Maternal and Neonatal Nutrition

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• Maternal and Neonatal Nutrition
• Nutrition in Developing Countries
• May 9, 2008

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Objectives for this session

• Review the causes and consequences of maternal
  malnutrition for mother and infant
• Discuss the most important interventions to
  support maternal nutritional needs
• Review the nutritional needs of newborns
• Discuss the role of breastfeeding in assuring
  infant health and development

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Maternal/ Neonatal Nutrition
Issues
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(No Transcript)
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Maternal MalnutritionA Life-Cycle Issue (1)

• Infancy and early childhood (0-24 months)
• Suboptimal breastfeeding practices
• Inadequate complementary foods
  
• Infrequent feeding
• Frequent infections
• Childhood (2-9 years)
• Poor diets
• Poor health care
• Poor education
  

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Maternal MalnutritionA Life-Cycle Issue (2)

• Adolescence (10-19 years)
• Increased nutritional demands
• Greater iron needs
• Early pregnancies
• Pregnancy and lactation
• Higher nutritional requirements
• Increased micronutrient needs
• Closely-spaced reproductive cycles

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Maternal MalnutritionA Life-Cycle Issue (3)

• Throughout life
• Food insecurity
• Inadequate diets
• Recurrent infections
• Frequent parasites
• Poor health care
• Heavy workloads
• Gender inequities

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Major Issuesin Maternal Nutrition

• Inadequate weight and height
• Micronutrient deficiencies

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Chronic Energy Deficiencyin Women 15-49 Years Old
Percent Women BMIlt18.5 kg/m2
ACC/SCN, 1992
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Consequences of Maternal Chronic Energy
Deficiency

• Infections
• Obstructed labor
• Maternal mortality
• Low birth weight
• Neonatal and infant mortality

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Low Birth Weight

• birth weight lt 2500 grams 16-20 of developing
  country infants
• may be due to prematurity, or to
• intrauterine growth restriction (IUGR)

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Determinants of Intrauterine Growth
Restriction
Kramer, 1989
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Determinants of prematurity

• low BMI (maternal undernutrition)
• Maternal infections
• PIH
• abruptio placenta
• incompetent cervix
• strenuous work
• cigarette smoking

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Consequences of LBW

• Substantially increased neonatal and
  post-neonatal mortality
• With IUGR, prolonged susceptibilty to growth
  faltering, illness, even later in life
• IUGR history of mother also associated with IUGR
  infants

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Maternal Iron Deficiency

• Most common form of malnutrition
• Most common cause of anemia
• Other causes of anemia
• Parasitic infection
• Malaria

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Dietary Iron RequirementsThroughout the Life
Cycle
Required iron intake (mg Fe/1000 kcal)
Pregnancy
Stoltzfus, 1997
Age (years)
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Causes of DietaryIron Deficiency

• Low dietary iron intake
• Low iron bioavailability
• Non-heme iron
• Inhibitors

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Parasitic Infection (intestinal)

• Causes blood loss
• Increases iron loss

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Malaria

• Destroys red blood cells
• Leads to severe anemia
• Increases risk in pregnancy

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Prevalence of Anemiain Women 15-49 years old
Percent
ACC/SCN, 1992
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Severity of Anemiain Pregnant Women
Percent
Stoltzfus, 1997
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Consequencesof Maternal Anemia

• Maternal deaths
• Reduced transfer of iron to fetus
• Low birth weight
• Neonatal mortality
• Reduced physical capacity, energy
• Impaired cognition

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Severe Anemia andMaternal Mortality (Malaysia)
Maternal deaths / 1000 live births
lt 65
gt 65
Pregnancy hemoglobin concentration (g/L)
Llewellyn-Jones, 1985
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Maternal Vitamin A Deficiency

• Inadequate intake
• Recurrent infections
• Reproductive cycles

UNICEF/C-16-8/Isaac
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Consequences of Vitamin A Deficiency in
Pregnancy (1)

• Increased risk of
• Nightblindness
• Maternal mortality
• Miscarriage
• Stillbirth
• Low birth weight

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Consequences of Vitamin A Deficiency in
Pregnancy (2)

• Increased risk of
• Reduced transfer of vitamin A to fetus
• HIV vertical transmission

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Neonatal Consequences of MaternalVitamin A
Deficiency
Low vitamin A concentration in breastmilk
UNICEFC-92-18/Sprague
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Maternal Iodine Deficiency
UNICEF/95-0065 Shadid
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Consequences of iodine
deficiency on intelligence of offspring

• 3 cretins
• 10 severely mentally impaired
• 87 mildly mentally impaired

UNICEF/C-79-39
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Maternal Zinc Deficiency

• Premature rupture of membranes
• Prolonged labor
• Preterm delivery
• Low birth weight
• Increased maternal and infant mortality

