Download No Slide Title

Chapter 11
Maternal and Infant Nutrition
in Health and Disease
Nutrition for a Healthy Pregnancy
Begins Before Conception






Achieve normal BG levels before conception (with diabetes)
Women with PKU need to adhere to low phenylalanine diet
Goal to meet the DRI for nutrients without excess or deficiency
Avoid excess vitamin A (preformed) to reduce risk of birth
defects (as found in certain acne creams)
Vegans require vitamins B12, D, and calcium
 B12 deficiency associated with impaired neurologic
development of the fetus and/or infant
Deficiency issues on fetal growth and development
 Pyridoxine (vitamin B6) deficiency may lead to impaired
learning and memory retention (women who used
anovulatory steroids prepregnancy are most at risk of B6
deficiency); Down syndrome associated with pyridoxine
deficiency (Baggot et al., 2008)
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
2
Folic Acid

Needed before or at time of conception and
throughout pregnancy for following benefits:







Reduced risk of neural tube defects (spina bifida), along
with possible role of choline (B vitamin)
Decreased homocysteine level for reduced risk of Down
syndrome
Decreased risk of fetal loss
Decreased risk of cardiac malformation
Decreased risk of small birth size
Decreased risk of orofacial clefts (along with vitamins B1,
B3, B6, E, and zinc)
Prevention of one form of anemia
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
3
Other Nutrition Issues
in Pregnancy

Safe food handling to prevent food poisoning


Steam or heat deli meat to lower risk of
pathogens
Avoidance of excess mercury intake


Decreased intake of tuna, shark, swordfish, marlin,
and lake trout
Small fish generally low in mercury (e.g., sardines)
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
4
Trimester Physiologic Changes

FIRST TRIMESTER (EMBRYO; CRITICAL STAGE)




Organs develop (4 to 12 weeks)
Central nervous system develops (4 to 12 weeks)
Skeletal structure hardens from cartilage to bone (4 weeks)
SECOND TRIMESTER (FETUS)


Growth and development continue (13 to 40 weeks)
Teeth calcify (20 weeks)
 Fetus can survive outside womb (24 weeks)

THIRD TRIMESTER TO BIRTH


Growth and development continue
Storage of iron and other nutrients (36 to 40 weeks; premature
babies often deficient in iron)
 Development of necessary fat tissue (36 to 40 weeks)
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
5
Comparison of Weight Gain Goals
Goal to prevent low birth weight and macrosomia
Current Goals:
Past Goals:


1960s < 20 lb
More recently:




From Institute of Medicine
(IOM):

25-35 lb (BMI 20-26)
28-40 lb (BMI <20)
15-20 lb (BMI >26)



Up to 30 lb normal weight
Up to 25 lb overweight
15 lb for obesity
For multiple births (triplets):

35 to 45 lb normal BMI
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
6
Risks of Low Birth Weight (LBW)





Low birth weight: <5.5 lb of unknown etiology
Small-for-gestational age (SGA) <10th percentile
height or weight based on gestational age; may also
be referred to as intrauterine growth retardation
(IUGR)
SGA infants are at later risk of hypercholesterolemia
IUGR or LBW related to low-normal kidney function
in adulthood
Increased risk of occurrence with poor dietary intake
and inadequate weight gain during pregnancy
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
7
First Trimester Issues

Prepregnancy BMI determines weight goals:



Morning sickness and hyperemesis (>5% weight loss)




Overweight/obese women weight gain goal related only to the
products of conception
Underweight woman increased weight gain goal to increase
blood volume and promote normal fetal growth
May benefit from small, frequent meals, especially including
CHO (crackers) before getting out of bed in the morning
Choline (B vitamin) appears important for brain development
and enhanced memory throughout life (high amounts found
in liver, eggs, and peanut butter)
Early screen for gestational diabetes for those at high risk
Anemia screening and treated prn; Fe+ used to help prevent
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
8
Prolonged Hyperemesis


Can cause dehydration; hospitalization needed for IV
fluid replacement
Associated with vitamin deficiencies:






