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Institute of Medicine (US) Committee on Nutritional Status During Pregnancy and Lactation. Nutrition Services in Perinatal Care: Second Edition. Washington (DC): National Academies Press (US); 1992.

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Nutrition Services in Perinatal Care: Second Edition.

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2Nutritional Concerns of Women in the Preconceptional, Prenatal, and Postpartum Periods

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


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

Goals of Preconceptional Nutrition Services

Preconception visits a provide valuable opportunities to reduce women's exposure to risk factors that influence their nutritional status and thus to improve their overall nutritional status before conception. This, in turn, may decrease the likelihood of unfavorable pregnancy outcomes, such as the delivery of a premature or low-birth-weight infant. Several sources agree that nutritional services should be one of several components of preconceptional care. 1 , 2 , 3 , 4 The publications ACOG Guide to Planning for Pregnancy, Birth, and Beyond 5 and Caring for Our Future: The Content of Prenatal Care 1 list nutrition-related topics to address at a preconception visit.

An increased emphasis on preconceptional care acknowledges that achieving substantial changes in diet and lifestyle often involves making incremental changes over time. It also recognizes that the primary prevention of nutrition-related fetal malformations or spontaneous abortions is possible only if risk reduction activities begin before conception; even an early prenatal visit would ordinarily be too late for effective intervention. Addressing behavioral change before conception can allow a woman to identify constructive actions and to delay conception until she has achieved a healthier physical state—one that will increase her chances for a successful pregnancy outcome.

Providing nutritional assessment, education, and interventions to encourage an optimal state of health may also benefit the many women who do not desire pregnancy. For these women, the provision of nutritional care as part of a periodic health assessment can be a mechanism for promoting their health over the short term, with the potential for preventing problems in the event of an unplanned pregnancy and for preventing or retarding the development of chronic diseases later in life. 6

The objectives of nutritional care in the preconceptional period are to encourage women to achieve appropriate weight for height and healthful dietary habits. To this end, a periodic health visit for women of childbearing age should include assessment to identify indicators of possible nutrition problems, education relating to healthful dietary practices, and counseling, referral, or other interventions as needed to solve or reduce the adverse effects of such problems. Detailed information on these care activities is given in Nutrition During Pregnancy and Lactation: An Implementation Guide. 7

The following section briefly discusses the nutrition-related health conditions that have been most closely linked to unfavorable pregnancy outcomes. There are also other health conditions occurring prior to conception that may increase the risk of nutrition problems during pregnancy, but data on such relationships are sparse. Data are also lacking on the relationship of multiple socioeconomic problems prior to conception and the risk of nutrition-related difficulties during pregnancy.

Health Conditions Warranting Special Nutrition Services Before Pregnancy

Exposure of a woman to either excessive or inadequate amounts of certain nutrients early in the first trimester of pregnancy may lead to spontaneous abortion or congenital malformations. Exposure to high, potentially harmful amounts of a nutrient is possible under several circumstances: if the woman has a metabolic condition (such as diabetes mellitus or phenylketonuria) that causes excessive maternal blood levels of one or more nutrients; if the mother takes high doses of retinol (preformed vitamin A); or if she takes a potentially teratogenic medication such as isotretinoin (a vitamin A analogue). Very low nutrient levels are possible if the mother's diet is chronically inadequate or if she takes certain medications or other substances that alter her metabolism or deplete her nutritional stores. For example, the medicines methotrexate and diphenylhydantoin (Dilantin®) alter folate metabolism, and alcohol increases the urinary excretion of zinc. For more information on these topics, see, for example, Berkowitz and colleagues, 8 Briggs and others, 9 the 1990 Institute of Medicine report Nutrition During Pregnancy, 10 and Niebyl. 11

Preexisting Diabetes Mellitus

Women whose pregnancies are complicated by preexisting diabetes mellitus are at increased risk for delivering infants with major congenital malformations. 12 These malformations occur in the first weeks after conception, often well before many women enter prenatal care. Many of these anomalies, however, may be prevented by the normalization of maternal blood glucose values throughout the first 12 weeks of gestation. 13 For blood glucose values to be normal at conception, it is desirable to provide the nutrition and medical services needed to achieve metabolic control well before conception. 14 , 15 In one recent study that involved intensive education and treatment, the incidence of major congenital anomalies in the group treated before conception was 1.2%, compared with 10.9% in the group treated at 6 weeks of gestation or later. 16 Scheffler and colleagues 17 reported that early enrollment (before 8 weeks' gestation) in the California Diabetes and Pregnancy Program, which has a strong nutrition component, had a high cost-benefit ratio: for each $1 spent on the program, the estimated short-term savings exceeded $5.


