The document discusses nutritional assessment and requirements for lactating women. It recommends that lactating women consume at least 500 extra calories per day to support milk production. Nutritional assessment should include analysis of diet, lifestyle, cultural practices, food intake, and appetite. Key indicators like hemoglobin, serum ferritin, and skinfold thickness are used to assess nutritional status. The needs for important nutrients like protein, calcium, iron, and vitamins increase during lactation. Risk factors for delayed lactation onset include long second stage of labor, high pre-pregnancy BMI, breastfeeding problems, and flat or inverted nipples.

1. CHAPTER THREE
NUTRITIONALASSESSMENT DURING LACTATION
• Nutritional assessment of lactating women is important for prioritizing,
designing and creating intervention programs for maternal nutrition
improvement.
• Nutritional assessment should be comprehensive and include
analysis of eating behavior, food resources, lifes tyle choices, cultural
practices, food intake, and appetite and food preferences.
• During lactation nutritional requirements are greater than during
pregnancy. To achieve proper lactation and sustain nutrient stores without
depletion, mothers should be counseled about their nutrients need,
particularly intake of protein, vitamins and calcium .

2. NUTRITIONALASSESSMENT DURING
LACTATION….
• Child mortality risk is increased among severely malnourished mothers due
to reduction in lactation performance . On average 0.7 to 0.8 liters of milk
is produced per day, containing 330 milligrams of calcium per liter. Because
of milk quality depends on mothers diet, at least 500 calories/day extra is
required to compensate daily milk production

3. ANTHROPOMETRIC ASSESSMENT
• Body composition indices can be estimated by anthropometric
measurements. Biceps, triceps, supra-iliac, and subscapular skinfold
thickness is measured by a Holtain skinfold caliper (UK) . These indices
are used to estimate body density . Body fat (BF) and body fat
percentage by using the Siri equation , Fat Free Mass (FFM) is
calculated based on maternal body

4. ANTHROPOMETRIC ASSESSMENT…
• weight (BW) as FFM = BW – BF . Mild to chronic under nutrition is
defined as BW less than 52 kg and FFM less than 42.8 kg respectively
• During lactation and 6 months postpartum many anthropometric
indicators change from pre pregnancy values.
• The rate of these changes is affected by many factors including: delivery
route and edema during pregnancy , parity, maternal age, pre-pregnancy
weight, postpartum weight and weight gained during pregnancy

5. BIOCHEMICALASSESSMENT
• Hemoglobin is one of the most important biochemical indicators
of nutritional anemia which is defined as values less than 12g/dl.
While serum ferritin concentration is considered an indicator of
iron status depletion, it is classified as shown in Box

6. Box 1 classification of iron
Ferritin Concentration µg/L Depletion of Iron Store
<12 Severe
12-29 Marginal
>30 Normal

7. Cont..
• During lactation blood values of vitamins, minerals, hormones, protein
metabolism and other metabolites are affected, for example, in lactating
women the level of insulin and glucose are very different than in the same
women after cessation of lactation reported that concentrations of vitamins
and minerals change during lactation,
• for example, increase of serum zinc concentration and decrease of serum
copper between first and second weeks and between 19th and 21st weeks
of lactation. A lower nitrogen balance was reported among lactating
women compared with non-lactating postpartum and nulliparous women at
similar levels of nitrogen intakes.

8. Nutrient Adequacy of Pregnant & Lactating
Mothers
• Women who are neither pregnant nor lactating are significantly more
likely to be meeting their calorie and protein requirements than those
who are pregnant or lactating. That is, pregnancy and/or
lactation status exerts a depressing effect on the nutrient adequacy ratio of
an adult woman.
The nutrient adequacy ratios are lowest for pregnant or
lactating women, followed by those for women who are both pregnant and
lactating

9. Cont…
• Economic position, measured in terms of per capita expenditure
on food/day, is the most important factor affecting the
nutritional status of pregnant and lactating women.

10. Some Physiological Aspects Of Breast Milk
Production
• Milk production is initiated in the breasts in the post-partum
period due to prolactin production and decreased estrogen and
progesterone after delivery of the placenta.

