Nutrition during pregnancy and lactation dr. Marlina Dewiastuti M.Kes

Nutritional Needs During PregnancyEnergy: First Trimester - no changeSecond Trimester - increases 340 kcal/dayThird Trimester - increases 450 kcal/day

Protein:Increases from 46 g/day to 71 g/day

Vitamin and MineralRequirements in PregnancyPregnant women are at increased risk for folic acid, iron, and calcium deficiencies.

Recommendations are:Iron increases to 27 g/dayFolate increases to 0.6 mg/day Calcium - 1000 mg/dayMagnesium - increases to 360 mg/dayVitamin C - increases to 85 mg/day

Weight Gain and Caloric IntakePattern of weight gain during pregnancy is more important than the total amount of weight gained It is better to gain the majority of your pregnancy weight during the last two trimesters Select the orange to proceed.

Weight Gain and Calorie Intake Do not consume anymore calories than normal per day during the first trimester 340 additional calories recommended per day during the second trimester 450 additional calories recommended per day during the third trimester Needed for adequate fetal growth and to support the higher maternal metabolismSelect the orange to proceed.

Recommended Weight GainInstitute of Medicine. Weight Gain During Pregnancy. National Academy Press. 1999.

Importance of Good Nutrition during Pregnancy

Important before, during and after pregnancyGood control of weight, blood pressure and blood glucose increase chances of healthy, normal weight, term infantAffects fetal and placental growth Select the orange to proceed.

Importance of Good Nutrition during PregnancyAffects maternal well being and maternal outcomes Not getting enough micronutrients causes low birth weight, premature birth, and other fetal problems Micronutrients include: folic acid, iron, omega-3 fatty acids, Vitamin A, calcium, Vitamin D and iodine Select the orange to proceed.

Neural Tube Defects (NTD) Prevention: Role of FolateFolate deficiency is the most common deficiency during pregnancy

Functions: Serves as a co-factor in one-carbon transfers, (nucleic acids and amino acids) and therefore required during periods of rapid growth. Increased maternal erythropoesis causes increased folate needs during second and third trimesters.

Role in Prevention: NTD are thought to result from a dietary deficiency of folate and/or a genetic defect affecting folate metabolism.

During pregnancy, the neural tube is formed from the 18th to the 26th DAY of gestation.

Folic AcidReduces risk of having a baby with neural tube defects Reduces the risk of premature birth Recommended amount of folic acid is 0.4 milligrams (400 micrograms) per day Most drugstores carry off-brands of this micronutrientEven some dollar stores carry Folic AcidSelect the orange to proceed.

Neural Tube DefectsSelect the orange to proceed.

Folic AcidSupplement should be started at least one month before getting pregnantIt is recommended that any woman of childbearing age should be taking folic acid supplements because they may not know they are pregnant until it is too late.

Select the orange to proceed.

Good Sources of Folic AcidGreen leafy vegetables Fortified cereals Select the orange to proceed.

Iron in PregnancyIron is an essential element in all cells of the body. During pregnancy, maternal blood volume increases 20-30%. Iron needs increase from 18 to 27 g/day during pregnancy. Deficiency increases risk of maternal and infant death, preterm delivery, and low birth weight babies.

IronReduces the risk of premature birth and low birth weight Not getting enough iron could cause anemia Could contribute to developmental delays and behavioral disturbances in the infant and poor health in the motherContributes to death and other disease development Select the orange to proceed.

Iron Essential for normal infant brain development Iron helps create blood that is necessary for fetal demands and blood loss during delivery.Select the orange to proceed.

Diagnosis of Iron Deficiency Anemia

The CDC reference criteria for anemia during pregnancy:

First trimester Hgb

Iron Deficiency AnemiaWeakness, fatigue, poor work performance, and changes in behavior. Physical signs include pallor, fatigue, coldness and paresthesia of the extremities, greater susceptibility to infections.

Infants and young children with iron deficiency may have low IQ levels, poor cognitive and motor development, learning, and behavioral problems.

Good Sources of IronLean red meatGreen leafy vegetablesFortified breakfast cereals Select the orange to proceed.

Omega-3 Fatty AcidsImportant for brain development and preventing preterm birthEssential for visual development Reduces the incidence of heart disease and heart related death of the infantRecommended 300 milligrams per day Select the orange to proceed.

