recommendation for Placental Abnormalities The risk of placental abnormalities is well documented in women, and this condition can be identified by a clinical diagnosis. There is no theoretical basis for benefit from participation in the WIC program. Therefore, the committee recommends discontinuation of use of placental abnormalities as a nutrition risk criterion for women in the WIC program. CONDITIONS SPECIFIC TO INFANTS AND/OR CHILDREN Prematurity Causes of prematurity include preterm spontaneous labor, antepartum hemorrhage, premature rupture of membranes, and maternal hypertension (IOM, 1990). Other associated conditions are low maternal age, low maternal weight, poor socioeconomic status, diabetes mellitus, nephritis, anemia, fetal anomalies, and multiple pregnancies (IOM, 1985; IOM, 1990). Incidence of and Factors Associated with Prematurity The incidence of prematurity ranges from approximately 8 percent for white infants to 18 percent for black infants. No estimate of the prevalence of prematurity among the WIC population was available to the committee. Prematurity as an Indicator of Nutrition and Health Risk Most premature infants have low birth weights (< 2,500 g); some have very low birth weights (VLBW, < 1,500 g). Other problems of prematurity that may have nutritional implications include immature sucking and swallowing; immature digestion and absorption of carbohydrates and lipids; immature excretory capacity; patent ductus arteriosus; poorly developing nutrient stores of vitamin E and iron; need for high mineral accretion rate (calcium and phosphorus); necrotizing enterocolitis; and small gastric capacity (Paneth, 1995).

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 216 Prematurity as an Indicator of Nutrition and Health Benefit Despite their increased caloric and nutrient needs for rapid growth, premature infants grow well on breast milk and may benefit from some of its unique nonnutritional components. Thus, encouragement to express milk until the newborn can feed orally and other forms of breastfeeding promotion may promote infant health. However, the mother's milk may need to be supplemented (from 20 kcal/oz to 24 to 30 kcal/oz). When used, formulas may need to be somewhat concentrated to optimize growth. A choice of feeding method— parenteral, enteral, gavage, bottle, or breast—is determined after evaluation of the infant's suck-swallow mechanism, gut maturity, and general clinical condition. After a preterm infant is large enough to leave the hospital, macro- and micronutrient needs continue to be higher than for term infants, especially during the first few months. The WIC program provides education about infant feeding and either an expanded breastfeeding supplemental food package (see Chapter 1) for mothers, to help cover the increased energy and nutrient demands of breastfeeding, or infant formula. Most premature infants catch up to normal growth and development indices by the second year of life. There is no indication of benefit of nutrition services to children who were premature at birth but who meet no other risk criteria (see earlier sections of this chapter on health problems associated with prematurity and Chapter 4 on growth delay). Use of Prematurity as a Risk Criterion in the WIC Setting Prematurity is reported to WIC program staff either by the mother or a health care provider. Table 5-1 lists the use of prematurity as a risk criterion by state WIC programs for infants and children. The cutoff point used by state WIC programs is 37 or 38 weeks. Recommendations for Prematurity The risk of prematurity is well documented in infants, and a suitable method is available to identify this condition. There is a theoretical and empirical basis for benefit from participation in the WIC program. Therefore, the committee recommends the use of prematurity as a nutrition risk criterion for infants, with a cutoff value of 37 weeks; but it recommends discontinuation of prematurity as a nutrition risk criterion for children.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 217 Hypoglycemia Hypoglycemia is defined as a blood glucose concentration less than 40 mg/ dl (Sperling, 1992). Symptomatic hypoglycemia is a risk observed in a substantial proportion of newborns who are small for gestational age (SGA), but it is uncommon and of shorter duration in newborns who are of the appropriate size for gestational age (IOM, 1990). In newborns, the symptoms may consist of jitters, tremors, lethargy, and apneic spells. Significant risk factors for hypoglycemia in infants include black race for males (Cole and Peevy, 1994), preterm birth, small for gestational age infant, and maternal diabetes mellitus (Singhal et al., 1992). Prevalence of and Factors Associated with Hypoglycemia Data on the prevalence of hypoglycemia among infants or children in the United States or among WIC program participants were not available to the committee. Hypoglycemia as an Indicator of Nutrition and Health Risk For SGA newborns, there may be a defect in the gluconeogenesis pathway and an imbalance among glycogen stores, fatty acid oxidation, and endocrine controls. All infants with fetal growth restriction must be considered at high risk for hypoglycemia during their first few days. Hypoglycemia as an Indicator of Nutrition and Health Benefit Nutrition management for infants and children with hypoglycemia must concentrate on frequent feedings and the provision of adequate glucose and nutrients to prevent deficiencies and to support adequate growth. Use of Hypoglycemia as a Risk Criterion in the WIC Setting Table 5-1 lists the number of states that use hypoglycemia as a nutrition risk criterion in the WIC. Recommendation for Hypoglycemia The risk of hypoglycemia is well documented among infants, and this condition can be diagnosed clinically. There is a theoretical basis for benefit from

