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Transcript
NUTRITION IN PREGNANCY AND LACTATION
Lingegowda Krishna1
Nageshu Shailaja 2
Namrata Kulkarni3
1- Professor and Head, Department of Obstetrics and Gynaecology, PES Institute of Medical
Sciences and Research, Kuppam.
2-Associate Professor, Department of Obstetrics and Gynaecology, PES Institute of
Medical Sciences and Research, Kuppam.
3- Assistant Professor, Department of Obstetrics and Gynaecology, PES Institute of
Medical Sciences and Research, Kuppam.
*Corresponding Author: Address: Dr.L Krishna, Professor and Head of the Department,
Obsterics
and
Gynaecology,
Medical
Superintendent
PESIMS&R,
Kuppam-517425,
Chittoor(Dt), Andhra Pradesh, India.
Phone:+9391833730, E- mail: [email protected]
Introduction
A critical element of the health care system is the health of women in the
childbearing age and children under five. A child’s nutritional well-being begins with
the mother’s nutritional status during adolescence and pregnancy. Pregnancy is a
critical period during which good maternal nutrition is a key factor influencing the
health of both mother and child. The vast majority of them die from complications,
which could be reduced through better nutrition.
Consequences of Maternal Nutritional Deficiency
 Inadequate intake of the micronutrients may have a profound impact on both
the mother and fetus during pregnancy.
 Vitamin A deficiency is linked to maternal death.
 Inadequate folate during preconceptional period and the first trimester of
pregnancy can cause birth defects like neural tube defects, such as spina
bifida and anencephaly.
 Folate deficiency can also increase the risk of low birth weight (LBW) and
maternal mortality.
 Iodine deficiency increases the risk of still birth and miscarriage and can
cause severe learning disabilities in children.
 Zinc deficiency can result in prolonged labour, which increases the odds of
the mother dying and can impair fetal development.
 LBW babies tend to have slower growth rate and stunting, unless there is an
early intervention.
Energy requirements during pregnancy and lactation
Pregnant and lactating women require additional dietary intake, as they have
to meet their own nutritional requirements and also supply nutrients to the growing
fetus and the infants. The Indian Council of Medical Research has recommended an
additional intake of 300kcals /day during the second and third trimester of
pregnancy. According to dietary guidelines women should consume a variety of
foods to meet the additional nutrient needs and achieve the recommended weight
gain.
Key nutrient &
Important functions
Important source
Comments
Calories
Provide energy for
Carbohydrates ,fats Calorie
N-2200
tissue building &
& proteins
P-2200(1st
increased metabolic
according to the
trimester)
requirements
stage of pregnancy,
RDA
requirements vary
P-2500(2nd & 3rd
size of pregnant
trimester)
woman, activity
L-2700
level, pre pregnant
weight & how well
nourished they are
Water or liquids
Carries nutrients to
Water, juices &
Liquid is often
N-8 glasses
cells
milk
neglected, but it is
P-10 glasses
Carries waste
an important
L-12-14 glasses
products away.
nutrient
Provides fluid for
increased blood,
tissue & amniotic fluid
volume.
Helps regulate body
temperature.
Aids digestion.
Protein
Builds & repairs
Meat, fish, poultry
Fetal increase by
N-50g
tissue.