Good Sources of Omega-3 Fatty AcidsFish oil capsulesCertain fish such as salmon, trout, mackerel, sardines, and fresh tunaVegetable oils such as sunflower, rapeseed, flaxseed, and walnut oilsSelect the orange to proceed.

Calcium and Vitamin DCalcium and vitamin D are needed for strong bones and teethVitamin D is needed for the formation of the fetal bonesRecommended 10 micrograms of Vitamin D per day Select the orange to proceed.

Good Sources of Calcium and Vitamin DMilk and other dairy products Eggs Meat Certain fish such as salmon, trout, mackerel, sardines, and fresh tunaSelect the orange to proceed.

IodineLack of iodine could contribute to stillbirth, birth defects, and decreased brain developmentIodine is important for brain development Select the orange to proceed.

No Alcohol and Limited CaffeineProtect the infant from fetal alcohol syndrome and other birth defects Avoid alcohol, including all wines, beers, hard liquor, and wine coolersHigh caffeine intake linked to low birth weight and spontaneous fetal deathAvoid food and beverages such as teas, coffee, colas, energy drinks, and chocolate Select the orange to proceed.

What about smoking?Women should be discouraged from smoking before and during pregnancy, because it is associated with decreased fertility and lower birthweight.If women are unable to comply with this advice, special attention should be paid to their overall nutrient intake, especially that of vitamin C, in order to help counteract the harmful effects of smoking on the fetus.

What about caffeine?Claims that consumption of caffeinated beverages is associated with reduced fertility and defects in fetal development have not been substantiated. Whilst moderate intakes (up to four or five cups of instant coffee a day) are unlikely to be harmful for most pregnant women.those at high risk of miscarriage should reduce their intake to one or two cups per day. Cola and tea also contain caffeine and their consumption should be taken into account.

Some women experience constipation or haemorrhoids when they are pregnant. Can diet help?These conditions are common during pregnancy. Practical advice to pregnant women should be to increase intake of fibre, by increasing intake of complex (starchy) carbohydrate, particularly wholegrain cereals and breads .An adequate fluid intake is also important, along with gentle exercise.

ConstipationConstipation during pregnancy is associated with:increased progesterone levels and smooth-muscle relaxation of the GI tract. This results in GI discomfort, a bloated sensation, increased hemorrhoids, and decreased appetite. Increase fluid and fiber intake to reduce constipation.

Nausea and vomiting are common in early pregnancy. Can diet help?Morning sickness, nausea and vomiting occur in around half to threequarters of pregnant women during the first trimester.Consumption of small, frequent meals can help if these symptoms are experienced.Plenty of carbohydrate foods should be encouraged and plenty of fluids. A warm drink and a dry biscuit or dry toast may also be helpful.

Nausea and VomitingAssociated with increased levels of HCGPeaks at 12 weeks gestation Strategies for managing morning sickness:Eat small, low-fat meals and snacks Drink fluids between meals, avoid caffeineReduce citrus, spearmint, peppermintLimit spicy and high-fat foods Avoid lying down after eating or drinkingTake a walk after mealsWear loose-fitting clothes

What is toxoplasmosis?Toxoplasmosis is caused by a parasite found in raw meat, cat faeces and occasionally in unpasteurised goats milk. In rare cases, the infection can be passed on to an unborn baby and cause eye and brain damage. A high regard for food hygiene is therefore very important for pregnant women .In particular, they should avoid eating raw or uncooked meat, unpasteurised goats milk or goats cheese, or unwashed fruit and vegetables. After handling raw meat, chopping boards, utensils and hands should be washed thoroughly. When gardening or emptying cat litter trays, rubber gloves should always be worn.

Physiology of LactationSuckling stimulates nipple --->pituitary gland secretes oxytocin--->let down reflex results in milk ejecting cells contract forcing milk from milk cells into milk ducts. Milk pools in lactiferous sinuses under the areola. Suckling stimulates milk to come from the nipple.

General Benefits of BreastfeedingMaternal-infant bondingInexpensiveConvenient (no preparation)Perfect temperatureEasily digestedImmunological protectionAllergy prophylaxis

Breastfeeding Advantages for MothersMay delay return of ovulation.Loss of pregnancy associated adipose tissue.Reduction in postpartum blood loss due to increased oxytocin levels.Reduction in pre-menopausal breast cancer and reduced risk of ovarian cancer.Improved bone remineralization postpartum.

