Nutrition During Pregnancy and Lactation

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Chapter 10

• Nutrition During Pregnancy and Lactation

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Objectives

• Identify maternal nutrition
• Identify nutritional demands of pregnancy
• Identify the nursing interventions for intake and
  output
• Describe lactation
• Identify nutrients in human breastmilk

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Nutrition during Pregnancy and Lactation

• Healthy body tissues depend directly on essential
  nutrients in food. This is especially true when
  a whole new body is being formed.
• The growth of the baby from conception to the
  time of birth depends entirely on nourishment
  from the mother.

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Nutrition during Pregnancy and Lactation

• Key Concepts
• The mothers food habits and nutritional status
  before conception, as well as during pregnancy,
  influence the outcome of her pregnancy.
• Pregnancy is a prime example of physiologic
  synergism in which the mother, fetus, and
  placenta collaborate to sustain and nurture new
  life.
• Through the food a pregnant woman eats, she gives
  her unborn child the nourishment required to
  begin and sustain fetal growth and development
• Through her diet, a breastfeeding mother
  continues to provide all of her nursing babys
  nutritional needs

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Nutritional Demands of Pregnancy

• Traditional practices diet restriction of
  kcalories, protein, water, and salt for pregnant
  women in order to produce a smaller lightweight
  baby easy to deliver
• Developments in nutritional and medical science
  have refuted this notion
• Increased amounts of essential nutrients are
  needed during fetal development

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Nutritional Demands of Pregnancy

• Energy Needs
• The mother needs more energy in the form of
  kilocalories ? intake of nutrient-dense foods
• Supply the increased fuel demand by the enlarge
  metabolic workload of both mother and fetus
• Spare protein for the added tissuebuilding
  requirements

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Nutritional Demands of Pregnancy

• Amount of energy increase
• 340 Kcal per day more during the 2nd Trimester
• 450 Kcal per day more during the 3rd Trimester
• Active, large, or nutritionally deficient women
  may require more

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Protein Needs

• Reasons for increased needs
• Protein serves as the building blocks for the
  growth of body tissues during pregnancy
• Rapid growth of the fetus
• Development of the placenta
• Growth of maternal tissues increase of uterine
  and breast tissue

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Protein Needs

• Increased maternal blood volume increases
  20-50 during pregnancy. With extra blood volume
  comes a need for more synthesis of blood
  components, especially
• hemoglobin and plasma protein
• Hemoglobin supplies oxygen to the growing
  number of cells

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Protein Needs

• Plasma Protein
• regulates circulation between capillaries and
  cells. Albumin prevents an abnormal accumulation
  of water in the tissues, beyond the normal edema
  of pregnancy
• Amniotic fluid contains various proteins
• Storage reserves to prepare for the large
  amount of energy required during labor, deliver,
  postpartum, and lactation

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Protein Needs

• Amount of increase during pregnancy
• approx. 50 more than the average adult
  requirements. High-risk or active pregnant women
  require more protein

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Protein Needs

• Food sources
• Complete protein foods of high biologic value
• Milk
• Eggs
• Cheese
• soy products
• meat
• Incomplete protein foods plant sources

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Key Mineral and Vitamin needs

• Minerals most increased during pregnancy to
  meet the greater structural and metabolic
  requirements. The following have a key role in
  pregnancy
• Calcium, magnesium, phosphorus, and vitamin D) -
  essential for fetal development of bones and
  teeth as well as maternal need
• Body has enhanced capability to absorb and retain
  nutrients from the diet specifically calcium,
  zinc, and selenium
• Calcium supplements may also be needed because of
  poor maternal stores or pregnancies involving
  more than 1 fetus.

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Key Mineral and Vitamin Needs

• Iron and iodine
• Iron is essential for hemoglobin synthesis and
  required for maternal blood volume. Contributes
  to babys prenatal storage of iron. Vitamin C in
  the diet enhances the bodys ability to absorb
  and utilize iron. Maternal diet alone may not be
  able to supply sufficient iron. Iron
  supplementation may be needed.
• Iodine produces thyroxine (T4) which is the
  thyroid hormone needed to control the increased
  basal metabolic rate (BMR) during pregnancy-
  easily available in iodized salt.

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Key Mineral and Vitamin Needs

• Zinc and Copper
• Increased during pregnancy
• Absorption of both may be inhibited by high Fe
  (iron) intake ? may need to supplement.