Phenylketonuria (PKU) is an inherited condition involving the inability to metabolize phenylalanine, an essential amino acid. Until recently, treatment to control serum levels of phenylalanine 18 had been targeted mainly to infants and children: if treatment with a phenylalanine-restricted diet is initiated early in infancy, it helps prevent abnormal brain development and severe mental retardation while allowing normal growth. This rather complicated diet (which requires the use of expensive, specially formulated low-phenylalanine products) is usually discontinued in adulthood, when elevated serum levels of phenylalanine have been presumed to be no longer neurotoxic.

If pregnancy occurs, however, excessive amounts of phenylalanine in the maternal serum are associated with an extremely high incidence of mental retardation, microcephaly, low birth weight, and congenital heart disease among infants who themselves have not inherited PKU. 19 , 20 , 21 There is evidence that the occurrence of these problems can be reduced (although not perhaps eliminated) if the mother maintains a low serum phenylalanine level before conception and throughout pregnancy. 21 , 22 , 23 , 24

To achieve and maintain the desired phenylalanine level, the mother should be identified before pregnancy 25 and helped to modify her intake. 26 For this purpose, she will need intensive support and follow-up by an interdisciplinary team, including a dietitian experienced in the treatment of this disorder. If the mother's intellectual abilities are limited (perhaps because of inadequate dietary control of her condition during her early years), simplified strategies for diet modification and skillful teaching will be needed. 27

History of Poor Pregnancy Outcome

Two adverse outcomes of a previous pregnancy—neural tube defects (such as spina bifida) and fetal alcohol syndrome—should alert the health care provider to the need for attention to preventive measures before pregnancy.

Once a woman has delivered an infant with a neural tube defect, her risk of delivering another affected infant (often called a recurrent neural tube defect) is very high—2 to 10%. 10 The results of a recent randomized clinical trial in Great Britain 28 indicated that high-dose (4-mg/day) folic acid supplements given before conception and throughout the first trimester were protective against recurrent neural tube defects. (The critical time for the development of the neural tube is 17 to 30 days after conception.) Subsequently, the Centers for Disease Control (CDC) 29 issued specific recommendations for high-dose folic acid supplementation (preconceptionally and throughout the first trimester, under a physician's supervision) to reduce the risk of recurrent neural tube defects. Questions remain concerning the etiology of neural tube defects, the most appropriate dosage, and the appropriate role of nutrition in preventing first occurrences. 30 , 31

Previous delivery of an infant with fetal alcohol syndrome calls for efforts to help the mother eliminate or greatly reduce her consumption of alcoholic beverages, if she has not already done so, and to achieve a healthful diet. (See the later section entitled “ Conditions Involving Unhealthy Behaviors.”)

Extremes of Maternal Weight for Height

The committee found no studies that examined the effects of losing or gaining weight before pregnancy on outcomes of pregnancy. However, because both high and low prepregnancy weight are associated with increased risk of various unfavorable pregnancy outcomes, it is prudent to achieve normal weight for height before conception through healthful diet and exercise. Underweight, women are at increased risk of delivering a low-birth-weight infant; 10 they may also be at increased risk of pregnancy complications such as antepartum hemorrhage, premature rupture of the membranes, preterm delivery, anemia, and endometritis. 32 , 33 Obese women are at increased risk for complications (e.g., chronic hypertension, preeclampsia, gestational diabetes mellitus, and cesarean delivery 34 ), and their infants are at increased risk for macrosomia or high birth weight—a condition associated with an increased risk of shoulder dystocia and of maternal and infant morbidity. 10

If gastric banding or stapling has been used to treat severe obesity, it is advisable to delay conception until metabolic function and dietary intake have stabilized and there has been time to replenish nutrient stores. 35 Both of these types of surgery initially result in greatly reduced food intake; either type can precipitate potentially serious deficiencies of many essential nutrients.

