Jump-Starting IYCF:Jump-Starting IYCF:

Infant nutritional Infant nutritional status depends on status depends on

the mother’s statusthe mother’s status

Starting in Starting in Pregnancy?Pregnancy?

Or Before?Or Before?

Nutrient status of the Nutrient status of the mothermother

Pre-pregnancy dietPre-pregnancy diet Pre-pregnancy nutritional statusPre-pregnancy nutritional status Pre-pregnancy work load or activity Pre-pregnancy work load or activity

levellevel Spacing between pregnanciesSpacing between pregnancies

Measuring Adult Measuring Adult Nutritional StatusNutritional Status

Body Mass IndexBody Mass Index

BMI = weight (kg) / height BMI = weight (kg) / height (m)(m)22

60.5 kg / (1.6 m x 1.6 m) = 2460.5 kg / (1.6 m x 1.6 m) = 24

Effects of Maternal Effects of Maternal NutritionNutrition

Ability to nourish in-utero starting at Ability to nourish in-utero starting at conceptionconception

Ability to provide quality Ability to provide quality breastfeeding without depleting her breastfeeding without depleting her own nutrient storesown nutrient stores

Maintenance of her quality of life, Maintenance of her quality of life, productivity and capacity to care for productivity and capacity to care for childchild

NutrientNutrient Pre-PregnancyPre-Pregnancy During Pregnancy by TrimesterDuring Pregnancy by Trimester During LactationDuring Lactation

!st!st 2nd2nd 3rd3rd 0-6 mos.0-6 mos. >6 months>6 months

EnergyEnergy 2200 kcal2200 kcal +0+0 +240+240 +452+452 +500+500 +400+400

ProteinProtein 46 g46 g +25+25 +25+25 +25+25 +25+25 +25+25

Vitamin AVitamin A 700 RAE700 RAE +70+70 +70+70 +70+70 +600+600 +600+600

IronIron 18 mg18 mg +9 mg+9 mg +9 +9 +9 +9 +0+0 +0+0

FolateFolate 400 ug400 ug +200+200 +200+200 +200+200 +100+100 +100+100

IodineIodine 150 ug150 ug +70+70 +70+70 +70+70 +140+140 +140+140

CalciumCalcium 1000 mg1000 mg +0+0 +0+0 +0+0 +0+0 +0+0

ZincZinc 8 mg8 mg +3 mg+3 mg +3 mg+3 mg +3 mg+3 mg +4 mg+4 mg +4 mg+4 mg

Changes in Nutrient Changes in Nutrient NeedsNeeds

Physiological changes Physiological changes during pregnancyduring pregnancy

40% increase in blood volume and 25% 40% increase in blood volume and 25% increase in red blood cell massincrease in red blood cell mass

Increase in lung ventilating capacity and Increase in lung ventilating capacity and raterate

Fat deposition during first half of Fat deposition during first half of pregnancypregnancy

Rapid growth of fetus and placenta during Rapid growth of fetus and placenta during second half of pregnancysecond half of pregnancy

Synthesis of large quantities of new Synthesis of large quantities of new protein tissue - also require energyprotein tissue - also require energy

Energy Intake during Energy Intake during PregnancyPregnancy

Increase roughly 200-300 Increase roughly 200-300 kilocalories/day during second and kilocalories/day during second and third trimesterthird trimester

Depends or pre-pregnancy BMIDepends or pre-pregnancy BMI Underweight women may need more Underweight women may need more

kcalkcal Active women must also decrease Active women must also decrease

physical activityphysical activity

Weight Gain During Weight Gain During PregnancyPregnancy

Average weight gain is 10 to 12 kg:Average weight gain is 10 to 12 kg: Fetus, placenta, amniotic fluidFetus, placenta, amniotic fluid 5 kg5 kg Maternal bloodMaternal blood 1 – 1 –

1.5 kg1.5 kg Maternal tissue fluidMaternal tissue fluid

1 – 1.5 kg1 – 1.5 kg Uterus, breastsUterus, breasts 1 – 1 –

1.5 kg1.5 kg Maternal adipose tissueMaternal adipose tissue 4 kg 4 kg

Energy Needs during Energy Needs during LactationLactation

Increase by up to 500 kilocalories per dayIncrease by up to 500 kilocalories per day Fat stored during pregnancy can be used Fat stored during pregnancy can be used

to satisfy this energy requirementto satisfy this energy requirement Increased energy intake does not result in Increased energy intake does not result in

increased milk production in adequately increased milk production in adequately nourished womennourished women

Sufficient amount of milk can be Sufficient amount of milk can be produced by women with low energy produced by women with low energy intakeintake

Why so much energy for Why so much energy for lactation?lactation?