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Vitamins Needed During Pregnancy

• Vit A and C Both are needed in higher amounts
  during pregnancy both are important elements in
  tissue growth
• Vit Bs Important because of their roles as
  coenzyme factor in energy production and protein
  metabolism
• Folate (folic acid) Builds mature red blood
  cells throughout pregnancy. Particularly needed
  during the periconceptual period (from about 2
  months before conception to week 6 of gestation)
  to ensure healthy embryonic tissue development
  and prevent malformation of the neural tube.

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Vitamins Needed During Pregnancy

• Folate deficiency
• 2 most common forms of neural defect are
• Spina Bifida - spinal cord and back bone do not
  develop correctly neural tube fails to close.
  Severity varies with the size and location of the
  opening in the spine
• Anencephaly upper end of the neural tube fails
  to close brain fails to develop or is absent
  entirely

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Vitamins Needed During Pregnancy

• Vitamin D to ensure absorption and utilitzation
  of calcium and phosphorus for fetal bone
  development
• Can be met by the mothers intake of 3-4 cups of
  fortified milk daily also by the mothers
  exposure to sunlight which increases endogenous
  synthesis of Vit D

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Weight Gain During Pregnancy

• Amount and quality sufficient to support and
  nurture mother and baby
• 29 lbs. average
• This will vary depending on prepregancy BMI and
  nutritional status

Fetus 7.5 lbs
Placenta 1.5 lbs
Amniotic Fluid 2.0 lbs
Uterus 2 lbs
Breast 2.0 lbs
Blood Volume 3.0 lbs
Maternal Stores 11 lbs
Total 29 lbs
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Weight Gain During Pregnancy

• Weight adjustments depend on the situation of the
  mother at the time of pregnancy
• E.g. teen pregnancy woman gt 35 years old
  undernourished, obese
• Important consideration the quantity of the
  weight gain and the quality of the foods consumed
  to bring it about
• CHO selected from enriched or whole grain breads
  and cereals, fruits, vegetables, and legumes, are
  the preferred energy sources

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Weight Gain During Pregnancy

• Rate of weight gain
• 2 4 lbs first trimester
• After that 1 lb a week however, watch for
  sudden weight gain after the 20th week ( water
  retention) or low maternal weight gain in the 2nd
  or 3rd trimester (risk for intrauterine growth
  restriction).
• Role of sodium
• Restriction not necessary
• Normal Diet
• Extra use of Na not necessary

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Daily Food Plan

• General plan Well balanced diet
• See p. 176 Table 10-1 Daily Food Plan
• Alternative food patterns
• Specific nutrients required - not necessarily
  specific foods - are required for successful
  pregnancy and may be found in a variety of foods.
• Encourage women to use foods that serve their
  personal and nutritional needs (E.g. ethnic,
  vegetarian preferences)

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Daily Food Plan

• Alternative Food Patterns cont.
• Vegan Vegetarian need to supplement diet can
  use soy foods, and complementary proteins
• Lacto Ovo Vegetarians do not need to
  supplement since they eat dairy also

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Daily Food Plan

• Avoid alcohol, caffeine, tobacco, or drugs
• Alcohol may lead to Fetal Alcohol Syndrome
  mental and physical abnormalities suffered by
  infants of mothers who abused alcohol during
  pregnancy
• A major cause of mental retardation/developmental
  delay in the U.S.

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Daily Food Plan

• Basic principles whatever the food pattern, 2
  important principles should govern the prenatal
  diet
• Eat a sufficient quantity of food
• Eat regular meals and snacks avoid skipping
  meals or fasting

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General Concerns

• Functional GI Problems
• Nausea and vomiting Morning sickness caused
  by hormonal adaptations in the first weeks of
  pregnancy
• Tx. small frequent meals, snacks that are
  fairly dry and consist mostly of easily
  digested energy foods (e.g. CHOs) liquids
  between -not with- meals
• Hyperemesis gravidarum severe, prolonged,
  persistent vomiting
• Hyperemesis gravidarum requires medical
  treatment

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General Concerns

• Constipation usually occurs during latter
  pregnancy. Helpful remedies Increase fluids,
  increase exercise, increase high fiber foods,
  fruits, juices prunes and figs avoid
  artificial laxatives
• Hemorrhoids enlarged veins in the anus, may
  protrude through the anal sphincter. Usually the
  result of the increased weight of the baby and
  the downward pressure. They may burn, itch or
  rupture and bleed under the pressure of a bowel
  movement. Remedy decrease constipation

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General Concerns

• Heartburn due to pressure of the enlarging
  uterus crowding the stomach
• Gastric Reflux may occur in the lower esophagus
  causing irritation and a burning sensation.
• common
• Remedies small meals, loose fitting clothing
  check with MD if persistent

