Evidence: Use of Height <145 cm to classify Pregnant Women (PW) at - - PowerPoint PPT Presentation

Evidence: Use of Height <145 cm to classify Pregnant Women (PW) at nutritional risk

Several studies have shown the risk of short stature (<145cm) among PW: Low birth weight (LBW) infants

• 29% LBW infants of PW (<145 cm) and 1.32 times

additional risk of LBW (Kamaladoss et al. 1992)

• 75% LBW infants of PW (<145 cm) (Bisai 2010)

Preterm birth and Small for Gestational Age (SGA) (Khanam et al. 2018) Stunting, growth retardation and slower postnatal growth velocity (Sinha et al. 2017)

Evidence: Use of BMI (<20 weeks) to classify Pregnant Women (PW) at nutritional risk

• WHO BMI for age categories: mainly on Caucasian population
• Asian cut-offs lower as compared to WHO: higher body fat, excess

metabolic perturbations, and cardiovascular risk factors at lower value of BMI in Asians versus white populations

Weight category (Pre- pregnancy weight/weight recorded <20 weeks) WHO BMI category (kg/m2) [WHO, 2000] Asian BMI category (kg/m2) [Misra et al. 2009] Severe thinness <16.0 <16.0 Thinness 16.0-18.49 16.0-18.49 Normal weight 18.5-24.9 18.5-22.9 Overweight 25-29.9 23-24.9 Obese ≥30 ≥25

Evidence: Weight gain monitoring in pregnancy [1]

(i) Gestational weight gain recommendation among Indian women

(ii) IOM, 2009/ WHO 2016 weight gain recommendations

Evidence: Weight gain monitoring in pregnancy [2]

(iii) Weight gain: Recommended weight gain 2kg/month in second and third trimester [SBA guidelines, GOI] (iv) Risk point: Weight gain <1kg/month in second and third trimester [Mother and Child Protection card/Kruger et al. 2005] (v) Risk point: Weight gain >3kg/month in second and third trimester [SBA guidelines, GOI]

Evidence: Weight gain monitoring in pregnancy [3]

Evidence: Use of MUAC for determining thinness/severe thinness in PW

MUAC Classification <19cm Severe malnutrition ≥19 and <22.0 cm Moderate malnutrition ≥22 and <23.0 cm Mild malnutrition ≥23.0 Normal Source: Food and Nutrition Technical Assistance III Project (FANTA). 2016. Nutrition Assessment, Counseling, and Support (NACS): A User’s Guide— Module 2: Nutrition Assessment and Classification, Version 2. Washington, DC: FHI 360/FANTA; Guidance Document – Nutritional care and support for patients with Tuberculosis in India, MoHFW, GOI, 2017

Evidence: Use of MUAC for determining obesity in PW [1]

PW (n=578) attending antenatal clinics, South Africa (Okereke et al. 2013; South African National Guidelines, 2014)

MUAC did not vary across the three trimester groups High Correlation

MUAC: ≥33cm had a sensitivity of 76% and specificity of 91% for BMI ≥30 kg/m2

Evidence: Use of MUAC for determining obesity in PW [2]

Evidence: Mild/Moderate/Severe Anemia cut-offs

Criteria Pregnant women

Normal Hemoglobin (Hb) ≥11 g/dl Mild anemia 10 – 10.9 g/dl Moderate anemia 7 – 9.9 g/dl Severe anemia < 7 g/dl

Source: Guidance Document – Nutritional care and support for patients with Tuberculosis in India, MoHFW, GOI, 2017; Anemia Mukt Bharat – Intensified National Iron Plus Initiative, Operational Guidelines for Programme Managers, Ministry of Health and Family Welfare, Government of India, 2018.

Micronutrient Supplementation and Deworming

Supplement Parameter Category Frequency IFA tablet (100mg iron and 500mcg folic acid) Hb ≥11mg/dl Hb:7-10.9 mg/dl No anemia Mild/moderate anemia One IFA tablet daily from second trimester onwards upto 6 months post-partum Two IFA tablets daily from second trimester

• nwards upto 6 months post-partum

Calcium tablets (500 mg elemental calcium and 250 International Unit (I.U.) vitamin D3 2 tablets daily from second trimester onwards upto 6 months post-partum Albendazole (400 mg): Deworming 1 tablet after the first trimester, preferably in the second trimester

Source: Anemia Mukt Bharat – Intensified National Iron Plus Initiative, Operational Guidelines for Programme Managers, Ministry of Health and Family Welfare, Government of India, 2018; National Guidelines for Calcium Supplementation During Pregnancy and Lactation. Maternal Health Division, Ministry of Health and Family Welfare, Government of India, 2014; National Guidelines for Deworming in Pregnancy, Maternal Health Division, Ministry of Health and Family Welfare, Government of India, 2014.