11. Risk factors for delayed onset of lactation are
• Stage II labor > 1 hr
• pre-pregnant maternal BMI > 27 kg/m^2
• breastfeeding problems at day 3, and
being primiparous
• flat or inverted nipples at day 7

12. Nutrition Tips for Breastfeeding Mothers
• a breast-feeding woman needs 200 more calories per
day than she did during pregnancy, and it is
important that the calories come from nutritious
foods.
• Breast-feeding women usually lose 1 to 4 pounds per
month without restricting their calorie intake.
• Some important nutrients are as follows

13. Cont….
Protein
breast-feeding mother should eat two to three servings of protein each
day. A serving is equal to 3 to 4 nouns of meat, fish or poultry.
Calcium
The suggested daily intake of calcium for breast feeding mothers is
1,300 milligrams per day.
Iron
breast-feeding mothers should get 10
milligrams of iron per day.

14. Cont….
• Vitamin C
Nursing mothers need slightly more vitamin C
than they did during pregnancy. If you are 18 years
of age or younger, they should get 115 milligrams of
vitamin C per day.
Those over 19 should get 120 milligrams per day.
• Vitamins and Minerals
Breast-feeding mothers need to take some sort of daily multivitamin that
contains 100 percent of the recommended dietary allowance (RDA).

15. Nutrition, Exercise , Hygiene & Other Health Aspects
• Exercise
A brisk walk every day will increase cardiovascular fitness.
Hygiene
It is essential that breastfeeding mothers
practice good hygiene. This includes taking a shower
or bath every day and cleaning their breasts.

16. Benefits Of Breast Feeding
 Infants
 Mothers
 Economic advantages

17. Box 2. Classification of Vitamin A Depletion
Serum Retinol Vitamin A
< 0.35 µmol/L Deficient
< 0.70 µmol/L Marginal

18. Nutrient – Dense Food
Calcium Rich Food Folic Acid Rich Food Vitamin C Rich Food
Milk leafy vegetables citrus fruits and juices
Yoghurt green beans strawberries
Cheese legumes broccoli
Sardines/salmon with
bones
whole grain cereals cabbage
Dark green leafy
vegetables
fruits Potato
Dried beans and peas
Fortified Tofu

19. ENERGY RECOMMENDATION
• Energy requirements during lactation are 2700 calories per day. This
recommended energy includes: quantity of milk produced, body fat stores that
supply energy for lactation, and the efficiency of the ratio of maternal energy
to milk energy .
• The ratio of energy in the milk to the amount of energy
spent in producing the milk is called the efficiency of milk production. An
efficiency of 80% was recommended by world health organization , while
97% efficiency of human milk was reported by an additional of 500
calories per day during lactation over the non pregnant state for the first six
months of the postpartum.
• The additional amount of energy over non pregnant non lactating (NPNL) can
be achieved by increasing energy intake, reducing energy expenditure by
decreasing physical activities, increasing the efficiency

20. Cont…
• Try small serving 3 oz of whole milk several times daily.
• Try yogurt containing active, live cultures.
• Try aged cheese such as cheddar cheese.
• Try taking lactase tablets or drops when drinking milk.
• Try lactase – treated milk and milk products.
• Try cultured butter milk for drinking or baking.

21. OTHER MICRONUTRIENTS
• Breast milk content of vitamins and minerals depends on
current intake and maternal stores. In some cases if a
woman is vegetarian or has limited sun exposure, has
religious or cultural or self – imposed food restrictions,
vitamin specific supplementation may be recommended

22. WEIGHT LOSS
• Weight loss is recommended for lactating women if prior to
becoming pregnant they were overweight or obese.
Prepregnancy obese women should have 6.5 pounds per month
weight loss once lactation is established while in women with
normal Body Mass Index prior to pregnancy a weight loss of 4.5
pounds per month is recommended .

23. VEGETARIANISM
Barth et al., 1985 reported that protein,
vitamin B12, magnesium, calcium, iron, riboflavin, vitamin D, B6, zinc,
and carnitine are lower in breast milk of veganism or liberal macrobiotic
women.
The high fiber content in the vegetarian diet of lactating women may be
significant in causing a decrease in the the bioavailability of some
minerals (iron and zinc) [33]. Exclusively breast fed infants by vegetarian
women have been reported to have vitamin B12 deficiency and nutritional
rickets .

24. Recommendation
• Promotion of proper health education to lactating mother.
• Social motivation.
• Introduction of nutritional education for nursing mother in
syllabus.
• Regular health monitoring of nursing mother.
• Supply adequate nutrition accordingly.
• Food fortification.

25. Discussing question
1: Explain Nutrition Tips for Breastfeeding Mothers?
2: describe Risk factors for delayed onset of lactation?

26. Thank you