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 218 participation in the WIC program. Therefore, the committee recommends use of hypoglycemia as a nutrition risk criterion for infants and children in the WIC program. POTENTIALLY TOXIC SUBSTANCES Long-Term Drug-Nutrient Interactions or Misuse of Medications This section covers interactions between prescription and over-the-counter medications and nutrients. Illegal drug use is discussed in the section ''Alcohol and Illegal Drug Use." Interactions between drugs and nutrients can be physicochemical, physiologic, or patho-physiologic (Roe, 1994). Physicochemical interactions result in reduced absorption of the drug, one or more nutrients, or both. Physiologic interactions are those that either slow or accelerate the uptake of drugs. Pathophysiologic interactions include those in which drugs, through their toxicologic effect, cause cellular damage so that nutrients cannot be activated within, used by, stored in, or removed from the body. Prevalence and Factors Associated with Drug-Nutrient Interactions or Misuse of Medications Prescription or over-the-counter drugs are widely used, and are sometimes misused. All drugs provided to or taken by pregnant women can be considered potentially harmful to the fetus because of cross-placental transfer and teratogenicity (Roe, 1994). Data on the prevalence of the use of prescription or over-the-counter drugs or drug-nutrient interactions in the WIC program were not available to the committee. Drug-Nutrient Interactions or Misuse of Medications as Indicators of Nutrition and Health Risk Predicting the risk of drug-nutrient interactions requires consideration of multiple factors. In addition to pharmaceutical preparations, some vitamins and their analogs may have both pharmacologic and nutrient properties. Absorption of most drugs occurs by diffusion through any portion of the mucosa of the gastrointestinal tract. Food components affect drug absorption and bioavailability (Welling, 1977), but effects differ for different drugs. Three general mechanisms explain these effects: gastric emptying time, interactions with the gut, and competitive inhibition. High-protein diets enhance metabolism

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 219 of some drugs, and protein-deficient diets tend to slow drug metabolism (Anderson et al., 1979; Kato et al., 1968). The level and type of dietary fat may affect drug absorption and metabolism. Drugs may affect appetite by their central and peripheral effects. Any drug that induces nausea, impairs the sense of taste, or has adverse effects on the gastrointestinal tract is likely to reduce food intake and hence to contribute to weight loss. Drugs used for cancer chemotherapy are the most important group of drugs that reduce appetite. Drugs such as phenothiazine, lithium, and benzodiazepine increase appetite. Certain drugs can deplete stores of such nutrients as vitamin K, calcium, and vitamin D. The mechanisms responsible for drug-induced maldigestion and malabsorption include the interactions of the drug and nutrients in the gastrointestinal tract, drug-induced changes in gastrointestinal function, and drug-induced enteropathy causing damage to the brush border of the intestinal villi, which results in interference with active transport mechanisms for nutrients (Roe, 1994). The risk of adverse side effects of drugs depends on the toxicity of the drug and secondary effects on appetite, and it increases with the number of drugs taken at the same time and with the duration of exposure. Misuse of certain drugs during early pregnancy can result in fetal malformations. Recently intake of more than 10,000 I.U. of vitamin A (retinol) daily from supplements was associated with increased risk of cranial-neural-crest origin birth defects (Rothman et al., 1995). Use of some prescription or over-the-counter drugs is not advisable when breastfeeding because of health risks to the infant, as covered in detail by the Committee on Drugs of the American Academy of Pediatrics (COD-AAP, 1994). Drug-Nutrient Interactions or Misuse of Medications as Indicators of Nutrition and Health Benefit Adverse effects of drug-nutrient interactions can be minimized through adequate nutrient intake and education about meeting dietary needs and timing of drug intake in relation to meals or breastfeeding. Participation in the WIC program may provide health and nutrition benefit through basic health education, particularly during pregnancy, supplemental foods that help maintain nutrient stores, and referrals to health care services for those in need of additional counseling or medical management because of adverse effects of drug-nutrient interactions.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 220 Use of Drug-Nutrient Interactions or Misuse of Medications as Risk Indicators in the WIC Setting No cutoff point for prescription or over-the-counter drug use or drug- nutrient interactions has been identified beyond the actual existence of documented drug-nutrient interactions or occurrences of misuse. Table 5-1 summarizes use of the risk indicator by state WIC agencies. Recommendations for Drug-Nutrient Interactions or Misuse of Medications The risk of specific drug-nutrient interactions or misuse of medications is documented in pregnant and lactating women, and the use of prescription and over-the-counter medications can be identified by the health care provider. There is a theoretical basis for benefit from participation in the WIC program. However, the potential to benefit is divided between those drugs for which a clear nutrient interaction is present, and those for which the interaction is weak or unclear. Therefore, the committee recommends use of drug-nutrient interactions or misuse of medications as a nutrition risk criterion for pregnant and lactating women in the WIC program, but only for a predetermined listing of pharmaceutical agents that have a known direct effect on