 Nutrition Issues During Lactation  WHO recommends human milk as the exclusive nutrient source for the first 6 months of life, with introduction of solids at this time, and continued breastfeeding until at least 12 months postpartum.

Recommending breastfeeding as the preferred feeding choice for infants stems from acknowledging benefits to infant nutrition; gastrointestinal function; host defense; neurodevelopment; and psychological, economic, and environmental well-being. breastfeeding decreases the rate of postneonatal infant mortality ( ∼ 21%), and reduces the incidence of a wide range of infectious diseases including bacterial meningitis, bacteremia, diarrhea, respiratory tract infection, necrotizing enterocolitis, otitis media, urinary tract infection, and late-onset sepsis rates in preterm infants. Breastfeeding is also associated with slight improvements in cognitive development in both term-born and prematurely born infants

During the first 4–6 months of life, an infant will double its birth weight accumulated during the entire 9 months of pregnancy The energy content of breast milk secreted in the first 4 months postpartum alone well exceeds the energy demands of an entire pregnancy ENERGY Estimated Energy Requirements The incremental energy cost of lactation is determined by the amount of milk produced (exclusivity and duration), the energy density of the milk secreted, and the energy cost of milk synthesis. Age, weight, height, and level of physical activity affect the required energy. Milk energy output is tabulated by multiplying the volume of milk produced by its energy density. The daily volume of milk produced from birth to six months is 0.78 l/day. From

7 to 12 months, mean milk production is estimated to be 0.6 l/day, reduced with the introduction of solid foods Generally, well-nourished women will lose on average 0.8 kg/month (1.8 pounds/month) for the first 6 months postpartum; undernourished women can expect to lose 0.1 kg/month.

Anemia and Iron Deficiency Pregnant women, women of childbearing age, and young children are especially vulnerable to iron deficiency and iron-deficiency anemia (IDA). Stages of iron deficiency 1.Iron depletion  Reduction of iron stores  ↓ Serum ferritin  ↑ Total iron binding capacity (TIBC)

Iron-deficient erythropoiesis  Exhaustion of iron stores  ↓ Serum iron  ↓ Transferrin saturation  ↑ Free erythrocyte protoporphyrin (FEP)  ↑ Serum transferrin receptor concentration Iron-deficiency anemia  Exhaustion of iron stores and microcytic, hypochromic erythrocytes  ↓ Hemoglobin  ↓ Hematocrit  Anemia is the most widely used indicator of ID in most settings.WHO reference values for anemia are hemoglobin < 11 g/dl for pregnant women and children under 5, < 12 g/dl for non- pregnant women, and < 13 g/dl for men.

 Not all anemia is caused by iron deficiency, and not all iron deficiency results in anemia. Megaloblastic anemia is associated with inadequate intakes of folate and vitamin B12 while infections and genetic can cause Thalassemia. Assessment Of Iron Deficiency And Anemia % of iron in the body is contained in Hb, an erythrocyte protein that transports oxygen from the lungs to tissues in the body. Hb concentration is used to diagnose anemia. Hct is also used in anemia Dx Both Hb & Hct concentrations can be influenced by factors influencing erythrocyte production and cause anemia. These include parasitic infections and other nutritional deficiencies (i.e. B12, folate, vitamin A). WHO recommends including hemoglobin and serum ferritin.

IRON REQUIREMENTS DURING PREGNANCY Iron (Fe) requirements increase dramatically during pregnancy due to the rapid expansion of BV, tissue accretion, and potential for blood loss during delivery. For a normal pregnancy, it has been estimated that women need at least 6 mg of Fe/day compared with only 1.3 mg of Fe/day when they are not pregnant.

Consequences Of Iron Deficiency And Anemia During Pregnancy 1. Anemia and Maternal Mortality Tiredness and, therefore, quality of life is affected Severe anemia (HB < 7 g/dl) is associated with an increased risk of mortality. Severely anemic women tend to be at increased risk of blood loss and cardiac failure, which can result in death. 2. Birth Outcomes Severe anemia has been associated with an increased risk of stillbirth and infant mortality, in addition to increased risk of delivering a preterm and/or low-birth-weight baby. Women who received iron–folate supplements along with vitamin A during pregnancy show reduction in LBW incidence 43-34%. Iron supplementation of iron-replete women during pregnancy significantly reduced the prevalence of LBW and prematurity by almost half.

Early Childhood Growth and Development  Iron stores in infants at birth depend on maternal iron status and that clinical practices, such as delayed clamping of the umbilical cord, could help boost iron stores safely.

 Full term babies typically have adequate iron stores during the first 6 months of life, but this is not for babies of anemic women.  Women continue to be at risk of developing anemia and/or ID during the postpartum; affect both mother and baby.  Women who are iron deficient may be at increased risk of depression and impaired cognitive function and this, in turn,

would affect their ability to take care of their child and may indirectly influence child growth and development

Strategies To Combat Iron Deficiency And Iron-Deficiency Anemia Role of Multivitamin–Mineral Supplements Coexistence of several micronutrient deficiencies in many developing countries as a result of poor diets, both in terms of quantity and quality are combined with the increased requirements during pregnancy Timing of Supplementation Weekly supplementation of women of reproductive age both before and during pregnancy improved iron reserves effectively and safely

Diabetes and Pregnancy Diabetes mellitus is the most common complication of pregnancy; 90% during pregnancy; 10% predated the pregnancy. Although morbidity & mortality, the prevalence of fetal complications in diabetic mothers > in non-diabetic. Optimal glycemic control, before and during pregnancy can reduce risk of perinatal complications. Previously, diabetic women were advised not to conceive or to abort; infants were often stillborn or born with major malformations. Medical nutrition therapy was the primary method of management for pregnant Even after insulin injections revolution, nutrition therapy remained. Weight gain and sodium were restricted After 1970, the same regimen for the general pregnant population was recommended for diabetic pregnant women.

Classification of Diabetes DM is defined as a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both. DM is classified into: Type 1 diabetes,  insulin-dependent or juvenile-onset diabetes,  autoimmune destruction of the pancreatic beta-cells,  5–10% of all diabetes cases,  requires exogenous insulin diagnosed primarily < 30 years of age

Type 2 diabetes, non-insulin dependent diabetes/ adult-onset  90% of diabetes cases,  Insulin resistance, rather than insulin deficiency, and obesity are associated with type 2 diabetes. GDM; degree of glucose intolerance with onset or first recognition during pregnancy.  Risk factors of GDM; age of onset, presence of preexisting complications and degree of metabolic control