c hapter 10 nutrition during pregnancy and lactation 1

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. 3

NUTRITION DURING PREGNANCY AND LACTATION

Key Concepts

The mother’s 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 baby’s nutritional needs

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NUTRITIONAL DEMANDS OF PREGNANCY

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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


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 tissue–building requirements 6


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 7

PROTEIN NEEDS

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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

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

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Amount of increase during pregnancy:approx. 50%

more than the average adult requirements. High-risk or active pregnant women require more protein

PROTEIN NEEDS

Food sourcesComplete 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 seleniumCalcium supplements may also be needed

because of poor maternal stores or pregnancies involving more than 1 fetus.

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Iron and iodine Iron is essential for hemoglobin synthesis and

required for maternal blood volume. Contributes to baby’s prenatal storage of iron. Vitamin C in the diet enhances the body’s 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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Zinc and Copper:Increased during

pregnancyAbsorption of

both may be inhibited by high Fe (iron) intake may need to supplement.

VITAMINS NEEDED DURING PREGNANCY

Vit A and C – Both are needed in higher amounts during pregnancy; both are important elements in tissue growth

Vit B’s – 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. 16


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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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Vitamin D – to ensure absorption and utilitzation of calcium and phosphorus for fetal bone development

Can be met by the mother’s intake of 3-4 cups of fortified milk daily; also by the mother’s exposure to sunlight which increases endogenous synthesis of Vit D

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 adjustments depend on the situation of the mother at the time of pregnancyE.g. teen pregnancy; woman > 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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Rate of weight gain2 – 4 lbs first trimesterAfter 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 sodiumRestriction not necessaryNormal DietExtra use of Na+ not necessary 21

DAILY FOOD PLAN

General plan – Well balanced dietSee p. 176 Table 10-1 Daily Food Plan

Alternative food patternsSpecific 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

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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

DAILY FOOD PLAN

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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.

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 CONCERNSFunctional 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 vomitingHyperemesis gravidarum requires medical

treatment 26

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

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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

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 body’s ability to absorb zinc. Good sources of zinc are: crab meat, beef, turkey, and fortified cereals 29

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 30


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Recognizing Special Counseling Needs:Teenage pregnancy – special care

needed to support adequate growth of both mother and baby

See p. 182 for further focusPlanning 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 INFANTSRecognizing Special Counseling Needs cont.

Age and parity (# pregnancies and time in between)Adolescent Pregnancies: Increased social and nutritional risksInformation, 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 33


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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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.


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 problemsLow 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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A deficiency of iron or folate nutritional anemia

Neural tube defect – insufficient folate spina bifida, anencephaly

Intrauterine growth failure -> survival and growth problems. Contributing factors: low pre-pregnancy weight, inadequate weight gain during pregnancy, and smoking/alcohol

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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 infantComplications: seizures and HELLP

syndromeHELLP syndrome: hemolysis, elevated liver enzymes, low platelets

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PIH cont’d

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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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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Gestational Diabetes, con’t:

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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LACTATIONTrends – Mothers choosing to breastfeed has been

on the rise since 1960’s with 70% American mothers initiating breastfeeding.

Contributing Factors:World Health Organization : Baby-Friendly

Hospital Initiative More mothers are informed of the benefitsPractitioners recognize that human milk

can meet unique infant needsMaternity wards and alternative birth

centers are being modified to support successful lactation

Community support is available 44

LACTATION

World Health Organization recommends:Exclusive breastfeeding through 6

monthsBreastfeeding 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 beyond45

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 baby’s developing immune systemSecretory 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, CONT’D

Fatty acids: needed for energy, as well as development of the brain, retina and nervous system DHA ARA

Vitamins: directly related to Mom’s 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, Int’l: 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, Crohn’s

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

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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.


Milk production and secretion is stimulated by 2 hormones:Prolactin and Oxytocin - Baby sucks

and sends a message to the mother’s brain releases Prolactin and Oxytocin. Prolactin (Anterior pituitary) helps

produce the milk Oxytocin (Posterior) the hormone that

is responsible for the “let down reflex”51


Milk production is a supply and demand procedure

Note: Cow’s milk is inappropriate for infants < 12 months old (AAP)Inadequate iron, Vitamin E, essential

fatty acidsToo much protein, sodium and potassium

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Anatomy of the breast

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NUTRITIONAL NEEDS DURING LACTATIONThe 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 woman’s normal total kcalorie need

Increased need for protein and vitamins and minerals 54

NUTRITIONAL NEEDS DURING LACTATION

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NUTRITIONAL NEEDS DURING LACTATION

FluidsAbout 3 liters/dayInclude water, juices, soup, milkLimit caffeine and alcohol (->breast 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 intolerancesEase of digestion – forms a softer

curd in the GI system

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LACTATION: ADVANTAGES OF BREASTFEEDING

Convenience and economyImproved cognitive development

– a positive relationship between the duration of breastfeeding and IQ in the child

Reduced risk of childhood obesity and heart disease

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c hapter 10 nutrition during pregnancy and lactation 1

Documents

fetusspare protein

increased needs

growth of body tissues

nutritional status

fetal growth

breastfeeding mother

energy increase

lactationhealthy body