nutrition. The committee encourages that such a listing be developed and made available to state WIC agency staff to ensure adequate assessments and referrals. Maternal Smoking Cigarette smoking continues to be a major public health threat in the United States, particularly among families who meet the WIC criteria for eligibility. Smoking generally refers to the active use of cigarettes and the recurring inhalation of tobacco smoke. In the present context, exposure to tobacco smoke is defined by: (1) fetal exposure to the components of tobacco that cross the placenta and enter fetal circulation, and (2) exposure after birth to tobacco- smoke-contaminated air either at home or in other environmental contexts (Samet et al., 1994). This section covers fetal exposure to maternal smoking. Exposure to tobacco smoke among infants and children after birth is discussed in Chapter 7. Prevalence and Factors Associated with Maternal Smoking The prevalence of tobacco use has decreased dramatically since the first report issued by the Surgeon General's Advisory Committee on Smoking and Health in 1964. This decline resulted from widespread educational efforts to

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 221 discourage tobacco and a substantial increase in the cessation of smoking among older adults. In 1991, 22 percent of women 18 to 24 years of age smoked, as did 28 percent of women 25 through 44 years of age (U.S. Department of Commerce, 1993). Of concern to WIC is that young females with low levels of education have shown the least reduction in smoking. The change in prevalence of smoking among white adolescents was negligible from 1980 to 1992 (DHHS, 1994). Prevalence of smoking is comparatively high among blacks, blue collar workers, and workers with lower levels of education (DHHS, 1989). According to WIC program data, in 1986, approximately 12 percent of pregnant women participating in the WIC program were certified using smoking as a nutrition risk criterion in the WIC program (USDA, 1987), and 16 percent were certified on the same basis in 1988 (USDA, 1994). Maternal Smoking as an Indicator of Health and Nutrition Risk Maternal cigarette smoking during pregnancy is associated with high rates of spontaneous abortions, stillbirths, bleeding during pregnancy, placental complications (abruptio placentae, placenta previa), complications of labor (preterm labor, prolonged and premature rupture of the membranes), fetal growth restriction (measured as decreased total body weight, decreased lean body weight, decreased length and head circumference), increased rates of small size for gestational age (SGA), and perinatal mortality. (For recent reviews, see Abel 1980; Berkowitz 1988; DHHS, 1989; Fredricsson and Giljam, 1992; Garn, 1985; Gilstrap and Little, 1992; Lincoln, 1986; Luke et al., 1993; and Naeye, 1992). Many reviewers concluded that adverse effects of maternal smoking on prematurity (Kramer, 1987; Shiono et al., 1986a) and certain types of neonatal mortality (e.g., respiratory distress syndrome and sudden infant death syndrome) are firmly established, and that they increase with maternal age (Luke et al., 1993). A number of studies conclude that there is no association between maternal smoking and congenital malformations (de Haas, 1975; Malloy et al., 1989; Seidman et al., 1990; Shiono et al., 1986b); however, one study indicated there may be an increased risk for specific malformations, including microcephalus, cleft defects, and club foot (Van den Eeden et al., 1990). There is ongoing debate about the exact nature of the mechanisms associated with smoking in the prenatal environment (e.g., Backe 1993; Cliver et al. 1992; English and Eskenazi 1992; Goldstein 1977; Hebel et al. 1988; Kleinman et al. 1988; Kline et al. 1977; Macarthur and Knox, 1988; Naeye, 1978; Shiono et al., 1986a; Wen et al., 1990; Yerushalmy, 1971). Several large prospective studies (the National Child Development Study of Great Britain; the U.S. National Collaborative Perinatal Project (NCPP); the Seattle, Washington, Longitudinal Study; and the Ottawa Prenatal Prospective

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 222 Study) and a few smaller studies have revealed consistent deficits in stature and other anthropometric measures among infants of smokers (reviewed by Rush and Callaghan, 1989). Heavy maternal smoking causes up to 10 percent deficits in birth weight, 5 percent deficits in birth length, and 2 percent deficits in head circumference. These deficits are proportional to the level of smoking and the duration of smoking while pregnant and are not rapidly countered by postnatal catch-up growth (Elwood et al., 1987). In most smokers the cumulative effects of smoking combined with alcohol or caffeine consumption must be considered. In a prospective study in Denmark (Olsen et al., 1991), higher levels of alcohol consumption were associated with a reduction in average birth weight of about 40 g, which increased to 200 g when the mother also smoked. Mean birth weights were more than 500 g higher for nonsmoking abstainers than for heavy smokers and drinkers. A Canadian study involving heavy smokers (15+ cigarettes per day) found a reduction in birth weight of more than 200 g when the mother consumed 300 mg or more of caffeine per day (Beaulac-Baillargeon and Desrosiers, 1987). Similarly, in London (Brooke et al., 1989; Peacock et al., 1991), consumption of caffeine and alcohol was found to be directly related to birth weights that were 10 to 18 percent lower for babies of smokers, independent of smoking levels (actual birth weights not reported). These effects were strongest when consumption was early in the pregnancy. Longitudinal data on postnatal growth and development from studies in Pittsburgh (Day et al., 1992), Ottawa (Fried and O'Connell, 1987), and Michigan (Jacobson et al., 1994) suggest that the interaction of alcohol consumption and smoking