Maternal Eating Disorders

Anorexia nervosa, bulimia, and bulimia nervosa 36 , 37 are serious eating disorders that affect a small proportion of U.S. women in their childbearing years. Severely restricting food intake may result in general malnutrition (which sometimes is so serious that it prevents ovulation), whereas purging may result in life-threatening fluid and electrolyte imbalances. 38 Women with eating disorders may begin pregnancy in a poor nutritional state; they are at risk of developing imbalances, deficiencies, or weight gain abnormalities during pregnancy if aberrant eating behaviors are not controlled. 39

Because treatment for these conditions requires long-term psychotherapy and behavior modification, referral for care should be accomplished before conceptionif possible. Published information on this problem during pregnancy is largely anecdotal but suggests that increased efforts are needed to identify women with bulimia nervosa. 40

Other Chronic Conditions or Diseases

Prior to pregnancy, dietary counseling may substantially improve the nutritional status of women with serious chronic gastrointestinal disorders such as Crohn's disease, celiac disease, or liver disorders. Preconceptional nutritional interventions such as weight loss programs for the treatment of hypertension and modified diets to control blood lipids may be useful alternatives to medications that are not considered desirable for the fetus.


Nutrition exerts an important influence on pregnancy outcome. 10 , 41 The U.S. surgeon general, 41 the publication Healthy People 2000, 42 and many expert groups (e.g., the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 2 the American Nurses Association, 43 the Public Health Service Expert Panel on the Content of Prenatal Care, 1 the Institute of Medicine, 44 and the U.S. Preventive Services Task Force 45 ) have all pointed out the value of interventions to help pregnant women achieve adequate diets. Congress has tangibly recognized the importance of prenatal nutrition by appropriating funds for the Special Supplemental Food Program for Women, Infants, and Children (WIC) continuously since 1974 (see Chapter 1). Moreover, at least 18 states have appropriated state funds to extend the reach of the WIC program (B. Jendrysik, Food and Nutrition Service, U.S. Department of Agriculture, personal communication, 1991).

Nutritional Demands of Normal Pregnancy

During pregnancy, maternal requirements for all nutrients increase; this is reflected in higher Recommended Dietary Allowances (RDAs) 46 for most nutrients during pregnancy (see Table 2-1). For some nutrients, the evidence indicates a direct link between chronic maternal deficiencies and poor outcomes for the mother or the infant. For example, prolonged deficiency of iron, folate, or vitamin B12 (or any combination of these) may lead to anemia in the mother; deficiency of vitamin D may lead to neonatal hypocalcemia and to maternal osteomalacia; and deficiency of vitamin A may lead to restricted fetal growth. 10 On the other hand, excessive intake of some nutrients may be harmful to the fetus, especially very early in pregnancy (see the previous section, “Preconceptional Nutrition”).

TABLE 2-1. Recommended Dietary Allowances for Nonpregnant, Pregnant, and Lactating Women a .


Recommended Dietary Allowances for Nonpregnant, Pregnant, and Lactating Women a .

In addition, total food intake (which serves as a proxy for energy intake) influences gestational weight gain. A large body of evidence indicates that gestational weight gain, particularly during the second and third trimesters, is an important determinant of fetal growth. Table 2-2 summarizes recommendations for total gestational weight gain. In a study of nearly 7,000 births, Parker and Abrams 47 found that maternal weight gains within these recommended ranges were associated with better outcomes: fewer infants were either small for gestational age or large for gestational age, and fewer woman had cesarean deliveries.

TABLE 2-2. Recommended Total Weight Gain Ranges for Pregnant Women , .


Recommended Total Weight Gain Ranges for Pregnant Women , .


A well-balanced diet is the appropriate source of nutrients during pregnancy. For the majority of pregnant women, iron is the only nutrient for which requirements cannot reasonably be met by diet alone. The 1990 IOM report Nutrition During Pregnancy 10 recommends a daily supplement containing 30 mg of ferrous iron as a part of routine care during the second and third trimesters; the report also recommends that guidance be provided for the safe, effective use of this supplement. Routine determination of the hemoglobin value or hematocrit is advised to identify women who need higher iron intake.