Beriberi and Wernicke’s encephalopathy
Possible fatal electrolyte imbalance
May cause hemorrhage due to rupture of esophageal
varices
Parenteral nutrition may be required via venous access
Monitor for ketones
May benefit with



Small, frequent meals, including snacking on crackers
Vitamin B6 (Powers et al., 2007)
Ginger (Ensiyeh and Sakineh, 2008)
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
9
Second Trimester Issues





At approximately week 24, the placenta is large
enough to release significant amounts of
hormones that work counter to insulin
Weeks 24 to 28—glucose tolerance test to rule
out gestational diabetes
Kilocalorie intake needs to increase; these needs
are individual and based on weight goals
Protein intake should be 60 to 100 g
Source of omega-3 fats now recommended and
available in some prenatal vitamins; vegans may
be fine with plant forms: walnuts, canola oil, flax,
seaweed
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
10
FYI

Childhood asthma may be prevented by


Supplementing mother’s diet with fish oil
Increasing intake of zinc and vitamins D and E
during pregnancy (Devereux, 2007; Litonjua et al., 2006)
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
11
Third Trimester Issues





Ensure adequate calcium and vitamin D to allow for fetal
bone and tooth development to occur
Mother may experience heartburn; small frequent meals and
sitting up after eating can help
Constipation can be a problem because of diminished
peristalsis for increased intestinal absorption of nutrients;
include fiber, water, and exercise as tolerated
Restless leg syndrome: transient form found in up to 1 in 4
women during pregnancy; associated with low hemoglobin
Pregnancy-induced HTN (PIH) or gestational HTNpreeclampsia: a leading cause of maternal and fetal
morbidity and mortality
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
12
Signs and Symptoms of PIH



Proteinuria
High blood pressure; Rx advised if systolic
BP >155 mm Hg
Decreased risk with following:



Good selenium and magnesium status
Control of blood glucose
Physical activity
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
13
Other Concerns





Avoid alcohol to prevent fetal alcohol syndrome
Avoid caffeine, a vasoconstrictor to ensure good
oxygen uptake by fetus
Anemia—may be caused by increased blood volume,
but in the United States is still treated with iron
supplements
Pica—based on old cultural practices of eating clay in
Africa (traditionally a source of trace minerals, but the
risk of toxins outweighs possible benefits in modern
times)
For women on Rx for epilepsy: increased intake of
folate, vitamin B6, biotin, vitamin D (Gaby, 2007), and
adequate intake of vitamin K four weeks before
delivery (Montouris, 2007)
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
14
Lactation Goals



The American Academy of Pediatrics
recommends exclusive breastfeeding/nursing for
6 months and continued nursing through the first
year of life or longer, as desired
Healthy People 2010’s goal to increase the
number of women who breastfeed to 75%
Baby-Friendly Hospital Initiative (BFHI), a
worldwide program sponsored by the World
Health Organization (WHO) and the United
Nations Children’s Fund (UNICEF) to encourage
and recognize hospitals and birthing centers that
provide high-quality care in support of lactation
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
15
Ten Steps to Promote Lactation
1.
2.
3.
4.
5.
Maintain a written breastfeeding policy that is
routinely communicated to all health care staff.
Train all health care staff in skills necessary to
implement this policy.
Inform all pregnant women about the benefits
and management of breastfeeding.
Help mothers initiate breastfeeding within one
hour of birth.
Show mothers how to breastfeed and how to
maintain lactation even if they are separated
from their infants.
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
16
Ten Steps to Promote
Lactation (continued)
6.
7.
8.
9.
10.
Give infants no food or drink other than breast
milk, unless medically indicated.
Practice “rooming in”—allow mothers and infants
to remain together 24 hours a day.
Encourage unrestricted breastfeeding.
Give no pacifiers or artificial nipples to
breastfeeding infants
Foster the establishment of breastfeeding
support groups and refer mothers to them on
discharge from the hospital or clinic (BFUSA, 2004).
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
17
Cited Reasons for
Early Lactation Cessation