Human milk is about 70 kcal/100 mlHuman milk is about 70 kcal/100 ml Maternal energy is converted with Maternal energy is converted with

about 80% efficiency to milk energyabout 80% efficiency to milk energy ~85 kcal of maternal energy needed ~85 kcal of maternal energy needed

to produce 100 ml of breast milkto produce 100 ml of breast milk An average milk secretion of 750 ml An average milk secretion of 750 ml

per day, requires 640 kcal/dayper day, requires 640 kcal/day Some of this can come from stored fatSome of this can come from stored fat

Nutrient Quality of Nutrient Quality of Breast MilkBreast Milk

Energy, protein, and some mineral Energy, protein, and some mineral content is not affected by maternal content is not affected by maternal dietary intake or storesdietary intake or stores

Vitamin C, thiamine, riboflavin, B6, B12, Vitamin C, thiamine, riboflavin, B6, B12, Vitamin A, iodine and selenium are Vitamin A, iodine and selenium are dependent on maternal intake or storesdependent on maternal intake or stores

Maternal intake has minimal effect on Maternal intake has minimal effect on content of zinc, iron, folate, Vitamin D, content of zinc, iron, folate, Vitamin D, calcium and copper content of breast calcium and copper content of breast milkmilk

ProteinProtein

About 925 g of new protein are synthesized About 925 g of new protein are synthesized and deposited in mother and fetusand deposited in mother and fetus

Average breast milk production per day - Average breast milk production per day - 750 ml with protein content of 1.25 g/100 750 ml with protein content of 1.25 g/100 mlml

Adequate energy intake from carbohydrates Adequate energy intake from carbohydrates is essential to assure new protein synthesisis essential to assure new protein synthesis

Iron-deficiency anemiaIron-deficiency anemia

50% of anemia is from iron deficiency50% of anemia is from iron deficiency Absorption may be as important as Absorption may be as important as

low dietary intakelow dietary intake InhibitorsInhibitors Heme vs. non-hemeHeme vs. non-heme

Other major causes of anemia:Other major causes of anemia: MalariaMalaria HelminthesHelminthes

Efficacy of Iron Efficacy of Iron SupplementationSupplementation

World Bank review found that World Bank review found that distribution was the limiting factor distribution was the limiting factor not utilizationnot utilization

Counseling on purpose is as Counseling on purpose is as important as counseling on important as counseling on controlling side effectscontrolling side effects

Some concern that iron inhibits zinc Some concern that iron inhibits zinc and copper absorptionand copper absorption

Actions to Prevent AnemiaActions to Prevent Anemia

Promote intake of iron-rich foods, especially Promote intake of iron-rich foods, especially animal products and fortified foodsanimal products and fortified foods

Provide iron supplementation to pregnant Provide iron supplementation to pregnant womenwomen Continue supplementation for 3 months post-Continue supplementation for 3 months post-

partum in areas with anemia prevalence >40 partum in areas with anemia prevalence >40 percentpercent

De-worming of pregnant women after first De-worming of pregnant women after first trimester, and lactating women, according trimester, and lactating women, according to WHO protocolto WHO protocol

Prevent and control malariaPrevent and control malaria

Vitamin AVitamin A

Provide post-partum high-dose vitamin Provide post-partum high-dose vitamin A supplementation to womenA supplementation to women If breastfeeding, within 8 weeks of deliveryIf breastfeeding, within 8 weeks of delivery If not breastfeeding, within 6 weeks of If not breastfeeding, within 6 weeks of

deliverydelivery Promote consumption of vitamin A-rich Promote consumption of vitamin A-rich

foods, including liver, fish, egg, and red foods, including liver, fish, egg, and red and yellow fruits and vegetablesand yellow fruits and vegetables

Promote consumption of vitamin A-Promote consumption of vitamin A-fortified foodsfortified foods

IodineIodine

Sufficient iodine intake in pregnancy Sufficient iodine intake in pregnancy and lactation is essential in prevention and lactation is essential in prevention of maternal and fetal hypothyroidismof maternal and fetal hypothyroidism

Insufficient iodine intake in pregnancy Insufficient iodine intake in pregnancy may have an adverse effect on fetus as may have an adverse effect on fetus as early as 8-10 weeks of gestationearly as 8-10 weeks of gestation

Iodine content of breast milk depends Iodine content of breast milk depends on iodine intake by lactating motheron iodine intake by lactating mother

