Chapter 10

1. Chapter 10 • Nutrition During Pregnancy and Lactation

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

3. 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.

4. 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

5. 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

6. 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 tissue–building requirements

7. 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

8. 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

9. 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

10. 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

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

12. Protein Needs • Food sources • Complete protein foods of high biologic value: • Milk • Eggs • Cheese • soy products • meat • Incomplete protein foods: plant sources

13. 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.

14. Key Mineral and Vitamin Needs 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.

15. 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.

16. 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.

17. 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

18. Vitamins Needed During Pregnancy 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

19. 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

20. Weight Gain During Pregnancy Weight adjustments depend on the situation of the mother at the time of pregnancy E.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

21. 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

22. 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)

23. 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

24. 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.

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. High Risk Mothers and Infants

32. 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)

33. 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

34. 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.

35. 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.

36. 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

37. 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.

38. Complications of Pregnancy 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

39. 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

40. Complications of Pregnancy 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

41. Complications of Pregnancy

42. 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

43. Complications of Pregnancy 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)

44. Lactation Trends – 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 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

45. 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

46. 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 system • Secretory IgA: protects ears, nose, throat, GI tract – highest in colostrum, but also high throughout first year

47. 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

48. 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

49. 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

50. 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.