Lack of confidence
Problems with infant latching or suckling
Lack of individualized encouragement
within 2 weeks after birth
50% receive help with breastfeeding after
hospital discharge (Lewallen et al., 2006)
Adolescent mothers report inadequate
information on benefits of lactation and
expressed desire for increased
professional follow-up (Spear, 2006)
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
18
Benefits of Lactation






Colostrum and milk provide antibodies and immunity factors
to the breastfed infant
Hormones promote uterine contractions that aid return to
prepregnancy size and promote weight loss by mother
Babies’ “chewing” action promotes strong jaw muscles and
helps prevent baby-bottle mouth (tooth decay)
Baby becomes a “gourmet” eater with increased acceptance
of variety of foods later in life
DHA (omega-3 fat) promotes brain development and
increased visual acuity; human milk also high in alpha
linoleic acid unless other mammal milk
Reduced risk for later obesity of the child
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
19
Lactation Management



La Leche League—books and personal support for
breastfeeding
“Supply and demand”—prolactin production from
tactile stimulation allows for milk production; due to
supply and demand, multiples can be at least
partially breastfed; pumps can be used to express
milk for preemies
Let-down reflex—oxytocin production allows “hind”
milk to be released (“fore” milk is the equivalent of
skim; hind milk is the equivalent of cream); mother
needs to be relaxed for production of oxytocin; “pins
and needle” sensation confirms let-down reflex
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
20
Support Woman’s Confidence




Eight to 12 feedings per 24-hour period a sign of good
intake (may be spread evenly over this time or increased
frequency in days and less at night)
Six or more wet diapers per 24-hour period indicate good
milk production (assuming no water bottles)
Remind women during periods of growth spurts that “supply
and demand” will result in increased milk production
Refer any woman having or perceiving lactation difficulty to
La Leche League (local chapter representative can be found
on-line) or to an International Board-Certified Lactation
Consultant (IBCLC) at a local hospital
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
21
Prevention and Management of
Cracked or Sore Nipples






Change infant’s feeding position to help get
tongue off of sore spot (e.g., football hold, lying
down with baby’s feet toward mother’s head)
Relaxation techniques to encourage let-down
reflex; use warm compresses before putting infant
to breast
Nurse on less sore side first
Aim for short, frequent nursings <10 minutes
Remove baby from breast with mother’s finger
inserted near baby’s mouth to break suction
Air dry nipples after nursing; use cold compresses
between nursings
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
22
Breastfeeding versus
Bottle-Feeding Issues




Frequency
 Breastfeeding required every 2 to 3 hours or 8 to 12
times per
24 hours for the young infant (older infants can go longer
periods
with lower frequency)
• Formula is more difficult to digest; baby may go
longer stretches between feeds but not receive
adequate nutritional intake for optimal growth and
development
Breastfeed—no preparation, “ready to go”; bottle requires
sterilization and heating
Vitamin D may be needed by infant with either method
Breast milk can be pumped or hand-expressed by working
moms; breast milk or soy milk formula can be given in a
bottle after
well
established
(>1
month
of
Elsevier breast-feeding
items and derived items © 2010,
2007 by
Saunders, an imprint of
Elsevier
Inc.
age)
23
Bottle-Feeding Concerns






Iron-fortified formula advised
Formulas now available with added omega-3
fats
Powdered form needs careful measuring,
mixing
Liquid (concentrated) diluted 1:1 with water
Need safe water source and sterile bottles
Refrigeration required after mixing or opened
liquid concentrate
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
24
Introduction to Solids





No solids until ages 4 to 6 months when GI tract is
ready and the baby has the ability to indicate
satiety
Start with low allergenic foods—baby rice cereal
with iron to maintain iron status
Add new foods one at a time to rule out allergies;
vegetables before fruits may allow better
acceptance of veggies
Add pureed meats after age 6 months
Pincer grasp by approximately age 9 months; add
juice by cup; solids in small pieces to prevent
choking
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.
25