Nutritional challenges for women who use alcohol and other drugs in pregnancy
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Nutritional challenges for women who use alcohol and other drugs in pregnancy. Amy Sanders Dietitian The Royal Women’s Hospital VAADA Conference 13 th February 2007. Overview. Role of dietitian Nutritional needs of pregnant women Impact of D&A use Barriers to accessing care

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Nutritional challenges for women who use alcohol and other drugs in pregnancy l.jpg

Nutritional challenges for women who use alcohol and other drugs in pregnancy.

Amy Sanders

Dietitian

The Royal Women’s Hospital

VAADA Conference 13th February 2007


Overview l.jpg
Overview drugs in pregnancy.

  • Role of dietitian

  • Nutritional needs of pregnant women

  • Impact of D&A use

  • Barriers to accessing care

  • Nutrition audit

  • Nutritional recommendations

  • Health promotion strategies


Women s alcohol and drug service l.jpg
Women’s Alcohol and Drug Service drugs in pregnancy.

  • Specialised maternity and drug and alcohol service for women with complex drug issues.

  • Multidisciplinary team:

    • Midwifes, social workers, psychologist

    • Specialist support from obstetricians, pediatrician, pharmacist, dietitian, psychiatrist and housing worker.

  • “A Multi disciplinary team working collaboratively can achieve optimal pregnancy, birth and parenting outcomes for each woman and her family”(National clinical guidelines 2006)


  • Role of dietitian l.jpg
    Role of Dietitian drugs in pregnancy.

    • Optimise the nutritional status for healthier pregnancy

    • Screens all clients - weekly outpatient clinics

    • Inpatient methadone stabilisation program

    • Health professional training days

    • Attends team meetings

    • Few dietitians working in this area of need ?

    • Lack of published nutrition guidelines

    • Need to advocate for equal service opportunities.


    Referral indicators l.jpg
    Referral indicators drugs in pregnancy.

    • Anaemia (iron, folate, B12)

    • Malnourished, thin women

    • Lack of weight gain or too much weight gain

    • Nausea, vomiting, constipation, appetite problems

    • Poor baby growth

    • Veiled, dark skinned women

    • Vegetarians

    • Previous GDM or PCOS

    • History disordered eating

    • Recent pregnancies

    • Multiple pregnancies

       Most of our women with D+A issues fit nearly all of these referral indicators !!


    Nutritional needs of pregnancy l.jpg
    Nutritional needs of pregnancy drugs in pregnancy.

    • Specific nutrient requirements

      - protein, iron, folate, calcium and other vitamins and minerals

    • Awareness of listeria, mercury and fish, Vitamin A, caffeine

    • Optimal nutrient stores

    • Adequate maternal weight gain

    • High risk women  refer to dietitian

    • Simple dietary advice specific to individual needs.


    Nutritional effects of d a use l.jpg
    Nutritional effects of D+A use drugs in pregnancy.

    • Appetite suppression

    •  nutrient uptake

    •  nutrient bioavailability

    •  nutrient losses/malabsorption

    • Altered nutrient synthesis, activation and utilisation

    • Impaired nutrient metabolism and absorption

    •  nutrient destruction

    •  metabolic requirements of nutrients

    • Delayed gastric emptying

      Eg. Marijuana ↓ zinc

      Cigarettes ↑ iron

      Alcohol ↑ thiamine

      Amphetamines ↑ metabolic rate

      Opiates ↓ GI motility



    Lifestyle effects of d a use l.jpg
    ‘Lifestyle’ effects of D+A use drugs in pregnancy.

    • Limited finances

    • Homelessness

    • Poor self care

    • Reliance on take away foods

    • Chaotic meal patterns

    • Poor food safety practices

    • Reduced self awareness of hunger-satiety


    Nutritional challenges l.jpg
    Nutritional challenges drugs in pregnancy.

    iron

    folate

    bowels

    housing

    $$

    dental

    BMR

    nutrient

    deficiency

    Vit C

    stress

    thin

    LOA

    Poor nutritional

    status

    calcium

    Pregnancy

    demands

    N+V

    Effects of

    drug use

    Lifestyle

    Factors

    anemia

    food

    skills

    over

    weight

    Compromises nutritional status

    Effects maternal health + fetal outcome


    Barriers for care l.jpg
    Barriers for care drugs in pregnancy.

    • Food insecurity

    • Poor nutrition knowledge & skills

    • Knowledge of nutrition services available

    • Suitability of appointment times

    • Tiredness, anxiety, depression

    • Stage of change


    Nutrition audit l.jpg
    Nutrition audit drugs in pregnancy.

    • n = 50 pregnant women attending WADS (March 04-05)

    • Average age 29 years

    • Polydrug use +

      • 62% on methadone (n =31)

      • 24% buprenorphine (n = 12)

      • 56% illicit drugs (heroin)

      • 86% smoking tobacco

      • 56% cannabis use

      • 18% alcohol use


    Nutrition audit13 l.jpg
    Nutrition audit drugs in pregnancy.

    • First clinic contact - 19 wks (average)

    • First dietitian contact - 22 wks (average)

      • Range 7 - 38 weeks

  • Average 4 sessions with dietitian

    • Range 0 - 10 sessions

    • Equates to monthly reviews

  • Average gestation delivered 37.8wks

  • Average infant birth weight 2849g


  • Nutrition recommendations l.jpg
    Nutrition recommendations drugs in pregnancy.