As explained in Nutrition During Pregnancy,evidence is not sufficient to warrant routine supplementation of all pregnant women with other nutrients. However, vitamin-mineral supplementation is recommended in certain situations. Therefore, the routine assessment of dietary practices is recommended for all pregnant women in the United States to determine the need for more intensive dietary counseling, for vitamin or mineral supplements, or both. A simple procedure for such assessment is described in Nutrition During Pregnancy and Lactation: An Implementation Guide. 7 The dispensing of supplements, however, is not considered a satisfactory substitute for a well-balanced diet or for taking steps to improve access to food. 10


Pregnant women need a sufficient intake of energy to support recommended weight gain. “Women who are thinner before pregnancy tend to have babies that are smaller than those of their heavier counterparts with the samegestational weight gain” (p. 8).10 Thus, women who enter pregnancy with low weight for height may need to devote extra attention to achieving adequate weight gain to reduce their risk of delivering low-birth-weight babies.

Screening for factors that may interfere with adequate weight gain is recommended for all pregnant women, as is the monitoring of weight gain over the course of pregnancy.

Nutrition in Complicated Pregnancies

The combination of pregnancy and a health problem often leads to complex nutritional problems that require the attention of a specialized team. For example, pregnancy makes it more important (and more difficult) to control the blood glucose of a woman with diabetes mellitus. On the other hand, some conditions that complicate pregnancy, such as multiple gestation and chronic hypertension, ordinarily require increased attention to basic nutrition services but not complex dietary management.

The following section clarifies why certain conditions ordinarily warrant special nutrition services or extended basic services. The list begins with conditions specific to pregnancy. It then covers various systemic problems, conditions related to unhealthy behaviors, and miscellaneous disorders. Although many of the diseases are quite uncommon, the role of special nutrition services in promoting favorable pregnancy outcomes for some of them is clear. The list of conditions is not all-inclusive: for example, extremely rare conditions such as cystinuria and Wilson's disease are omitted.

Conditions Specific to Pregnancy

Hyperemesis Gravidarum.Severe hyperemesis gravidarum is a serious complication of pregnancy that involves intractable vomiting with dehydration, electrolyte imbalance, ketonuria, weight loss, and possibly neurologic disturbances and liver or renal abnormalities. Death has occurred with severe disease. Conservative therapy includes intravenous hydration, sedation, antiemetic medication, and brief psychotherapy. When these fail to arrest the condition, parenteral nutrition may be life saving. 48 , 49 In addition to the emotional support and services of a psychotherapist, the advice of a dietitian is often helpful in directing therapy; it is invaluable when the woman is fed parenterally.

Increased Risk for Preterm Birth.In the United States, approximately 7% of newborn babies are of low birth weight (that is, they weigh less than 2,500 g), 42 and in the majority of cases, the cause is preterm delivery. 44 At the first prenatal visit, it is advisable to evaluate all women for the possibility of preterm delivery. Many practitioners use a specific risk score based on a careful history and physical examination to evaluate the potential for this problem (e.g., see Meis et al. 50 and Papiernik et al. 51 ). Although there is debate over the accuracy of certain scoring systems, it is well documented that previous preterm birth and certain physical symptoms (uterine cramps, bloody spotting, and increased vaginal mucus discharge) are strong predictors of preterm birth.

There is suggestive evidence that the risk of preterm birth can be reduced by a combination of intensive prenatal visits, uterine activity monitoring, and patient education. 50 So far, studies have not identified which elements of prenatal care are more powerful in preventing preterm birth.

As a part of comprehensive care, women found to be at high risk for preterm birth should be the beneficiaries of intensive evaluation, diet counseling, and, if necessary, food and vitamin-mineral supplementation. Because cigarette smoking, excessive alcohol intake, and illegal substance use all lead to an increased likelihood of preterm birth, the entire health care team needs to assist the woman who uses these substances to quit and to obtain outside help.

If preterm labor occurs and is treated with bedrest and tocolytic therapy, the woman may need extra nutritional care to deal with problems (e.g., decreased appetite, increasing constipation, glucose intolerance) associated with one or both of these treatments.

Multiple Pregnancy.The presence of more than one fetus in a gestation imparts added risk for preterm labor, preeclampsia, and diabetes mellitus. The mother will benefit from nutritional counseling to help her meet her increased nutritional demands comfortably and within any limits that may be imposed on her physical activity. Vitamin-mineral supplementation is advisable in combination with a well-balanced diet. 10 One study 52 indicates that nutritional intervention may reduce the occurrence of low birth weight and of very low birth weight among twins.