eggs, milk, cheese,
1/3rd in late
P-65g
Helps build blood,
dried beans & peas, pregnancy as the
L-75g
amniotic fluid &
peanut butter,
placenta.
nuts, whole grains
Helps form antibodies. & cereals
Supplies energy
baby grows
Minerals
Key nutrient &
RDA
Calcium
N-400mg
P-1000mg
L-1000mg
Phosphorous
N-800mg
P-1200mg
L-1200mg
Important functions
Important source
Helps build bones &
teeth.
Important in blood
clotting.
Helps regulate use of
other minerals in the
body.
Helps build bones &
teeth
Milk, cheese, whole
grains, vegetables,
egg yolk, whole
canned fish, ice
cream
Iron
N-30mg
P-38mg
L-30mg
Combines with
proteins to make
hemoglobin.
Provides iron for fetal
storage.
Zinc
N-12 mg
P-15mg
L-19mg
Iodine
N-150mcg
P-175mcg
L-200 mcg
Magnesium
N-280mg
P-320mg
L-355g
Component of insulin.
Important in growth of
skeleton.
Helps control the rate
of body’s energy use.
Important in thyroxine
production.
Helps energy, protein
& cell metabolism.
Enzyme activator.
Helps tissue growth &
muscle action.
Comments
Fetal requirements
increase in late
pregnancy.
Caffeine can
decrease the amount
of calcium available
to fetus.
Milk, cheese, lean
Calcium &
meats
phosphorous exist in
a constant ratio in
the blood,an excess
limits the use of
calcium
Liver, red meats
Fetal requirements
Egg yolk, whole
increase 10 fold in
grains, leafy
the last 6 weeks of
vegetables, nuts,
pregnancy.
legumes, dried fruits, Supplement 30prunes & apple juice 60mg of iron daily is
recommended by
National Research
Council.
Meat, liver, eggs, sea Deficiency can cause
food (especially
malformations of
oysters & nervous
fetal skeleton &
system)
nervous system
Sea foods, iodised
Deficiency may
salt
cause goiter in infant
Nuts ,cocoa, green
vegetables, whole
grains & direct beans
& peas
Most is stored in
bones.
Deficiency may
cause dysfunction.
Fat soluble vitamins
Key nutrient & RDA Important
functions
Vitamin A
Helps bone & tissue
N-600mcg RE
growth &
P-600mcg RE
development.
L-950mcg RE
Essential in
development of
enamel-forming cells
in gum tissue.
Helps maintain
health of skin &
mucous membrane.
Vitamin D
Needed for
N-5mcg
absorption of
P-10mcg
calcium &
L-10mcg
phosphorous, &
mineralization of
bones & teeth
Vitamin E
Needed for tissue
N-8mg α TE
growth, cell wall
P-10mg α TE
integrity & red blood
L-12mg α TE
cell integrity.
Vitamin K
Essential for
N-65mcg
synthesis of blood
P-65mcg
clotting factors.
L-65mcg
Important source
Comments
Butter, fortified
margarine, green &
yellow vegetables,
liver
In excess amounts ,it
is toxic to fetus.
It loses its potency
when exposed to
light.
Fortified milk,
Toxic to fetus in
fortified margarine,
excess amounts.
fish, liver, oil ,
sunlight on your skin
Vegetable oils,
cereals, meat, eggs,
milk, nuts & seeds
-
Enhances absorption
of vitamin A.
Produced in the
body by the
intestinal flora.
Water soluble vitamins
Key nutrient &
RDA
Folic acid
N-180mcg
P-1400mcg
L-280mcg
Niacin
N-15mg
P-17mg
L-20mg
Riboflavin
N-1.3mg
P-1.6mg
L-1.8mg
Thiamin (B1)
N-1.1mg
P-1.5mg
L-1.6mg
Pyridoxine(B6)
N-1.6mg
P-2.2mg
L-2.1mg
Cobalamin (B12)
N-2.0mcg
P-2.2mcg
L-2.6mcg
Vitamin C
N-40mg
P-40mg
L-45mg
Important functions
Essential in
hemoglobin synthesis.
Involved in DNA &
RNA synthesis.
Needed for synthesis
of amino acids.
Needed for energy &
protein metabolism.
Essential for energy &
protein metabolism.
Important for energy
metabolism.
Important in
aminoacid metabolism