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General Concerns

• Effects of iron supplements gray or black
  stools sometimes nausea, constipation, or
  diarrhea.
• Take iron supplements 1hr before a meal or 2
  hours after a meal. Iron should also be taken
  with foods containing Vit C which helps absorb
  more iron.
• High iron intake from supplements can reduce the
  bodys ability to absorb zinc. Good sources of
  zinc are crab meat, beef, turkey, and fortified
  cereals

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High Risk Mothers and Infants

• Identifying risk factors and addressing them
  early in pregnancy are critical in promoting a
  healthy pregnancy
• Nutrition-related factors p. 180 Clinical
  Application box
• Dietary patterns that do not support optimal
  maternal and fetal nutrition include
• Insufficient food intake, poor food selection,
  and poor food distribution throughout the day

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High Risk Mothers and Infants
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High Risk Mothers and Infants

• Recognizing Special Counseling Needs
• Teenage pregnancy special care needed to
  support adequate growth of both mother and baby
• See p. 182 for further focus
• Planning personal care help each mother develop
  a food plan that is both practical and
  nourishing. Identify fad diets, , extreme
  macrobiotic diets or pica (Craving for and
  consumptions of non food items such as dirt,
  chalk, laundry starch, and clay)

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High Risk Mothers and Infants

• Recognizing Special Counseling Needs cont.
• Age and parity ( pregnancies and time in
  between)
• Adolescent Pregnancies Increased social and
  nutritional risks
• Information, emotional support, and good prenatal
  care need throughout pregnancy
• Women 35 years Information re high BP, rate
  of weight gain, use of dietary sodium, and
  gestational diabetes

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High Risk Mothers and Infants

• Recognizing Special Counseling Needs cont.
• Increased parity (several pregnancies within a
  limited number of years)
• At risk for a poor pregnancy outcome because the
  mother enters each successive pregnancy drained
  of nutrient resources and faces physical and
  economic pressures of child rearing and child
  care.

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High Risk Mothers and Infants

• Detrimental Lifestyle Habits alcohol use,
  cigarettes, drugs Teratogens (any drug or
  substance causing birth defects).
• Can cause fetal damage, prematurity, Low Birth
  Weight, malformed fetuses, placental
  abnormalities, mental retardation and other birth
  defects.

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High Risk Mothers and Infants

• Recognizing Special Counseling Needs cont.
• Detrimental Lifestyle Habits cont.
• Drugs can include illegal drugs, self-medicating
  with OTC drugs, megadosing vitamins, caffeine
  use. Many can cross the placental barrier and
  enter fetal circulation ? fetal addiction
• Socioeconomic problems
• Low income situations need resources for
  financial assistance and food supplements

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Complications of Pregnancy

• Anemia
• Iron deficiency anemia is common during
  pregnancy approx. 6 of women in U.S., ages
  12-49, have low Hematocrit and Hemoglobin
• More prevalent among poor women who live on
  marginal diets barely adequate for subsistence.

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Complications of Pregnancy

• A deficiency of iron or folate ? nutritional
  anemia
• Neural tube defect insufficient folate ? spina
  bifida, anencephaly
• Intrauterine growth failure -gt survival and
  growth problems. Contributing factors low
  pre-pregnancy weight, inadequate weight gain
  during pregnancy, and smoking/alcohol

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Complications of Pregnancy

• Pregnancy-Induced Hypertension (PIH) formerly
  called toxemia associated with diets low in
  protein, kcalories, calcium and salt. Affects the
  liver and its metabolic activities.
• Can be fatal for mother and infant
• Complications seizures and HELLP syndrome
• HELLP syndrome hemolysis, elevated liver
  enzymes, low platelets

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Complications of Pregnancy

• PIH contd
• Calcium supplements may reduce the risk of
  complications for women at higher risk and for
  those with low baseline levels
• Optimal nutrition and medical treatment required

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Complications of Pregnancy
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Complications of Pregnancy

• Gestational Diabetes
• Glucose in the urine during pregnancy not
  uncommon
• Results from increased metabolic workload during
  pregnancy and increased blood volume with its
  load of metabolites, including glucose.
• Some of this extra glucose spills over into the
  urine

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Complications of Pregnancy

• Gestational Diabetes, cont
• Women at higher risk include
• History of diabetes, still births, large babies,
  women over 30
• More likely to occur in Afro-American, Hispanic,
  and Native American women
• Preexisting disease HTN, DM, PKU
  (phenylketonuria)

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Lactation

• Trends Mothers choosing to breastfeed has been
  on the rise since 1960s with 70 American
  mothers initiating breastfeeding.
• Contributing Factors
• World Health Organization Baby-Friendly
  Hospital Initiative ?
• More mothers are informed of the benefits
• Practitioners recognize that human milk can meet
  unique infant needs
• Maternity wards and alternative birth centers are
  being modified to support successful lactation
• Community support is available

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Lactation

• World Health Organization recommends
• Exclusive breastfeeding through 6 months
• Breastfeeding with addition of other foods to 2
  years or beyond
• American Academy of Pediatrics recommends
• Exclusive breastfeeding through 6 months
• Breastfeeding w/ other foods through 12 months or
  beyond

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Ingredients what makes human breastmilk so good
for babies?