Fetal Growth Restriction.The term fetal growth restriction,formerly called intrauterine growth retardation, refers to infants born at an abnormally low weight for their gestational age. Among the nutrition-related factors associated with fetal growth restriction are the abuse of many kinds of substances, 53 , 54 , 55 , 56 , 57 low weight for height, low weight gain during the second and third trimesters, 10 and serious maternal infectious diseases such as acquired immune deficiency syndrome (AIDS). Prenatal participation in WIC (which includes food supplementation and nutrition education) is associated with higher birth weight even among infants born before 37 weeks of gestation. 58 Women who are suspected of having a growth-restricted fetus may need expert and intensive nutritional management.

Systemic Health Problems

Diabetes Mellitus.A primary aim of pregnancy management for the woman with diabetes mellitus is the maintenance of normal blood glucose 59 , 60 , 61 while allowing sufficient energy intake to achieve recommended weight gain. The goal for women with preexisting diabetes mellitus is to achieve normal blood glucose values before conception (see the previous section, “Preconceptional Care”) and sustain normal values throughout gestation to minimize the risk for fetal anomalies, fetal death, macrosomia, respiratory distress syndrome, maternal infection, and possibly preeclampsia. 62 , 63 , 64 , 65

The expertise of a dietitian is highly desirable when providing nutrition services for pregnant women with diabetes mellitus. According to the Third International Workshop-Conference on Gestational Diabetes Mellitus (GDM), “nutritional counseling is the cornerstone of the management of all women with GDM. . . .” (p. 200). 61 Nutritional assessment, planning, and counseling are coordinated with medical management as a component of collaborative prenatal care. 17 , 66 , 67 , 68 , 69

At present, no consensus exists concerning the most favorable dietary recommendations for pregnant women with diabetes mellitus. 69 , 70 , 71 , 72 In all approaches, however, the proportion of fat and carbohydrate is controlled in some way, usually the proportion of simple sugars is decreased, and generous intake of food sources of fiber is encouraged. The distribution of food in meals and snacks is also controlled. If insulin is administered, a very careful balance must be struck between diet, physical activity, the insulin dosage, and sometimes other factors (such as infection) that influence metabolism. The self-monitoring of blood glucose with memory-based meters, usually on an outpatient basis, provides useful information for making decisions regarding diet and insulin for the day-to-day maintenance of normal blood glucose.

Hypertensive Disorders.In the past, nutritional interventions such as restriction of energy and sodium were recommended for the prevention of preeclampsia and the treatment of chronic hypertensive disease during pregnancy, but those interventions are no longer recommended. 73 , 74 The effects of calcium supplementation for women at risk of developing preeclampsia are under study. 10 , 75 , 76

Because pregnancy increases the body's requirement for sodium, sodium restriction is ill-advised. Women who receive medication for hypertensive diseases are now encouraged to avoid excessive intake of salty foods but to salt foods to taste. Diuretics are seldom required except in the presence of cardiopulmonary failure or in the rare case of resistance to other forms of antihypertensive therapy.

Renal Disorders.Advanced renal disease and chronic renal failure are conditions rarely seen among pregnant women. Nonetheless, women with these conditions require special nutrition services (see, for example, Fröhling and colleagues 77 ) to balance the increased nutrient requirements of pregnancy, the impaired ability to excrete certain nutrients, and the increased losses of certain nutrients that may result from dialysis or drug treatment. Close monitoring is critically important to guide dietary adjustments.

Human Immunodeficiency Virus.Because women infected with human immunodeficiency virus (HIV) are at increased risk for problems with gastrointestinal function, weight loss, and anemia, 78 , 79 it is prudent to provide a thorough initial nutritional assessment, to recommend vitamin-mineral supplementation, and to monitor the woman's nutritional status frequently. This is especially important for women with AIDS. Because the effect of the virus on the fetus appears to be quite varied and unpredictable, it seems advisable to provide dietary management that not only avoids maternal weight loss but encourages normal weight gain during pregnancy, provides the nutrients essential to the proper functioning of the immune system, 80 and includes education concerning the prevention of foodborne diseases. 81 , 82

Conditions Involving Unhealthy Behaviors

Cigarette Smoking. Maternal cigarette smoking poses a serious threat to both the health and the growth of the developing fetus. 10 , 83 , 84 The high frequency of smoking (25 to 30%) among U.S. women 85 makes smoking a national problem as well as an individual one. Women who smoke need strong encouragement to stop this behavior and assistance to do so before and during pregnancy. Attention to the use of smokeless tobacco products is also warranted among some populations (e.g., a substantial proportion of young females from some American Indian tribes use such products; 86 , 87 S. Pelican, Indian Health Service, personal communication, 1991).