& protein synthesis
required for fetal
growth.
Essential in protein
metabolism.
Important in formation
of red blood cells.
Important
source
Liver, green leafy
vegetables &
yeast
Pork, organ
meats, peanuts,
beans, peas &
enriched grains
Milk, lean meat,
enriched grains,
green leafy
vegetables
Pork, beef, liver,
whole grains &
legumes
Unprocessed
cereals, grains,
wheat germ, nuts,
seeds, legume &
corn
Milk, eggs, meat,
liver, cheese
Helps tissue formation Citrus fruits,
& integrity.
berries, melons,
It is “cement”
tomatoes, chilly,
substance in
pepper, green
connective & vascular
vegetables &
tissue.
potatoes
Increases iron
absorption.
Note: N – Nonpregnant P – Pregnant L - Lactation
Comments
Deficiency leads to anemia,
neural tube defects.
Can be destroyed in cooking &
storage.
Supplement of 400 mcg/day is
recommended by National
Research Council.
Oral contraceptives may reduce
blood level of folic acid.
Stable; only small amounts are
lost in food preparation.
Oral contraceptives may reduce
serum concentration of
riboflavin.
Essential for conversion of
carbohydrates into energy in the
muscular & nervous systems.
Excessive amounts may reduce
milk supply in lactating women.
May help reduce nausea in early
pregnancy.
Deficiency leads to anemia & CNS
damage.
It is manufactured by
microorganisms in the intestinal
tract.
Oral contraceptives may reduce
serum concentration.
Large supplementary doses in
pregnancy may create a larger
than normal need in infant.
Benefits of large doses in
preventing cold have not been
confirmed
Protein requirement during pregnancy and lactation:
During pregnancy, the expansion of blood volume and the growth of
maternal tissues requires substantial amount of protein. Growth of the fetus and
placenta also places protein demand on the pregnant woman. Thus an additional
protein intake is essential for the maintenance of a successful pregnancy.
Factorial Estimate of Protein Components of Weight Gain in a
Normal Full-Term Pregnancy
Component
Weight (in kg)
Protein (in kg)
Fetus
3.4
0.44
Placenta
0.7
0.1
Amniotic fluid
0.9
0.003
Uterus
0.9
0.166
Blood
1.5
0.081
Extra cellular fluid
1.5
0.135
Total
8.9
0.925
The deposition of protein is not linear throughout pregnancy. Early during
pregnancy the protein requirement for fetal development is minimal, whereas the
requirement for maternal volume expansion and tissue growth may be substantial.
Late in pregnancy the fetus may account for a major increase in protein needs.
Safe Level of Additional Protein During Pregnancy
Trimester
Additional Protein Required(g/day)
1
1.2
2
6.1
3
10.7
An extra 25 gram/day of protein with a chemical score of 70 is recommended
during lactation by FAO/WHO.
A safe level of extra protein intake during lactation is 16g/day during the
first 6 months of lactation, 12g/day during the second 6 months and 11g/day
thereafter.
The protein content of pulses is twice that of cereals (22-25%) and almost
equal to that of meat and poultry but the quality of protein is inferior to animal
protein.
Recommended Essential Fatty Acid Intake
Adequate intakes (AI) have been set for Linoleic acid(LA) and Alpha Linolenic
acid(ALA)
The AI for LA is 17 and 12g/d for men and women aged 19 – 50yrs,
respectively. The AI for ALA is 1.6 and 1.1g/d for men and women aged 19 to >
70yrs, respectively.
Recommendations Concerning Essential Fatty Acid Intakes:

The ratio of linoleic to alpha-linolenic acid in the diet should be between 5:1 and
10:1

Individuals with a ratio in excess of 10:1 should be encouraged to consume more
n-3 rich foods such as green vegetables, legumes, fish and other seafood.

Particular attention must be paid to promoting adequate maternal intakes of
essential fatty acids throughout pregnancy and lactation to meet the requirements
of fetal and infant development
Emerging role of Docosahexaenoic acid (DHA):
DHA is an omega 3 fatty acid, the predominant fatty acid in the brain and retina. Due
to low conversion rate of alpha linolenic acid (ALA) to DHA, it is important to directly
consume DHA, especially during pregnancy and lactation. The brain has its growth spurt in
the third trimester of pregnancy and during early childhood. Therefore, an appropriate
pre-and post-natal supply of these LCPs or their precursors is thought essential for normal
fetal and neonatal growth, neurologic development and function, learning and behavior.
DHA also has an important role in fetal retinal function and in prevention of maternal
postpartum depression.
Dietary sources of DHA: fish and fish oil, present in fatty fish and algae
Recommendations on DHA intake:
Organization
DHA Recommendations
International society for the study Adequate intake for adults to be at least 220mg per day
of Fats and Lipid (ISSFAL)
and 300mg per day for pregnant and lactating women
Committee On Medical Aspects Of 1.5g EPA plus DHA per week(i.e 214mg mg per day)
Food Policy (COMA)
British Nutrition Foundation(BNF)
8g EPA plus DHA per week for women(i.e 1145 mg per
day) 10g EPA plus DHA per week for men(i.e 1430 mg
per day)
Expert workshop of the European “ People who do not eat fish should consider consuming
Academy of Nutrition Sciences held marine n-3 PUFA equivalent to the amount obtained
in 1997(EANS)
from fatty fish, namely 200mg EPA plus DHA daily”.
EPA- Eicosapentaenoic acid
Importance of dietary fibre:
Dietary fibre consists of the remnants of edible plant cells, polysaccharides,
lignin and associated substances resistant to digestion. Modest increases in the
intake of fruits, vegetables, legumes and whole and high-fiber grain products, would
bring the majority of the Indian pregnant women close to the recommended range
of dietary fiber intake of 20 – 35 g/day.
An intake of food high in fiber is likely to be less calorically dense and is
lower in fat and added sugar.
Dietary fiber intake should be considered while counseling patients about
the management of gestational diabetes, constipation and other problems like
hemorrhoids, bowel distress and elevated blood pressure.
Food guide pyramid during pregnancy
Everyday use nine servings of cereals, four servings of vegetables, three
servings of fruit, milk and meat. Use fats sparingly. An increased amount of calcium
can be obtained from low fat milk, low fat cheese, yogurt, dark green vegetables or
fruit juices with calcium added.
Sample menu for a pregnant lady
BREAKFAST
MID MORNING
LUNCH
MID AFTERNOON
TEATIME
MID EVENING
DINNER
BED TIME
1cup milk (225ml), 2 dosas with green chutney (without coconut)
1cup milk (150ml) + 1 sweet lime
1 katori rice, 3 chapathis, 2 katori tur dal, palak fish(3 slices), French
beens bhaji, toasted salad
1 glass buttermilk (made from skim milk)
1cup tea with half cup skim milk (75ml), 1 katori poha with peas
1cup skim milk + 1 apple
Mixed vegetable soup, khichidi 2 katoris, kadhi 1 ½ katori,potato
cauliflower bhaji 1 katori,pumpkin raitha
1 cup milk(225ml) & papaya (2 slices)
Weight gain during pregnancy:
The pre-pregnancy weight, socioeconomic status, genetics, health condition,
parity, and nutritional factors affect maternal weight during pregnancy.
The components of weight gain can be divided into 2 parts – the products of
conception and maternal tissue accretion. The products of conception comprise of
the fetus, placenta and amniotic fluid. Cross-sectional data indicate that fetal growth
follows a sigmoid curve with growth slowing in the final week of gestation. The rate
of placental growth also declines towards the end of pregnancy. The expansion of
maternal tissue accounts for approximately two-thirds of the total gain. In addition
to increases in uterine and mammary tissue mass, there is also an expansion of
maternal blood volume, extracellular fluid, fat stores and possibly other tissues.
Components of weight gain
Component
Baby
Placenta
Amniotic fluid
Mother
 Breasts
 Uterus
 Body fluids
 Blood
 Maternal stores of fat, protein
and other nutrients
Total
In Kg
3.4
0.7
0.9
0.9
0.9
1.5
1.5
3.1
12.9
Weight – for – height and Recommended Weight gain
Weight – for – height category
Recommended total gain, kg(lb)
Normal (BMI 19.1 – 24.9kg/m2)
11.5 – 16(25 – 35)
High (BMI > 25 – 29.9kg/m2)
7 – 11.5 (15 – 25 )
Obese (BMI > 30kg/m2)
No more than 7
Twin Gestation(any BMI)
23
Medical conditions where consultation with registered dietician is advisable:

Multiple gestation

Frequent gestation (<3months interpregnancy interval)

Tobacco, alcohol of chronic medicinal or illicit drug use

Severe nausea and vomiting

Eating disorders

Inadequate weight gain during pregnancy

Adolescents

Restricted eating

Food allergies/intolerances

GDM/prior history of GDM

Prior history of LBW babies/other obstetrical complications

Social factors that may limit appropriate intake(Eg.religion,poverty)
Nutrition during labour

Withholding food and drink inappropriately from women in labour may
result in dehydration, ketosis, fatigue and can increase levels of stress which
in turn can affect the Neuro-hormonal balance that enables labour to
progress unhindered.