• Optimal protein balance
• Higher fat and carbohydrate content than other
  animal milks, suitable for our bigger brains
• Carnitine more bioavailable in breastmilk. Helps
  the body use fatty acids for energy
• Immunoglobulins that protect the babys
  developing immune system
• Secretory IgA protects ears, nose, throat, GI
  tract highest in colostrum, but also high
  throughout first year

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Ingredients what makes human breastmilk so good
for babies?

• Lysozyme that promotes the growth of beneficial
  flora in the intestines and defends against E.
  coli and Salmonella infection
• Bifidus factor that promotes the growth of the
  beneficial bacterial Lactobacillus
• Lactose, a carbohydrate that provides both energy
  and helps increase absorption of calcium,
  phosphorus and magnesium

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Ingredients, contd

• Fatty acids needed for energy, as well as
  development of the brain, retina and nervous
  system
• DHA
• ARA
• Vitamins directly related to Moms intake
  often recommended that prenatal vitamins be
  continued during nursing
• Lactoferrin, which inhibits the growth of
  iron-dependent infectious organisms like yeasts
  and coliform bacteria

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Breastmilk benefits

• La Leche League, Intl Children who were
  breastfed
• tend to avoid obstructive sleep apnea later in
  life
• tend to avoid obesity later
• have lower rates of non-insulin-dependent (Type
  2) diabetes later
• have lower rates of high cholesterol problems
  later
• At least 7-9 months tend to have higher IQs than
  infants breastfed less than 7 months
• Have lower risk for celiac disease, UTIs, Crohns
  disease, atopic disease and reduced endometriosis
• LLLI Mothers who breastfeed have
• Lower rates of breast and ovarian cancers,
  osteoporosis

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Physiologic Process of Lactation

• Mammary glands are highly specialized secretory
  organs and are capable of extracting certain
  nutrients from the maternal blood in addition to
  synthesizing other compounds.
• This combined effort results in nutrient-complete
  breast milk.

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Physiologic Process of Lactation

• Milk production and secretion is stimulated by 2
  hormones
• Prolactin and Oxytocin - Baby sucks and sends a
  message to the mothers brain ? releases
  Prolactin and Oxytocin.
• Prolactin (Anterior pituitary) helps produce the
  milk
• Oxytocin (Posterior) the hormone that is
  responsible for the let down reflex

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Physiologic Process of Lactation

• Milk production is a supply and demand procedure
• Note Cows milk is inappropriate for infants lt
  12 months old (AAP)
• Inadequate iron, Vitamin E, essential fatty acids
• Too much protein, sodium and potassium

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Nutritional Needs During Lactation

• The basic diet followed during pregnancy and
  prenatal supplements can be continued through the
  lactation period.
• Milk production requires energy for both the
  process and the product
• Some of this energy need may be met by the extra
  fat stored during pregnancy
• In addition about 500 kcal/day needed during
  lactation more than a womans normal total
  kcalorie need
• Increased need for protein and vitamins and
  minerals

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Nutritional Needs During Lactation
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Nutritional Needs During Lactation

• Fluids
• About 3 liters/day
• Include water, juices, soup, milk
• Limit caffeine and alcohol (-gtbreast milk)
• Rest and relaxation Because the production and
  let-down reflexes of breastfeeding are hormonally
  controlled, some negative environmental and
  psychological factors can adversely affect the
  amount of milk a mother can produce.
• Such factors are called prolactin-inhibitors
  and include stress, fatigue, prolonged bed rest,
  complications, or irregular breastfeeding.

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Lactation advantages of breastfeeding

• Fewer infant infections mother transfers
  antibodies immune properties
• Fewer allergies and intolerances
• Ease of digestion forms a softer curd in the GI
  system

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Lactation advantages of breastfeeding

• Convenience and economy
• Improved cognitive development a positive
  relationship between the duration of
  breastfeeding and IQ in the child
• Reduced risk of childhood obesity and heart
  disease