Windsor and colleagues 88 estimate that the dissemination of available, tested, cost-effective smoking cessation methods (with quit rates of 12 to 14%) could lead to cessation by an additional 28,000 pregnant women who are served by the public sector and an additional 84,000 who are served by the private sector each year. Shipp and colleagues 89 present a method for estimating the break-even point for smoking cessation programs for pregnant women.

Pregnancy is a time when all members of the family may be much more willing to try to stop substance abuse of all kinds because of their concern for the fetus, and all members of the family should be offered help. Improved diet and nutritional supplements may help improve fetal outcomes for smokers or former smokers, 90 , 91 , 92 but those measures are not an acceptable substitute for smoking cessation.

Alcohol Use.Alcohol intake during pregnancy—especially if the intake is high—is associated with fetal anomalies, prenatal or postnatal growth restriction, and mental retardation. 93 Information about alcohol abuse often emerges in a nutritional history; all members of the health care team are advised to learn to ask specific questions, such as those presented by Sokol and colleagues, 94 to improve the chance of detecting the problem. 95 Masis and May 96 provide evidence that a comprehensive local program can help to prevent fetal alcohol syndrome. Intensive nutritional management should complement a program of drinking cessation and subsequent support.

Use of Illegal Drugs.Illegal drug use has reemerged as a serious and widespread problem among women of childbearing age in the United States. 10 , 97 Stimulant drugs such as cocaine and amphetamines are easily obtained. Moreover, the relatively low-cost, highly addictive forms of these drugs, such as “crack” and “ice,” are being used with increasing frequency by young men and women. Drug addiction has been associated with serious health problems (including infections such as AIDS, syphilis, and hepatitis); such addiction can also cause serious social and nutritional problems. One major nutritional effect of stimulant drugs is that they suppress the appetite. 98 Moreover, women with limited income may spend all their household food money for drugs or trade their WIC foods and food stamps either for drugs or money.

All addicted women, no matter what drug or drugs they are using, need comprehensive, concentrated nutritional assistance and counseling to complement their prenatal care and drug rehabilitation programs.

Miscellaneous Disorders

Phenylketonuria.Pregnancy complicated by PKU is rare, but the consequences of inadequate dietary treatment are serious and potentially quite costly. Dietary treatment prior to conception (see “Preconceptional Nutrition”) and throughout gestation may help to reduce the high rates of spontaneous abortion, mental retardation, microcephaly, and congenital heart disease seen in the offspring of these pregnancies. 20 , 27 Because of changing protein and energy needs over the course of pregnancy, frequent, careful monitoring and evaluation are advisable to determine the need for dietary adjustments. Some women may need assistance to be able to obtain the expensive formula that is the foundation of the diet.

Gastrointestinal Disorders.The pregnant woman with preexisting primary disease of the gallbladder, pancreas, stomach, or intestine (including malabsorption syndrome and conditions that have led to extensive resection of the intestine) is likely to benefit from special nutrition services to promote optimal maternal and fetal outcomes, as will women with other conditions that interfere with food intake by mouth (e.g., see Granström and colleagues 99 ). Special formulas, tube feeding, or parenteral nutrition may be required to provide sufficient nutrients to support both the mother and fetus. If the gastrointestinal tract can be used, many types of tube feeding mixtures and delivery methods can be considered. The type of feeding and the volume of it to be delivered must be individualized for the pregnant woman's needs.

Parenteral feedings generally contain a nonprotein energy source (glucose, fat emulsions, or both), amino acids, electrolytes (including calcium, magnesium, and phosphorus), trace elements, and both water- and fat-soluble vitamins in amounts individualized to the woman's needs. Total parenteral nutrition has been reported to reverse gestational weight loss and to promote fetal growth. 100 This highly specialized feeding method may be used for a relatively brief or extended period either in the hospital or at home, during any trimester of pregnancy. 101 , 102 , 103 , 104 , 105 Watson and colleagues 106 support the use of peripheral as well as central routes of administration. Close monitoring of the patient and adjustment of the feeding regimen as needed are essential when alternative feeding methods must be used. Extensive training is required for home use of such methods. (See also Chart 3-3, Chapter 3.)