The prophylactic use of antacids or reduction of the volume of stomach
contents by restricted oral Intake has not been shown to be successful in
preventing Mendelson’s syndrome.

For those women for whom a general anaesthetic is not anticipated a light,
low residue, low fat diet may be recommended in latent phase. Allow oral
fluids to maintain hydration in the active phase

For those women for whom a general anaesthetic is anticipated allow only
clear liquids.

The administration of opioids delays stomach emptying. So, allow only liquid
diet.
Suggested drinks for women in labour:

Low fat yoghurt drinks

Fresh fruit juices(avoid apple, pineapple, mango and lemon as they
tend to be more acidic)

Coffee/Tea with skimmed milk

Soups (cream of tomato or vegetable etc)

Squash drinks – not too concentrated

Water and ice

Naturally carbonated mineral water
Suggested foods for women in labour:

Idli

Toast with low fat spread, jam/honey

Cereals with skimmed milk/ganji

Plain sweet biscuits

Smooth soup

Low fat, smooth yoghurt
Guidelines for diet in gestational diabetes mellitus
Energy (Calories):
Carbohydrates: 55-60% of total calories. Encourage complex carbohydrates i,e
grains, cereals, pulses, beans, vegetables and salads. Avoid simple and refined
carbohydrates like sugar , honey, maida and jaggery.
Foods with low glycemic index is advised. Breakfast is 10-15%, Lunch and
dinner 25-30% and 4 snacks of 5-10% of total calories required per day.
Proteins: 1gm/kg body weight + 14 grams. Avoid red meat and egg yolk.
Fats: 22-15% of total calories. Saturated fat should be 6-7% of total calories.
Fruits: Consume one fresh fruit per day. Avoid juices. Ideal fruits are citrus fruits,
guava, apple, papaya and watermelon
Dietary fibres: 30-40 gram/day. Indian diet is rich in fibre. Avoid the loss of fibre
by refining and processing the food.
Condiments and spices: Include in diet plan. Provide antioxidants, trace elements,
minerals and omega 3 fatty acids.
Artificial sweeteners: Use of aspartame and artificial sweeteners is prohibited in
pregnancy and lactation.
Role of nutrition in IUGR:
Nutrition is the major intrauterine environmental factor that alters
expression of the fetal genome and may have life long consequences (Barker
hypothesis).Protein energy supplementation decreases the risk of IUGR by 30% in
those with inadequate nutritional intake. Mothers with decreased serum zinc
concentration benefit from zinc supplementation. Zinc is recognized as an important
factor for normal fetal growth and development.
Nutritive needs in Pregnancy induced hypertension:
Nutritional interventions such as calcium supplementation, antioxidants like
Vitamin C & E and fish oil have shown promise in the prevention and reduction of
PIH , especially in high risk groups, teenage pregnancies and in women with diets
low in calcium.
Maternal nutrition – tips to give your patient
Pregnancy is very special moment in someone’s life, it includes the joys and
challenges of motherhood and requires that your patient is given adequate
information with the best possible care, essential for a healthy pregnancy. It is
undoubtedly a very exciting time, but is also a period of great psychological stress
for a woman as she nurtures a growing fetus in her body. Fetal development is
accompanied by many physiological, biochemical and hormonal changes which
occur in the maternal body and influence the need for nutrients and the efficiency
with which the body uses them.
Nutrition is not only important for the unborn baby but is also essential for
the mother’s current and future state of health. The diet during pregnancy and
lactation is designed to promote optimal nutrition for the woman and fetus in
pregnancy and for the mother and infant during lactation.
1. A pregnant woman is always advised to eat what she wants, in amounts she
desires and food should be salted to her taste. Mothers who are in negative
energy in terms of both food storage and heavy workload deliver low birth
weight babies. Pregnant women from low socio economic group should make
efforts to ensure a healthy diet.
2. Proteins are needed for repair of the mother’s tissue as well as for added
demands of growth, increased blood volume and repair of placenta, uterus
and breast. They can be supplied from either meat, milk, eggs, pulses ,
legumes, cheese, poultry or fish. Generally if a pregnant woman consumes
enough calories in her food, her protein needs are taken care of.
3. Her weight should be checked serially with the intention of gaining about 10 –