    Underweight women

    • 40% underweight pre preg (BMI <20)

      Risks

    • Underweight → strong predicator of poor pregnancy outcome (↑ prematurity,↑ LBW)

    • Low BMI → more dependent on nutritional intake to achieve good weight gain.

      Recommendations

    • Assess pp BMI

    • Discuss normal weight gain and monitor

    • Dietary advice - ↑ meal regularity, ↑ snacks, ↑nutrient dense foods, trial oral nutritional supplements.


    Nutrition recommendations15 l.jpg
    Nutrition recommendations drugs in pregnancy.

    Maternal weight gain

    • Suboptimal wt gain (9kg)

    • Slow in 2nd trimester

    • 25% poor wt gain (<5kg)  LBW <2.5kg

      Risks

    • Adequate weight gain = optimal pregnancy outcome

    • Low maternal wt gain ↑ LBW

      Recommendations

    • Monitor weight

    • Aim 12.5 – 18kg total weight gain (low BMI)


    Nutrition recommendations16 l.jpg
    Nutrition recommendations drugs in pregnancy.

    Iron Deficiency

    • 33% early pregnancy & 60% later pregnancy

      Risks

    • ↑ preterm delivery, ↑ fetal growth retardation

    • Tiredness  access to care

    • ↑ risk infection, poor concentration

      Recommendations

    • Routine ferritin

    • Iron therapy - monitor tolerance/compliance.

    • ↑ dietary iron & consider factors affecting absorption


    Nutritional recommendations l.jpg
    Nutritional recommendations drugs in pregnancy.

    Vitamin D deficiency

    • 6 of 7 women deficient

    • Recent data - 58% deficient (n =34)

      Risks

    • Infants dependant on maternal Vitamin D status

    • May affect infant skeletal growth

      Recommendations

    • Test Vitamin D

    • Supplement deficient mother & baby if breastfed

    • Encourage small amounts of sunlight exposure


    Nutritional recommendations18 l.jpg
    Nutritional recommendations drugs in pregnancy.

    Nutritional Supplements

    • 66% iron, 58% folate, 28% multivitamins, 14% VitB

      Barriers

    • Women confused what to take

    • Financial costs

    • Poor compliance → GI effects

      Recommendations

    • Advise on appropriate supplementation – mv + iron

    • Avoid high doses Vitamin A & herbal preparations

    • Consider cheaper alternatives


    Nutritional recommendations19 l.jpg
    Nutritional recommendations drugs in pregnancy.

    GI Symptoms

    • Constipation most severe problem (50%)

    • 22% laxatives, 20% fibre supplements

      Risks

    •  desire to eat→  quality of diet

      Recommendations

    • ↑ dietary fibre & ↑ fluids

    • Fibre supplements, then laxatives

    • Review iron therapy

    • Encourage gentle daily exercise


    Nutritional recommendations20 l.jpg
    Nutritional recommendations drugs in pregnancy.

    GI Symptoms

    • Nausea and vomiting common (40%)

    • 12% antiemetics

      Risks

    • Dehydration, electrolyte imbalances, nutrient intake

    • Loss of 5% pp weight → negative implications

      Recommendations

    • Small frequent meals, adequate fluids, avoid empty stomach, avoid rich/spicy/fatty foods

    • Review of pharmacotherapy & antiemetics


    Nutritional recommendations21 l.jpg
    Nutritional recommendations drugs in pregnancy.

    • Dietary Ax

    • 12% diet adequate for pregnancy

    • Poor iron intake (50%)

    • Irregular meals

    • High reliance takeaway food

    • Poor fruit and vegetable intake

    • Recommendations

    • Simple practical meal and snack ideas

    • Encourage regular meal pattern/snacking

    • ↑ Iron rich foods

    • Budget eating, shopping and cooking hints

    • Healthier takeaway choices


    Health promotion strategies l.jpg
    Health Promotion Strategies drugs in pregnancy.

    • Dietitian to screen all women

    • Educate: - nutrition for pregnancy

      - listeria, mercury, caffeine, VitA

      - drug effects on nutrition

      - symptom management

    • Recommend multivitamins

    • Assistance with crisis food support, community food programs, budget shopping

    • Refer to dental services

    • Monitor weight, biochem, symptoms & diet

    • Multidisciplinary team meeting


    Health promotion strategies23 l.jpg
    Health Promotion Strategies drugs in pregnancy.

    • Specific nutrition resources

      • “Healthy pregnancy hints” & “Eating well and pregnancy”

  • Visual displays

    • Nutrition posters & food/product displays

  • Oral nutritional supplement

    • Sustagen®, Ensure ®, Enlive Plus®

  • Recipe books - quick easy meals

  • Cooking classes


  • Conclusion l.jpg
    Conclusion drugs in pregnancy.

    • Women attending a maternity D+A unit are at high nutritional risk

    • Nutritional deficiencies can be caused by a number of direct & indirect effects of drug use.

    • These women do not tend to seek nutritional support but are keen for advice

    • Dietitians can assist multidisciplinary teams to promote better nutrition.

    • By optimising nutritional status in pregnancy we can improve health outcomes for women and babies.


    Further information l.jpg
    Further information drugs in pregnancy.

    • Women’s Alcohol and Drug Service

      • [email protected]

      • (03) 9344 3631

  • Nutrition Department, The Royal Women’s Hospital

    • [email protected]

    • (03) 9344 2116


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