Cystic Fibrosis.Nutritional care for women with cystic fibrosis includes the use of pancreatic enzymes (in pancreatic-insufficient patients); a high-energy, nutrient-rich diet; and supplemental vitamins. Because women with cystic fibrosis may have difficulty consuming and absorbing enough nutrients, they are at increased risk of low weight gain during pregnancy. 107 They may need extra nutritional support using alternative feeding methods such as parenteral nutrition, 108 especially if the work of breathing interferes with adequate dietary intake. Glucose intolerance may occur, further complicating nutritional management.

Other.Cancer, cerebral palsy, and many other conditions may greatly complicate the nutritional care of pregnant women if they interfere with adequate food intake by mouth.


Basic nutrition services for all women warrant increased attention during the postpartum period, but nutritional requirements and the kinds of nutrition services needed at this time differ, depending on whether or not the woman is breastfeeding. The main nutritional focus may be on efforts to replenish nutrient stores, achieve adequate nutrient intake during lactation, or assist with breastfeeding (see Chapter 4). Regardless of breastfeeding status, many women are concerned about returning to their prepregnancy weight and are likely to need guidance to do so in a way that promotes their health.

A study by Caan and colleagues 109 indicates that interconceptional dietary intervention may improve the outcome of a subsequent pregnancy. Women with intervals of ≤27 months between pregnancies, who did not breastfeed but who received benefits from WIC during the first 5 to 7 months of the postpartum period, had heavier, longer infants in their second pregnancy than did women who received WIC benefits for 2 months or less post partum. This difference occurred even though both groups of women had received WIC benefits during pregnancy. On average, infants born to the women who were supplemented for 5 to 7 months postpartum weighed 131 g more, were 0.3 cm longer, and had a lower risk of being of low birth weight.

Replenishing Nutrient Stores

Stores of several nutrients (e.g., calcium, vitamin B6, folate) may need to be replenished during the postpartum period. Women who do not consume an adequate diet despite counseling, or those who are in high-risk categories because of having carried more than one fetus or because of heavy smoking, alcohol abuse, or abuse of illegal drugs, 10 may benefit from continuing to take the low-dose multivitamin-mineral supplement that was prescribed during pregnancy.

Dietary iron requirements during the postpartum period decrease to nonpregnant levels unless blood loss exceeded the usual amount lost during a vaginal delivery (approximately 500 ml). 110 Hemoglobin and hematocrit values ordinarily rise post partum with the contraction of blood volume to nonpregnant levels. In addition, the gradual disintegration of excess red blood cells releases iron that can be used for the synthesis of new hemoglobin.

Nutrition Recommendations for Lactating Women

Diet and Lactation in General

As described in Nutrition During Lactation, 111 lactation is a robust process. Milk quantity and quality are maintained reasonably well within a wide range of maternal diets, presumably reflecting subsidy of lactation by maternal stores.

The RDAs for most nutrients are increased during lactation (see Table 2-1)—in some cases by more than 50%. 46 The extra nutrient intake needed to cover exclusive breastfeeding for 4 to 6 months is substantially greater than that needed to cover the entire pregnancy. It is appropriate to encourage intake of a wide assortment of nutritious foods during lactation to help meet a woman's increased nutrient needs.

Specific Nutrients and Energy

During lactation, the nutrients that are most likely to be consumed in lower than recommended amounts are calcium, magnesium, zinc, vitamin B6, and folate. 111 In general, an additional 500 kcal of energy daily is recommended throughout lactation. 46 This recommendation assumes that there will be gradual loss of maternal body fat to supply some of the energy needed during lactation. A higher increment in energy intake is recommended for lactating women who are slender. Higher energy intake is also needed by women who produce unusually large amounts of milk (for example, those who nurse more than one infant or who donate to a milk bank) and by women who are very active physically (such as those who participate in more than 45 minutes of aerobic exercise daily).