during pregnancy may have significant adverse effects on postnatal growth and development. Evidence is equivocal that maternal smoking during pregnancy has important long-term negative effects on the growth, development, behavior, and cognition of the infant, in addition to its fetal effects. The most consistent predictors of fetal growth restriction are small maternal size, low maternal weight gain, history of previous low-birth-weight infant, and smoking (Kramer, 1987). It has long been hypothesized that reductions in birth weight associated with maternal smoking are in fact nutritionally mediated. Early researchers suggested that much of the effect of maternal smoking during pregnancy was mediated through reduced maternal weight gain (e.g., Davies and Abernethy, 1976; Lancet, 1979; Rush, 1974, 1976). In particular, they attributed the comparatively lower gestational weight gain of smokers to lower caloric intake. Subsequent work showed that, among women at equivalent levels of smoking, growth restriction in the infants was inversely related to higher gestational weight gain and higher prepregnancy weight (Garn et al., 1979; Luke et al., 1981). Moreover, within maternal weight gain or prepregnancy weight categories, frequencies of LBW and absolute values of birth

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 223 weight, length, and head circumference were related to the level of smoking (Meyer, 1978; Luke et al., 1981). However, the apparent mediating effect of the interaction between smoking and nutrition was not observed in studies that reported smoking-related decreases in birth weights without differences in maternal weight gain (Abel, 1980). Naeye (1978, 1981a, b) reported that, at least among heavy smokers, maternal weight gains are independent of either fetal or placental weight. Similarly, Haworth and co-workers (1980) noted that infants of obese smokers still weigh significantly less than those of obese nonsmokers. In fact, some of the effects of smoking (e.g., increased placental size/placental ratios) are contrary to those described for moderate maternal malnutrition (Lechtig et al., 1975). Moreover, since the incidence of proportional rather than disproportional SGA increases with smoking, and since the effects involve lean body tissue rather than deposition of subcutaneous fat (D'Souza et al., 1981; Harrison et al., 1983), the hypothesis of a simple energy availability effect is probably partly inadequate. Studies show that smokers, including pregnant women, do not generally eat less than nonsmokers or ex-smokers, even after controlling for socioeconomic status and height differences, and often eat more (Haste et al., 1990; McKenzie- Parnell et al., 1993; reviewed by Klesges et al., 1989; and Perkins, 1992). Thus, the lower weights and pregnancy weight gains of smokers are not necessarily due to appetite suppression or reduced intake of calories, and must therefore be explained by other mechanisms (IOM, 1990). One possibility is the chronic increase in metabolic rate observed in smokers (Perkins et al., 1989). In general, smoking is associated with lower levels of vitamin E, vitamin C, beta-carotene, selenium, and B-complex vitamins (Preston, 1991). The concentration of vitamin C in amniotic fluid during the third trimester has been reported to be almost 10 times lower in smokers (0.33 mg/dl) versus 2.8 mg/dl in nonsmokers (Barrett et al., 1991). Both maternal serum and neonatal cord serum vitamin C, vitamin E, and beta-carotene levels are lower when the mother smokes, despite no differences in maternal intakes (Norkus et al., 1987) Smoking has been reported to decrease production of breast milk in breastfeeding mothers (Hopkinson et al., 1992; IOM, 1991). The volume of breast milk was 20 percent less in breastfeeding mothers of postterm infants who smoked compared with breastfeeding mothers of postterm infants who did not smoke (Hopkinson et al., 1992). Furthermore, the volume of breast milk produced by breastfeeding mothers who smoked did not increase from 2 to 4 months postpartum.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 224 Maternal Smoking as an Indicator of Health and Nutrition Benefit If nutritional factors mediate the observed effects of maternal smoking during pregnancy on the growth and development of the fetus and infants, as has been hypothesized, the supplemental food and nutrition education provided by the WIC program could benefit pregnant women. The juices provided by the WIC food package may help maintain adequate levels of vitamin C. Few studies in WIC populations have assessed whether WIC participation was beneficial in smokers versus nonsmokers, and results of several are equivocal (Rush et al., 1988b; Schramm, 1986; Stockbauer, 1987). However, the only randomized trial of the WIC program concluded that although there was not a significant difference in birth weight of infants born to all women studied, WIC participation was associated with a 176 g increase in birth weight of infants born to women who were heavy smokers (greater than 10 cigarettes per day), after adjusting for several covariates (Metcoff et al., 1985). A benefit of WIC participation for smokers (yes/no, as reported no birth certificates) was also reported by the observational 1988 New York State WIC program evaluation, but relationships varied according to type of financial coverage for delivery. Among women with private payment, WIC participation was associated with significantly reduced proportions of low birth weight and preterm deliveries for nonsmokers, but not smokers. However, WIC participation was associated with significant reductions in low birth weight and preterm delivery only among smokers in the "self-pay" group. Finally, WIC was significantly associated with better birth outcomes for both smokers and nonsmokers in the Medicaid group, and greater proportional decreases in low birth weight and preterm