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Maternal Folic Acid Deficiency

• Maternal anemia
• Neural tube defects
• Low birth weight

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Interventions to improveperinatal/neonatal
nutrition

• What is the evidence for their effectiveness in
  community settings?
• From Bhutta et al, Pediatrics 2005 115519-617

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Maternal nutrition interventions

• Supplementation - /-
• Protein x
• Balanced protein/cal x
• Iron x
• Periconceptual folate x
• Antenatal folate x
• Iodine x
• Antenatal Vitamin A x
• Zinc x
• Multivitamins x

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Control of parasites - malaria, deworming

• Intervention - /-
• Chemoprophylaxis
• or IPT x
• Insecticide-treated
• bednets x
• Deworming x

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Neonatal nutrition interventions

• Intervention - /-
• Breastfeeding x
• Vitamin A supplements x

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Maternal and infant nutrition Approaches
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Major Interventionsin Maternal Nutrition

• Improve weight and height
• Improve micronutrient status

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Improving Maternal Weight

• Increase caloric intake
• Reduce energy expenditure
• Reduce caloric depletion (e.g., infections)

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Improving Maternal Height

• Increase birth weight
• Enhance infant growth
• Improve adolescent growth

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What are the obstacles to increasing maternal
weight and height?
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Optimal Behaviors to improve maternal and infant
nutrition

• Pregnancy
• Increase food intake (by 2-300 kcal/day)
• Take ironfolic acid supplements daily
• Reduce workload
• Management of malaria, other parasites and
  other infections

UNICEF/C-55-10/Watson
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Optimal behaviors to improve maternal and infant
nutrition

• Lactation
• Increase food intake
• (by 5-600 kcal/day)
• Take a high dose
• vitamin A at delivery
• Reduce workload

UNICEF/C-88-15/Goodsmith
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Optimal behaviors to improve infant nutrition
exclusive breastfeeding
Early Infancy Exclusive breastfeeding
to about six months of age
UNICEF/C-79-10
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What is exclusive breastfeeding?
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What is exclusive breastfeeding?

• Mother initiates breastfeeding within 1 hour of
  birth
• Mother gives infant only breastmilk for the first
  6 months
• Frequent demand feedings, at least 8x/day
  initially and at least every 4 hours (6 at night)

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Why exclusive breastfeeding?

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Why exclusive breastfeeding?

• Provides perfect nutrition
• Secure source of food
• Clean source of food reduces infections
• Supports infants immune response
• Promotes recovery of sick children
• Promotes infant/mother bonding
• No added financial cost
• Delays return of fertility by 6 months (LAM)

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So why doesnt every mother do it?

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Barriers to exclusive breastfeeding

• Very time-consuming for busy mothers
• Cultural beliefs re supplements, colostrum
• Not enough milk
• Anxiety
• Illness, medical problems (HIV)
• Faulty technique (latching on)
• Modern to bottle feed formula promotion
• HIV-related concerns

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Technique

• Good attachment is necessary to allow effective
  suckling, ensure adequate supply
• Poor attachment can lead to inadequate suckling,
  sore nipples, mastitis

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Who promotes formula feeding?
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What has been done about it?

• 1981 International Code of Marketing of
  Breastmilk Substitutes passes at WHA after
  extensive review and discussion
• Vote is 118 in favor, 1 against, 3 abstaining
• Code addresses behavior of governments, formula
  companies, health care systems and personnel in
  promoting breastfeeding, reducing aggressive
  marketing of formula

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Baby-Friendly Hospital Initiative

• WHO and UNICEF initiative in 1992
• To qualify, need to meet a standard set of
  requirements
• Over 15,000 hospitals globally have achieved
  Baby-Friendly status (48 in the US)

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Ten steps to successful breastfeeding promotion

• Give newborns only breastmilk
• Rooming in
• Encourage breast-feeding on demand
• No pacifiers
• Establish breast- feeding support groups

• Written policies
• Train all staff
• Inform all pregnant women about bfdg
• Help mothers initiate bfdg 30 min after birth
• Teach mothers lactation methods

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Current status of exclusive breastfeeding?

• Approximately 40 of newborns globally are
  exclusively breastfed for first 4 months (but a
  wide range, from 5-70)
• Rates are rising, but slowly in the developing
  world

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Optimal Behaviorsto Improve Infant Nutrition
Late Infancy and Childhood
Appropriate complementary feeding from about six
months
UNICEF/C-55-3F/Watson
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Optimal Behaviorsto Improve Nutrition

• Continue frequent
  on-demand breastfeeding to 24 months
  and beyond

UNICEF/C-56-7/Murray-Lee
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Optimal Behaviors to Improve Maternal and Infant
Nutrition

• Delay first pregnancy
• Increase birth intervals

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THANKS !