Diet for and Supplementation of the Lactating Woman

The increased needs for nutrients of a lactating woman can be provided by a well-balanced diet. 111 Nutrition During Pregnancy and Lactation: An Implementation Guide 7 outlines appropriate dietary guidance for healthy lactating women. For women enrolled in WIC, the program provides food supplements that help supply the extra nutrients needed during lactation.

Among apparently healthy lactating women, situations that may justify nutrient supplementation can be identified by a brief screening process. 111 However, measures to improve dietary intake of nutrients are strongly preferred over supplementation with pharmaceutical preparations, 111 especially since lactation substantially increases the demand for energy, protein, and minerals such as calcium. Multivitamin-mineral supplements do not provide energy or protein, and they provide little calcium.

Weight Loss

From the standpoint of the patient, return to prepregnancy body weight appears to be one of the most common postpartum nutritional concerns. Women who need or want assistance with weight loss can be helped with information about expected weight changes: many women will gain weight during the first 4 days after delivery, but by the fifth postpartum day, most will have begun to lose weight. 112 An above-average rate of weight loss immediately post partum occurs among women who experienced hypertension or preeclampsia during pregnancy—probably because of postpartum diuresis. 113 Women ordinarily lose weight through 4 to 6 months post partum; 114 however, some women gain weight, even if they are breastfeeding. After a period of rapid weight loss in the first few weeks post partum, the average rate of weight loss by lactating women is 0.5 to 1.0 kg (῀1 to 2 lb) per month through the sixth month post partum. 111

If weight loss is an appropriate goal, the woman should be encouraged to set a reasonable body weight goal, and she should be assisted in developing a healthful plan for achieving that goal. For overweight breastfeeding women, the maximum suggested rate of weight loss after the first month post partum is about 2 kg (῀4.5 lb)/month. 111 The total energy intake by these women should not be less than 1,800 kcal/day to allow adequate intakes of protein, vitamins, and minerals. Although this level of energy intake may seem high to some women who are familiar with reducing diets, it takes into account the energy required for breastfeeding. Liquid diets and weight loss medications are not recommended.

Conditions Warranting Special Nutrition Services

Most women have no need for special nutrition services immediately after delivery. Those who have delivered by cesarean section may require temporary diet modifications that consider the effects of the surgery and anesthesia on their gastrointestinal function. Women with chronic disorders that call for modified diets require postpartum modifications to adjust for their changing physiologic status and nutrient needs, especially if they are breastfeeding. For example, breastfeeding women who require insulin are at increased risk for hypoglycemia and thus need adequate monitoring and diet counseling. 115

Special Considerations at the Postpartum Visit

The postpartum visit (usually 4 to 6 weeks following delivery) offers an opportunity to address new or continuing nutritional problems or breastfeeding concerns (see Chapter 4for information about breastfeeding support). Many women experience some emotional lability (especially symptoms of mild depression) during the postpartum period; some families find it difficult to adapt to the newborn; and families with twins or multiple offspring are confronted with special challenges. Consequently, it is advisable for the primary care provider to determine whether any such stresses are present and whether they are adversely affecting the mother's appetite, access to food, and sleeping or eating habits. In addition, it is recommended that care be taken to identify cases of substance abuse or addiction (including cigarette smoking, alcohol consumption, or illicit use of other mood-altering drugs).

The health status of women who experienced complications during pregnancy should be reassessed at the postpartum visit. For example, assessment of blood glucose status is appropriate for women who experienced gestational diabetes, assessment of blood pressure and of renal status may be indicated for women who experienced preeclampsia, and monitoring of iron status is desirable for women at increased risk of anemia because of hemorrhage associated with delivery. If any abnormal findings are observed, special nutrition services may be initiated.

The postpartum visit also offers an opportunity to promote healthful eating for the entire family and to verify that the infant is receiving well baby care. Information can be provided about meal planning, food preparation, and nutritious food choices for children in the household as well as for adults. A diet rich in grains and cereals, fruits and vegetables, and low-fat dairy products and meats is as appropriate for children over 2 years of age as it is for adults.


Beginning before conception and extending throughout pregnancy and lactation, primary care providers need to integrate basic nutrition services into their care and to be on the alert for conditions that call for special nutrition services.


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

Copyright 1992 by the National Academy of Sciences.
Bookshelf ID: NBK235913


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