delivery were observed among the smokers (Bureau of Nutrition, 1990). Many of the maternal food supplementation trials in populations where women rarely smoke but are at risk for other factors (e.g., poor nutritional status by anthropometric and biochemical criteria) have shown beneficial effects of supplementation on weight gains and birth weights (Adair and Pollitt 1985; Prentice 1991; Smith 1992). Since nutritional factors could be partially responsible for the low birth weight in the offspring of women who smoke, supplementary feeding of pregnant women who smoke may reduce their risk of delivering a low-birth-weight infant. Several clinical trials of smoking cessation programs have reported some success in achieving smoking cessation (Ershoff et al., 1989; Mayer et al., 1990; Sexton, 1991). The 1990 Surgeon General's Report on Smoking and Health concluded that discontinuing smoking up to 30 weeks of gestation leads to increased birth weight compared to continuing to smoke (DHHS, 1990). The WIC program can help link participants with smoking cessation programs.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 225 Use of Maternal Smoking as a Nutrition Risk Criterion in the WIC Program According to 1992 state plans, 51 state WIC agencies include tobacco use as a nutrition risk criterion in the WIC for pregnant women (USDA, 1994). Cutoff values range from any tobacco use to smoking more than 20 cigarettes per day. Recommendation for Maternal Smoking Risks of maternal smoking to the health of mothers and their fetuses are well documented, and risks to breastfeeding infants have also been reported. Too few studies have been conducted to determine whether the WIC food package contributes to the amelioration of the toxic effects of cigarette smoking. However, consumption of nutritious foods is beneficial for other reasons, and the committee felt that both the education and referral components of the WIC program have the potential to benefit women who smoke during pregnancy and/ or lactation. The committee strongly supports current public health policies recommending that women abstain from smoking during pregnancy. The lack of scientific evidence as to appropriate cutoff points relative to the potential for women who smoke during pregnancy or lactation from to benefit from the WIC program makes setting a cutoff point difficult. Therefore, as an interim approach, the committee recommends maternal smoking as a nutrition risk criterion for pregnant and lactating women in the state WIC program, with a cutoff of "any smoking." However, the committee recommends that this criterion be given lower priority, comparable to that of the predisposing risk category that is currently in use.2 The committee further recommends (1) that research be conducted to address the extent to which women who smoke benefit from the WIC program and the level of smoking that should be set as the cutoff point, if applicable, and (2) that USDA appoint an expert committee to provide guidance on cutoff points for cigarette smoking that will identify pregnant and lactating women who are most likely to benefit from the WIC program. Members of the expert committee should have expertise in maternal smoking and its assessment and treatment, public policy, nutrition, and epidemiology. 2 Two committee members (Barbara Abrams and Barbara Devaney) preferred a recommendation of establishing higher cutoff points (such as > 10 cigarettes per day) and keeping the risk criterion at its current high priority level. This approach could more clearly delineate women whose smoking places them at higher risk of poor pregnancy and lactation outcomes and who would therefore be more likely to benefit from WIC program participation. However, if cigarette smoking at lower levels produces poor health outcomes, or if women underreport their smoking habit, using these higher cutoffs may exclude some women from the program who could benefit.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 226 Alcohol and Illegal Drug Use Prevalence of and Factors Associated with Alcohol Use The 1988 National Maternal Infant Health Survey reported that 45 percent of women respondents consumed alcohol during the 3 months before they learned of their pregnancy. Nearly 21 percent reported consuming alcohol after learning that they were pregnant, 17 percent took three or fewer drinks per month during pregnancy, and 0.6 percent took six or more drinks per week during pregnancy (CDC, 1995a). Alcohol use was most prevalent among white, non-Hispanic women, followed by Hispanic and black women. Alcohol Use as an Indicator of Nutrition and Health Risk Infants are at risk from alcohol and illicit substances transmitted through the placenta and/or through breast milk. They are also at risk of nutritional deficits secondary to maternal nutrition deficits. Postnatally, the infant may also be at nutritional risk owing to the impaired ability of the mother to provide optimal care, including nutrition. Alcohol is a rapidly absorbed drug that enters the fetal circulation and maternal milk. The safe amount of alcohol consumption during pregnancy is unknown. Pregnant women who consume greater than 6 fluid ounces of liquor daily (or the equivalent) have at least a 20 percent likelihood of delivering an infant with fetal alcohol syndrome (FAS) (Benson and Pernell, 1994). FAS is characterized by prenatal and postnatal growth restriction, distinct facial anomalies, and mental deficiency. Between 2 and 5 cases of FAS are estimated to occur per 1,000 live births (Bloss, 1994). Adverse physical and neurobehavioral effects may also occur at lower levels of exposure to alcohol (Bloss, 1994). These effects range from spontaneous abortion to subtle behavioral effects in the offspring. Fetal growth restriction has been noted, although inconsistently, at levels of alcohol ingestion of 1 to 2 oz/day (Hanson et al., 1978; Little, 1977; Wright et al., 1983). Postnatal growth may be adversely affected in children who do not have full FAS. Many animal studies have demonstrated a direct dose-response effect of alcohol on fetal growth and development (IOM, 1990), and malnutrition may be involved. Chronic alcoholics typically have an inadequate nutrient intake. In a prospective study of alcohol use during pregnancy, those with positive scores on the Michigan Alcoholic Screening Test had lower intakes of protein from meat and vegetable sources, dairy foods, cereal and breads, calcium, B vitamins, and vitamin D (Sokol et al., 1981). Heavy alcohol intake may interfere with nutrient absorption and lead to impaired nutrient metabolism by the liver. Specific deficiencies