Immunological Contentsof Breast MilkImmunoglobulinsIgA, IgG, IgM, leukocytes, cytokinesHost resistance factors Complement macrophages, lymphocytes, lactoferrin Anti-inflammatory componentsEnzymes: catalase, histaminase, lysozymes, lactoperoxidaseAntioxidants: acsorbic acid, alpha-tocopherolProstoglandinsInterleukin-6Stimulates an increase in mononuclear cells in breast milk.

Breastfeeding Advantages for BabyDecreased incidence and/or severity of otitis media, diarrhea, lower respiratory infections, bacteremia, bacterial meningitis, botulism, urinary tract infections, and necrotizing enterocolitis. Less hospitalization in first 6 months. Possible protective effect against sudden infant death syndrome, type 1 diabetes, Crohns disease, ulcerative colitis, lymphoma, allergies, and chronic digestive diseases.

Composition of Breast MilkColostrum: small amount during days 3 to 5High in protein, immunoglobulins and minerals,Low in lactose and fatTransitional milk: produced during days 6 to10High in fat, lactoseLower in protein and mineralsMature milk: available by 2 weeks post-partumAverage secretion: 750 mg/dProvides 20-22 kcal/ounce60-80% whey protein, 40% lactose, 50% fatGrowth factorLow in vitamin D

What is colostrum and how does the composition of milk change, both during a feed and as the baby grows?Colostrum is the first milk produced after the baby is born. It is of a different composition to the milk that follows and is particularly rich in protective factors and growth factors. As well as changing in composition over time, breast milk also changes in composition during a feed. The milk available at the start of a feed is richer in nutrients and energy.

Nutrition and LactationWhich aspects of diet are particularly important for women who are breast-feeding?It has been calculated that breast-feeding carries a daily energy cost of 650 kcal. However, some of this is obtained by using up fat stored during pregnancy for this purpose. Consequently, women who exclusively breast-feed for 34 months need an extra 500 kcal/day, on average, which corresponds to an average milk output of 750 ml/day.Assuming that this extra energy is obtained via consumption of a balanced and varied diet, the additional needs for essential vitamins and minerals will also be met. Additional requirements for calcium are particularly high

Nutritional Requirements During LactationBreastfeeding is an anabolic state, resulting in increased energy and nutrient needs:500 kcal/day (birth to 6 mo)400 kcal/day (7 - 9 mo)

Protein, zinc, niacin, vitamins A, E, C requirements increase above those in pregnancy.Protein = 71 g/day

Chronically low maternal iron, vitamin B, C, D, thiamin, and folate intake leads to low content in breast milk.

Should women who are breast-feeding avoid any particular foods?Some women report that, after they have consumed certain foods, e.g. spicy foods or onions, their babies experience abdominal discomfort. If this occurs, such foods should perhaps be avoided, provided omission of the trigger foods does not result in an unbalanced diet.Non-nutritive substances such as caffeine, nicotine and other amines and alkaloids can pass into breast milk, and heavy consumption of coffee, tea and cola drinks has been reported to cause restlessness in some infants.With regard o the prevention of allergy or other food intolerance in the baby, the benefits of mothers avoiding specific foods during pregnancy and lactation are not proven. Furthermore, exposure via the mother may be an important factor in establishing a normal immune response to proteins in the diet. Avoidance of foods associated with allergic reactions, e.g. milk, eggs or nuts, should be seriously considered only when there is a strong family history of atopy.

Is fluid intake important?An adequate fluid intake is crucial postpartum for establishing breast-feeding and remains important throughout, given that, by 23 months of age, a baby may be taking as much as 820 ml of milk a day. The best guide to requirement is thirst, and forced drinking of extra fluid will not increase milk quality or quantity.

**Calcium can be prescribed as well if the diet is totally inadequate***Tell students to remember ~5# in 1st trimester; 1#/wk for 2nd and 3rd trimester***********As a side note, does anyone know is breast milk higher or lower than formula in Fe? BM is lower, but Fe is more bioavailable. ********Colace, metamucil can also be prescribed, especially if a patient is Rx FeSo4***The biggest key thing is the immunological protection as this isnt received in formula**Know this, but you wont need to discuss with patients**Colostrum is made even before the deliveryEven if the baby is breastfed 2 weeks, there will be a benefit. If formula is utilized, its rec. to introduce 6-8 weeks to prevent confusion. Vitamin D may need to be supplemented*Bottom Line continue PNV