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Jump-Starting IYCF: Infant nutritional status depends on the mother’s status Starting in Pregnancy? Or Before? Nutrient status of the mother Pre-pregnancy diet Pre-pregnancy nutritional status Pre-pregnancy work load or activity level Spacing between pregnancies Measuring Adult Nutritional Status Body Mass Index BMI = weight (kg) / height (m)2 60.5 kg / (1.6 m x 1.6 m) = 24 Effects of Maternal Nutrition Ability to nourish in-utero starting at conception Ability to provide quality breastfeeding without depleting her own nutrient stores Maintenance of her quality of life, productivity and capacity to care for child Changes in Nutrient Needs Nutrient PrePregnancy During Pregnancy by Trimester During Lactation !st 2nd 3rd 0-6 mos. >6 months +0 +240 +452 +500 +400 Energy 2200 kcal Protein 46 g +25 +25 +25 +25 +25 700 RAE +70 +70 +70 +600 +600 Iron 18 mg +9 mg +9 +9 +0 +0 Folate 400 ug +200 +200 +200 +100 +100 Iodine 150 ug +70 +70 +70 +140 +140 1000 mg +0 +0 +0 +0 +0 8 mg +3 mg +3 mg +3 mg +4 mg +4 mg Vitamin A Calcium Zinc Physiological changes during pregnancy 40% increase in blood volume and 25% increase in red blood cell mass Increase in lung ventilating capacity and rate Fat deposition during first half of pregnancy Rapid growth of fetus and placenta during second half of pregnancy Synthesis of large quantities of new protein tissue - also require energy Energy Intake during Pregnancy Increase roughly 200-300 kilocalories/day during second and third trimester Depends or pre-pregnancy BMI Underweight women may need more kcal Active women must also decrease physical activity Weight Gain During Pregnancy Average weight gain is 10 to 12 kg: Fetus, placenta, amniotic fluid Maternal blood Maternal tissue fluid Uterus, breasts Maternal adipose tissue 5 kg 1 – 1.5 kg 1 – 1.5 kg 1 – 1.5 kg 4 kg Energy Needs during Lactation Increase by up to 500 kilocalories per day Fat stored during pregnancy can be used to satisfy this energy requirement Increased energy intake does not result in increased milk production in adequately nourished women Sufficient amount of milk can be produced by women with low energy intake Why so much energy for lactation? Human milk is about 70 kcal/100 ml Maternal energy is converted with about 80% efficiency to milk energy ~85 kcal of maternal energy needed to produce 100 ml of breast milk An average milk secretion of 750 ml per day, requires 640 kcal/day Some of this can come from stored fat Nutrient Quality of Breast Milk Energy, protein, and some mineral content is not affected by maternal dietary intake or stores Vitamin C, thiamine, riboflavin, B6, B12, Vitamin A, iodine and selenium are dependent on maternal intake or stores Maternal intake has minimal effect on content of zinc, iron, folate, Vitamin D, calcium and copper content of breast milk Protein About 925 g of new protein are synthesized and deposited in mother and fetus Average breast milk production per day - 750 ml with protein content of 1.25 g/100 ml Adequate energy intake from carbohydrates is essential to assure new protein synthesis Iron-deficiency anemia 50% of anemia is from iron deficiency Absorption may be as important as low dietary intake Inhibitors Heme vs. non-heme Other major causes of anemia: Malaria Helminthes Efficacy of Iron Supplementation World Bank review found that distribution was the limiting factor not utilization Counseling on purpose is as important as counseling on controlling side effects Some concern that iron inhibits zinc and copper absorption Actions to Prevent Anemia Promote intake of iron-rich foods, especially animal products and fortified foods Provide iron supplementation to pregnant women Continue supplementation for 3 months post-partum in areas with anemia prevalence >40 percent De-worming of pregnant women after first trimester, and lactating women, according to WHO protocol Prevent and control malaria Vitamin A Provide post-partum high-dose vitamin A supplementation to women If breastfeeding, within 8 weeks of delivery If not breastfeeding, within 6 weeks of delivery Promote consumption of vitamin A-rich foods, including liver, fish, egg, and red and yellow fruits and vegetables Promote consumption of vitamin A-fortified foods Iodine Sufficient iodine intake in pregnancy and lactation is essential in prevention of maternal and fetal hypothyroidism Insufficient iodine intake in pregnancy may have an adverse effect on fetus as early as 8-10 weeks of gestation Iodine content of breast milk depends on iodine intake by lactating mother Calcium about 30 g of Ca is accumulated in pregnancy to meet fetal needs and demands of lactation absorption of Ca increases up to two times in the second half of pregnancy thus reducing needs for increased intake • Ca content of breast milk does not depend on calcium intake Zinc Some data suggest that Zn deficiency may cause intrauterine growth retardation of fetus Zn levels in maternal serum decline during pregnancy (dilution effect) When Zn intake is low (less than 7.3 mg/day) absorption of Zn increases; This may be sufficient to meet maternal needs without extra Zn supplements • Zn absorption is decreased by Fe supplements Folic Acid Folate deficiency during pregnancy may cause megaloblastic anemia Deficiency of folate in pregnancy is related to occurrence of neural tube defects in fetus The critical period for preventing neural tube defects is often before pregnancy is diagnosed Folate in foods is destroyed by boiling Essential Nutrition Actions 4. Prevention of vitamin A deficiency for women 5. Promotion of adequate intake of iron and folic acid for women 7. Promotion of optimal nutrition for women: Consume more food during pregnancy and lactation Pregnancy: 285 extra kcal/day Lactation: 500 extra kcal/day Increase protein intake during pregnancy and lactation (e.g. pulses, animal source foods, oilseeds) Provide iron/folic acid supplementation for pregnant women Treat and prevent malaria De-worm during pregnancy in areas where helminths are a determinant of anemia Provide post-partum vitamin A supplementation Promote consumption of iodized salt What to do in the field? At the Community Level: BCC: incorporate maternal nutrition messages at key contact points Promote increased caloric consumption of pregnant and lactating women and decreased physical activity Promote improved dietary diversity among all women of reproductive age Promote consumption of fortified foods Engage spouses and in-laws during home visits Promote uptake of key maternal nutrition services Home Food Production of nutrient-rich animal foods, fruits and vegetables Food supplementation to food insecure households Food fortification: vitamin A, iron/folic acid, and iodine With the Health Services Micronutrient supplementation: vitamin A and iron/folic acid Complementary maternal health services Malaria prevention and treatment Helminth prevention and treatment Develop and strengthen referral systems When intervention is urgent: >10% of adult population has a BMI <18.5 For women, based on pre-pregnancy weight >15% of newborns are LBW (<2500g) = high public health concern Thank-you