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 227 of zinc, vitamin A, folate, and thiamin may occur with chronic alcohol consumption, and one study suggests that maternal zinc deficiency may act as a co-teratogen with alcohol (Flynn et al., 1981). During the breastfeeding period, excessive alcohol may be associated with failure to initiate the let-down reflex and with lethargy in the breastfed infant. Although a strong positive association has been reported between psychomotor development scores (Bayley Scales of Infant Development) and proxy measures of exposure to alcohol through breastfeeding (Little et al., 1989), the actual differences between exposure groups were minor. Maternal deficiencies (for example, of thiamin and folate) may be reflected in low intakes of these micronutrients by the breastfed infant. Prevalence of and Factors Associated with Illegal Drug Use A prospective study of consecutive prenatal patients from a poor inner-city population in 1989 reported that 18 percent had used cocaine during pregnancy (Zuckerman et al., 1989). Estimates of the prevalence of marijuana use during pregnancy have ranged from 10 to 27 percent in hospital-based studies (Hatch and Bracken, 1986; Linn et al., 1983; Zuckerman et al., 1989). Illegal Drug Use as an Indicator of Nutrition and Health Risk There is growing evidence that cocaine use during pregnancy is associated with both preterm delivery and fetal growth restriction as well as spontaneous abortion and abruptio placentae (IOM, 1990). Data on the influence of marijuana on pregnancy outcome in humans are limited and inconsistent. Adverse effects that have been reported include lower birth weight and body length; increased frequency of preterm delivery; higher rates of precipitate labor; increased risk of infant features compatible with FAS; and altered neural behavioral responses in neonates (IOM, 1990). Head circumference and birth length are disproportionately decreased in infants when mothers use cocaine during their pregnancy (Zuckerman et al., 1989). Detection of cocaine in maternal urine is associated with decreased fetal fat, suggesting that cocaine may alter nutrient transfer to the fetus and fetal energy metabolism. High maternal serum values of cocaine, phencyclidine (PCP), and marijuana have been associated with decreased maternal serum levels of ferritin and folate. Cocaine is an appetite depressant and may reduce maternal intake of energy and nutrients. Marijuana may stimulate appetite, but there has been no consistent finding of increased maternal food intake during pregnancy. Detection of marijuana metabolites in maternal urine is associated with decreased fetal muscle mass, suggesting maternal-fetal hypoxia, which could be secondary to increased carboxyhemoglobinemia (IOM, 1990).

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 228 Among current users of alcohol or illicit substances, multiple substance use and smoking are common. It is quite likely, therefore, that the mother and infant can be at risk nutritionally from more than one drug substance. Marijuana appears in the human milk as b-9-tetrahydrocannabinol, which is poorly absorbed but may cause lethargy and decreased feedings in the breastfed infant. Heroin and cocaine also appear in human milk and place the infant at considerable risk of toxicity. Alcohol or Illegal Drug Use as Indicators of Nutrition and Health Benefit If eaten, a balanced diet can help correct the nutrient shortfalls that are common among pregnant, lactating, or postpartum women who are abusing alcohol or illicit drugs. However, there is no convincing evidence that improved nutrition can counteract other adverse effects of alcohol or drugs. The committee is unaware of studies on the effects of nutrition intervention in pregnant alcohol or cocaine users or in pregnant or postpartum substance users. In theory, linking substance users with medical care and social supports is a potentially beneficial intervention for the WIC program. Use of Alcohol and Illegal Drug Use as Risk Indicators in the WIC Setting History of alcohol or drug use through self-reports or written referrals are used to document these risks in the WIC setting. See Table 5-1 for state WIC agencies using these nutrition risk indicators. Cutoff points vary widely, from any use of alcohol or drug use through a history of drug use, to ''addict" or "alcoholic." Recommendations for Alcohol and Illegal Drug Use Risks of use of alcohol or illegal drugs, or both, to the health of mothers and their fetuses are well documented, and risks to breastfeeding infants have also been reported. Too few studies have been conducted to determine whether the WIC food package contributes to the amelioration of the toxic effects of these substances. However, consumption of nutritious foods is beneficial for other reasons, and the committee felt that both the education and referral components of the WIC program have the potential to benefit women who use alcohol or illegal drugs during pregnancy and lactation. The committee strongly supports current public health policies recommending that women abstain from these substances during pregnancy. Setting a cutoff point is difficult because of the lack of scientific evidence relative to the potential for women who use alcohol