12 kg during the whole period of 40 weeks.
4. Iron is the only nutrient for which requirements cannot be met by diet alone.
Iron deficiency anemia is a significant cause of increased maternal mortality
and has an adverse effect on the health and development of the newborn.
Tablets of simple iron salts that provide 30 – 60mg of iron/day should be
taken. Iron supplementation is not necessary in the first trimester and it also
aggravates nausea and vomiting. Recheck the hemoglobin concentration at 28
– 32wks to detect any significant decrease.
5. The increased requirements of all vitamins can be generally supplied by the
usual diet, except for folic acid, which is required more in pregnancies, that
are complicated by protracted vomiting, hemolytic anemia, multiple fetuses
and those on antiepileptic drugs. Folic acid tab of 5mg/day should be taken
not only during pregnancy but also three months before you are planning to
start a family, especially in cases with a genetic or family history of neural
tube defects.
6. Strict vegetarians may have low vitamin B12, so supplementation of vitamin
B12 may be required in such cases. Studies show that multi vitamin
supplementation for women who do not consume an adequate diet are not
really helpful.
7. Calcium is deposited in the fetus during later pregnancy. This amount
represents about 2.5% of maternal calcium, most of which is present in the
bone and can be readily used for fetal growth. So it is only in developing
countries where there is deficiency of vitamin D and calcium that
supplementation is required. One cup of cow’s milk provides approximately
1gm of calcium.
8. Iodised salt should always be used. So as you can see, pregnancy does not
require too much of extra nutrition. Rather a good balanced diet with all the
specific nutrients is required for the benefit of the mother and the growing
fetus.
Nutritional guidelines for a pregnant mother
o Drink plenty of fluids in the form of water and juices, which help increase the
volume of breast milk.
o The maximum amount of energy should be derived from whole grain cereals
rather than from fats and sugars.
o The source of carbohydrates should be mainly from the consumption of
whole grain cereals rather than from sugars and refined products.
o Non-vegetarians can get protein from meat, poultry and eggs. Vegetarians
can derive quality proteins from a combination of cereals, legumes, pulses
and nuts. Intake of sprouted pulses is desirable.
o Mineral and vitamin requirements should be met by consuming a variety of
fruits(including seasonal) and vegetables, especially those rich in vitamin C
such as orange and green leafy vegetables.
o Vegetarians should drink milk can serve as a source of calcium and vitamin
B12 and D.
o A combination of PUFA (Poly unsaturated fatty acids) and MUFA (Mono
unsaturated fatty acids) oils as a source of energy and is preferable to
saturated fats.
o Eat foods rich in vitamin C, such as citrus fruits, amla, guava, sprouts etc with
meals in order to improve the absorption of iron from the food.
o Milk and curd are the best sources of biologically available calcium.
o Foods that are not nutritious, like those that are fried or barbecued, should
be avoided, including those that can cause allergic reactions in the pregnant
woman.
o A pregnant mother may also require calcium, iron and vitamin B-12
supplements.
o Choose at least five daily servings of fruits and vegetables. Also try whole
grain foods such as ragi, dal, brown bread, whole grain pulses and lentils.
o Whenever possible eat fruits with the peel and remember that eating a fruit
is more beneficial than drinking fruit juice.
o Drink at least 12 glasses of fluid per day.
o Only take chemical laxatives prescribed by an obstetrician.
If weight gain is too rapid during any part of the pregnancy, the following guidelines
should be used to manage weight:
 Avoid high-calorie, low-nutrient foods such as sweets, cakes, pastries,
desserts and fried snacks like chips, vadas, bondas etc.
 Use low-fat dairy products-skimmed milk and yogurt/curd made with
skimmed milk.
 Use only lean meats, poultry and fish.
 Bake, broil, grill, or stir-fry instead of frying foods.
 Increase physical activity.
 Do not crash diet!!!
References:
1) Williams obstetrics 23rd edition
2) D.K.James - High risk pregnancy management options 4rd edition
3) Steven G Gabbe -Obstetrics 5th edition
4) Maternal nutrition: A Quintessential Guide- Kamini Rao, Vindhya Subbiah