CalciumCalcium

about 30 g of Ca is accumulated in about 30 g of Ca is accumulated in pregnancy to meet fetal needs and pregnancy to meet fetal needs and demands of lactationdemands of lactation

absorption of Ca increases up to two absorption of Ca increases up to two times in the second half of times in the second half of pregnancy thus reducing needs for pregnancy thus reducing needs for increased intakeincreased intake

• • Ca content of breast milk does not Ca content of breast milk does not depend on calcium intakedepend on calcium intake

ZincZinc

Some data suggest that Zn deficiency may Some data suggest that Zn deficiency may cause intrauterine growth retardation of fetuscause intrauterine growth retardation of fetus

Zn levels in maternal serum decline during Zn levels in maternal serum decline during pregnancy (dilution effect)pregnancy (dilution effect)

When Zn intake is low (less than 7.3 mg/day) When Zn intake is low (less than 7.3 mg/day) absorption of Zn increases;absorption of Zn increases;

This may be sufficient to meet maternal needs This may be sufficient to meet maternal needs without extra Zn supplementswithout extra Zn supplements

• • Zn absorption is decreased by Fe Zn absorption is decreased by Fe supplementssupplements

Folic AcidFolic Acid

Folate deficiency during pregnancy Folate deficiency during pregnancy may cause megaloblastic anemiamay cause megaloblastic anemia

Deficiency of folate in pregnancy is Deficiency of folate in pregnancy is related to occurrence of neural tube related to occurrence of neural tube defects in fetusdefects in fetus

The critical period for preventing The critical period for preventing neural tube defects is often before neural tube defects is often before pregnancy is diagnosedpregnancy is diagnosed

Folate in foods is destroyed by boilingFolate in foods is destroyed by boiling

Essential Nutrition Essential Nutrition Actions Actions

4. Prevention of vitamin A deficiency for women4. Prevention of vitamin A deficiency for women 5. Promotion of adequate intake of iron and folic acid 5. Promotion of adequate intake of iron and folic acid

for women for women 7. Promotion of optimal nutrition for women:7. Promotion of optimal nutrition for women: Consume more food during pregnancy and lactationConsume more food during pregnancy and lactation

Pregnancy: 285 extra kcal/day Pregnancy: 285 extra kcal/day Lactation: 500 extra kcal/dayLactation: 500 extra kcal/day

Increase protein intake during pregnancy and lactation Increase protein intake during pregnancy and lactation (e.g. pulses, animal source foods, oilseeds)(e.g. pulses, animal source foods, oilseeds)

Provide iron/folic acid supplementation for pregnant Provide iron/folic acid supplementation for pregnant womenwomen

Treat and prevent malariaTreat and prevent malaria De-worm during pregnancy in areas where helminths are a De-worm during pregnancy in areas where helminths are a

determinant of anemiadeterminant of anemia Provide post-partum vitamin A supplementationProvide post-partum vitamin A supplementation Promote consumption of iodized saltPromote consumption of iodized salt

What to do in the field?What to do in the field?

At the Community Level:At the Community Level: BCC: incorporate maternal nutrition messages at key BCC: incorporate maternal nutrition messages at key

contact pointscontact points Promote increased caloric consumption of pregnant and Promote increased caloric consumption of pregnant and

lactating women and decreased physical activitylactating women and decreased physical activity Promote improved dietary diversity among all women of Promote improved dietary diversity among all women of

reproductive agereproductive age Promote consumption of fortified foodsPromote consumption of fortified foods Engage spouses and in-laws during home visitsEngage spouses and in-laws during home visits Promote uptake of key maternal nutrition servicesPromote uptake of key maternal nutrition services

Home Food Production of nutrient-rich animal foods, fruits Home Food Production of nutrient-rich animal foods, fruits and vegetablesand vegetables

Food supplementation to food insecure householdsFood supplementation to food insecure households Food fortification: vitamin A, iron/folic acid, and iodineFood fortification: vitamin A, iron/folic acid, and iodine

With the Health ServicesWith the Health Services

Micronutrient supplementation: Micronutrient supplementation: vitamin A and iron/folic acidvitamin A and iron/folic acid

Complementary maternal health Complementary maternal health servicesservices Malaria prevention and treatmentMalaria prevention and treatment Helminth prevention and treatmentHelminth prevention and treatment

Develop and strengthen referral Develop and strengthen referral systemssystems

When intervention is When intervention is urgent:urgent:

>10% of adult population has a BMI >10% of adult population has a BMI <18.5<18.5 For women, based on pre-pregnancy For women, based on pre-pregnancy

weightweight

>15% of newborns are LBW >15% of newborns are LBW (<2500g) = high public health (<2500g) = high public health concernconcern

Thank-youThank-you