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 229 or illegal drugs during pregnancy or lactation to benefit from the WIC program. Therefore, as an interim approach, the committee recommends alcohol use and illegal drug use as nutrition risk criteria for pregnant and lactating women in the state WIC program, with a cutoff of "any use." However, the committee recommends that these criteria be given lower priority, comparable to that of the predisposing risk category that is currently in use.3 The committee further recommends (1) that research be conducted to address the extent to which women who use alcohol or drugs benefit from the WIC program and the level of substance use that should be set as the cutoff point, if applicable, and (2) that USDA appoint an expert committee to provide guidance on cutoff points for alcohol and substance abuse that will identify pregnant and lactating women who are most likely to benefit from the WIC program. Members of the expert committee should have expertise in alcohol and substance abuse during pregnancy and lactation, assessment and treatment of alcohol and substance abuse, public policy, nutrition, and epidemiology. Lead Poisoning The persistence of lead in the environment is an ongoing public health problem. Major sources of lead exposure have included lead in gasoline, soldered cans, paint, and the soil. Within the past two decades, however, the amount of lead used in gasoline has decreased 99.8 percent, the amount in paint has been limited to less than 0.06 percent by weight, and lead-soldered food or beverage cans are no longer manufactured in the United States (Pirkle et al., 1994). The remaining sources of lead exposure are from residual deposits (in soil dust, old paint and plaster), occupational exposures, and lead-containing imported containers used for serving or storing food or beverages. Lead poisoning (defined as a blood lead concentration of ≥ 10 µg/dl), although entirely preventable, is one of the worst environmental health threats to children in the United States (CDC, 1991; CEH-AAP, 1993). For women and children, pica can include the ingestion of lead-containing toxic substances (see also Chapter 6). Factors associated with lead poisoning include young age, male gender, low-income, non-Hispanic black race/ethnicity, poor housing, homelessness, poor nutrition, limited child supervision, and family history of pica 3 Three committee members (Barbara Abrams, Barbara Devaney, and Roy Pitkin) preferred a recommendation of establishing higher cutoff points for alcohol use and keeping the risk criteria for both drug and alcohol use at their current high priority level. The higher cutoff for alcohol use would more clearly delineate women whose level of alcohol use places them at higher risk of poor pregnancy and lactation outcomes and therefore would be more likely to benefit from WIC program participation. A higher cutoff could be based on a validated scale for assessing "problem drinking." For illegal drug use, they agree with the committee's cutoff of "any use."

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 230 (Pirkle et al., 1994; USDA, 1991b). Children's hand-to-mouth activities expose them to greater risk of lead poisoning. Prevalence of and Factors Associated with Lead Poisoning Data from phase one of NHANES III indicate substantial reductions in blood lead levels across all segments of the U.S. population between NHANES II and NHANES III (or, for Mexican Americans, between Hispanic HANES and NHANES III) (Pirkle et al., 1994). The percentage of all persons surveyed with blood lead concentrations greater than or equal to 10 µg/dl dropped from 77.8 to 4.3 percent. Among children 1 to 5 years of age, the prevalence of high blood lead concentrations dropped from 88.2 to 8.9 percent, among women from 66.7 to 1.8 percent, and among low-income (up to and 130 percent of the poverty level) individuals, from 78.6 to 8.8 percent. Data on the prevalence of lead poisoning among the WIC program population were not available to the committee. Lead Poisoning as an Indicator of Nutrition and Health Risk Lead ingested by pregnant women crosses the placenta and detrimentally affects the developing fetus. Mobilization of lead stored in bone occurs during lactation, but the kinetics of this lead release are not understood relative to the factors that might alter the rate or amount of transfer of lead from mother to nursing infant. In humans, umbilical cord blood lead concentration tends to equal to or be slightly lower than maternal blood lead concentrations (Goyer, 1990). During pregnancy, release of lead stores may increase the total dose presented to the fetus. One study found that lactating women over 30 years of age have higher levels of lead in their milk than younger women. Because bone serves as a reservoir for calcium during lactation, these higher lead levels may reflect the greater concentration of lead in mineralized tissue as a function of age (Silbergeld, 1990). Lead increases blood pressure in adults (Harlan, 1988; Sharp et al., 1989). Analysis of data from NHANES II showed a significant linear association between blood lead concentrations and blood pressure. Additional analysis by Pirkle et al. (1985) showed that large initial increments in blood pressure occur at relatively low blood lead concentrations (range 7 to 34 µg/dl); this is followed by a leveling of blood pressure at higher blood lead concentrations. Clinical investigations of the gastrointestinal absorption of lead among adults have produced inconsistent findings. Lead absorption has been estimated to be around 40 percent (Ziegler et al., 1978). Lead ingested during fasting is absorbed to a much greater extent than that ingested with food (Rabinowitz,