Counseling Material [1]

Group counseling (while waiting for test results and doctor’s visit) Individual need based counseling (before leaving the facility)

Counseling Material [2]

Recipe book for underweight Recipe book for obese

Counseling Material [3]

Refer/Treat for underlying conditions as per GOI guidelines

Underlying conditions Severe Anemia Hb: <7 g/dl Genito-urinary infection Burning or itching sensation during urination Tuberculosis Cough for >2 weeks/blood in sputum Goitre Visible neck swelling Hypertension SBP: ≥140 mmHg

• r DBP: ≥90

mmHg Fluorosis Dental/Skeletal GDM 2 hour blood sugar (OGTT): ≥140mg/dl Night blindness/Bitot’s spot Vitamin A deficiency Malaria Fever with chills ≥3 days

Management of severe thinness through diet (National Guidelines

• f various countries)

Several intervention studies on increasing energy requirements [Range: 700-1200 kcal] for PW with severe thinness have shown positive effects:

• Fewer babies dying during labour
• Fewer SGA and LBW babies
• Incr. in BW among undernourished women
• Incr. head circumference

Study details Sample Intervention Malawi National guidelines, 2006 Pregnant women: Acute undernutrition- MUAC < 19 cm Treatment up to BMI 17 : 2 pots of RUTF (260g, 2700 kcal) per day or 6 sachets of RUTF (92g, 3000 kcal) per day Pakistan National guidelines, 2009 Pregnant women: MUAC <21.0 cm (undernutrition) RUTF (2-3 sachets/day) if sufficient supplies are available. Total calorie intake 2500 Kcal Uganda National guidelines, 2010 Pregnant women: MUAC <22.0 cm and presence of bilateral oedema (undernutrition) Supplementary ration should provide from 1000 – 1200 Kcal per person per day and 35 – 45g of protein

Management of severe thinness through GoI schemes

Many states are providing additional calories and protein in the form of One full meal/THR/milk and eggs to pregnant women

THR/OFM: Across Indian States under ICDS Ingredients Nutrient composition Telangana (OFM) Karnataka (OFM) Rice (150g), Dal (30g), Oil (16g), Milk (30 days) 200 ml [additional], Egg (1/day), 50g [additional], Vegetables: 50g Additional chikki (jaggery + peanuts) Energy: 1192 kcal Protein: 37.0 g Calcium: 579 mg Odisha (Ready to Eat wheat based Chhatua – THR) Chhatua: Wheat, Bengal gram (whole/roasted), Groundnut and sugar 2 boiled eggs/week (additional) Chhatua - Energy: 754 kcal, Protein: 24.9g Recommendation: 200g of Chhatua to be consumed, 2-3 times a day

Management of severe thinness through diet

Trimester (IOM recommendations) Normal Pregnant women (kcal/d) over and above the RDA Underweight Pregnant women (kcal/day) over and above the RDA First No additional calories + 150 kcal Second + 340 + 590 kcal (340 + 250 kcal) Third + 452 + 752 kcal (452 + 300 kcal)

Normal RDA (sedentary women) - Energy: 1900 kcal, Protein: 55 g (ICMR, 2010) Pregnancy - Energy: 1900 + 350 = 2250 kcal, Protein: 55 + 23 = 78 g Evidence: Increased requirements for PW with severe thinness

Source: Guidelines on Nutritional care and support for patients with Tuberculosis in India, GOI (2017) recommendations

Hospital management of severe thinness: F-100

F-100 (350ml) – twice a day to be provided along with normal diet

Options to meet additional requirements

• a. If in facility, F-100 (350 ml), twice a day
• b. If in OPD, consider high risk pregnancy link for:

1) ICDS double THR (1200 kcal and 38-40 g protein) 2) Food basket through PDS 3) Egg/Milk through NRLM

Management of severe thinness [after review of evidence]