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 231 1980). The particular component of food intake that so dramatically reduces lead absorption largely remains to be identified. Inconsistencies in various lead absorption studies on adults were attributed to measurement techniques, timing and severity of deficiency, dietary factors, or related compensatory responses to the deficiencies. Deficiencies in such nutrients as iron, calcium, protein, and zinc increase the absorption of lead (Mahaffey, 1981, 1990; Needleman and Bellinger, 1991). In addition, studies have reported an inverse relationship between blood lead concentration and stature (Frisancho and Ryan, 1991; Schwartz et al., 1986). The mechanism for the effects of lead on the central nervous system is unclear, but many studies have supported the fact that the mean intelligence quotients (IQ) achieved by children rise when elevated blood lead concentrations are reduced. The data do not, however, provide a threshold lead-IQ relationship. There is contradictory evidence whether blood lead concentrations of 10 to 25 µg/dl in infants or children are associated with decreased IQ scores or with deficits in particular cognitive processes (Davis and Svendsgaard, 1987; Mushak et al., 1989). Long-term deficiency of iron in animals increases the absorption and biotoxicity of lead (CDC, 1991). Children who are iron deficient have significant delays in mental and motor development, but whether these development effects are additive or interactive with the effects from elevated blood lead concentrations needs to be determined (Wasserman et al., 1992). Severe lead poisoning in infants and children is associated with increased risk of coma, convulsions, and even death. Adverse effects of higher blood lead concentrations include damage to the central nervous system, kidneys, and hematopoietic system. Lead Poisoning as an Indicator of Nutrition and Health Benefit Adequate intake of calories, calcium, magnesium, iron, zinc, and various vitamins (e.g., thiamin, ascorbic acid, and vitamin E) is known to decrease the absorption of lead in adults and decrease children's susceptibility to the toxic effects of lead (Mahaffey, 1990). In conditions of lead exposure, however, nutrition factors will not prevent lead intoxication. Mahaffey (1990) discussed the role of nutrition as an adjunct intervention in ameliorating the untoward health effects of lead and recommended that nutritional assessment and dietary intervention be a component of the strategy to minimize the neurobehavioral and cognitive impacts of chronic low-dose lead exposure. The primary benefits of participation in the WIC program for individuals with lead poisoning result from referrals to lead treatment programs and possibly supplemental food.

BIOCHEMICAL AND OTHER MEDICAL RISK CRITERIA 232 Use of Lead Poisoning as a Nutrition Risk Criterion in the WIC Setting Health care providers report lead poisoning to WIC program staff. Table 5-1 lists numbers of state WIC agencies that use lead poisoning as a nutrition risk criterion in the WIC. Data on cutoff values used in the WIC program were not available to the committee. Recommendation for Lead Poisoning The risk of lead poisoning is well documented in women, infants, and children, and a practical clinical method for identifying this condition is available. There is empirical evidence and a theoretical basis that those with high lead concentrations can benefit from participation in the WIC program. Therefore, the committee recommends use of lead poisoning as a nutrition risk criterion for women, infants, and children in the WIC program, with the CDC cutoff value of ≥ 10 µg/dl. SUMMARY In general, most biochemical and medical risk criteria predict nutrition risk, with varying degrees of benefit. The most common concern of the committee was the lack of scientific justification for the generous cutoff points for biochemical and other medical risk criteria currently used by state WIC agencies. When evidence of risk and benefit was present, the committee found no reason that all states should not use scientifically justified nutrition risk criteria. Table 5-4 summarizes the committee's recommendations for biochemical and other medical risk indicators. In general, it should be assumed that any medical condition not mentioned in this chapter would be a suitable nutrition risk criterion if it causes ongoing impairment of self feeding, digestion, absorption, or utilization of nutrients. Risk criteria for which there was risk and benefit only under specific conditions included long-term drug-nutrient interactions. The committee felt that this criterion is too vague to be useful in its current form and recommends that a listing of drugs for which there are clear drug-nutrient interactions or potential for misuse be developed. For chronic and recurrent infections, evidence of risk and benefit was available only for the chronic infections for which there were documented nutrition deficits, and the committee recommended that states should clearly define "chronic" or "recurrent" in determining cutoff points for these indicators. The committee recommends that the criterion prematurity be used only for infants and that the criterion high parity be discontinued.

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This book reviews the scientific basis for nutrition risk criteria used to establish eligibility for participation in the U.S. Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The volume also examines the specific segments of the WIC population at risk for each criterion, identifies gaps in the scientific knowledge base, formulates recommendations regarding appropriate criteria, and where applicable, recommends values for determining who is at risk for each criterion. Recommendations for program action and research are made to strengthen the validity of nutrition risk criteria used in the WIC program.

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