nutr
"Breast Milk Is Not Nutritious."
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"Breast-Feeding Causes Cancer."
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"Breast-Feeding Is Painful."
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"Breast-Feeding Will Ruin My Figure."
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"I Cannot Go to Work or School if I Breast-Feed."
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"I Will Have to Change My Diet to Breast-Feed."
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"My Breasts Aren't Big Enough."
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"What if I Become Pregnant?"
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"What if I Have Pierced Nipples or Have Had Breast Surgery?"
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"What if I Have Twins?"
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"What if the Baby Has Down Syndrome?"
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"What if the Baby Is Premature?"
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(200 IU/day), which is the same as for the nonpregnant woman.6 Food sources include fortified milk, liver, egg yolk, and fortified margarine.
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(Copyright 2006 JupiterImages Corporation.)
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1.Eat an appropriate quantity of food.
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1.It is the major mineral required to control the extracellular fluid compartment.
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1.Milk content: An average daily milk production for lactating women is 780 mL (26 oz). The energy content of human milk averages 0.67 to 0.74 kcal/g. Thus 26 oz of milk has a value of about 525 kcal.
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1.Supply the increased energy and nutrient demands created by the increased metabolic workload, including some maternal fat storage and fetal fat storage to ensure an optimal newborn size for survival.
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2.Eat regularly, avoiding fasting or skipping meals, especially breakfast. During pregnancy a variety of familiar foods usually supply the woman's need for added nutrients and make eating a pleasure. The increased quantities of essential nutrients needed during pregnancy may be met in many ways by planning around a daily food pattern and using key types of suggested core foods. The MyPyramid Plan for Moms (www.mypyramid.gov/) offers a credible and easily accessible source for a woman to develop an eating plan appropriate for her trimester of pregnancy, age, height, prepregnancy weight, and physical activity level. Figure 11-3 displays one example of a dietary plan for a pregnant woman.
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2.Milk production: The metabolic work involved in producing this amount of milk is about 80% efficient and requires from 400 to 450 kcal. During pregnancy the breast is developed for this purpose, stimulated by hormones from the placenta, and forms special milk-producing cells called lobules (Figure 11-5). After birth the mother's production of the hormone prolactin continues this milk-production process, which the suckling infant stimulates. Thus milk production depends on the demand of the infant. The suckling infant stimulates the brain's release of the hormone oxytocin from the pituitary gland to initiate the letdown reflex for the release of the milk from storage cells to travel down to the nipple. This reflex is easily inhibited by the mother's fatigue, tension, or lack of confidence, a particular source of anxiety in the new mother. She may be reassured that a comfortable and satisfying feeding routine is usually established in 2 to 3 weeks 3. Maternal adipose tissue storage: A component of the energy need for lactation (170 kcal/day in the first 6 months) is drawn from maternal adipose tissue stores deposited during pregnancy in normal preparation for lactation to follow in the maternal cycle. Depending on the adequacy of these stores, additional energy input may be needed in the lactating woman's daily diet.
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2.Spare protein for tissue building.
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2.This vital body water is increased during pregnancy to support its successful outcome.
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4. Exercise: Lactating women generally balance energy expenditure from exercise with increased energy intake and alterations in prolactin to maintain an adequate milk supply.85,86 In some women, the weight gained during pregnancy may be largely retained and contribute to obesity. Some overweight women who are breast-feeding have concerns whether a weight loss program might endanger the growth of their infants. Research with overweight women who were exclusively breast-feeding has shown that a diet and exercise program that led to a weight loss of around 0.5 kg/week (approximately 1 lb/week) from 4 to 14 weeks postpartum did not affect infant growth.87 However, the mother who is involved in any specific weight loss program during lactation should be monitored closely as should her infant. Women may desire to use herbal or botanical products as galactogogues (agents that stimulate breast milk production), relaxants, or analgesics. The safety for mother and infant and efficacy of such products during lactation have not been adequately evaluated in randomized, placebo-controlled trials. In general, women should not use herbals and botanicals during lactation; however, some may be appropriate for use within defined quantities.34
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A Baby for the Delgados
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A deficiency of iron is by far the most common cause of anemia in pregnancy. The total cost of a single normal pregnancy in iron stores is large—approximately 500 to 800 mg. Of this amount, the fetus uses nearly 300 mg. The remainder is used in the expanded maternal blood volume and its increased red blood cells and hemoglobin mass. This iron requirement typically exceeds the available reserves in the average woman. Thus in addition to including iron-rich foods in the diet, a daily supplement or increased therapeutic dose may be required as previously described.
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A fairly common complaint during the latter part of pregnancy is that of hemorrhoids. These are enlarged veins in the anus, often protruding through the anal sphincter. This vein enlargement is usually caused by the increased weight of the fetus and its downward pressure. The hemorrhoids may cause considerable discomfort, burning, and itching. Occasionally, they may rupture and bleed under pressure of a bowel movement, causing anxiety. The problem is usually controlled by the dietary suggestions given for constipation. In addition, sufficient rest during the latter part of the day may help relieve some of the downward pressure of the uterus on the lower intestine.
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A less common megaloblastic anemia of pregnancy results from folate deficiency. During pregnancy, the fetus is sensitive to folate inhibitors and therefore has increased metabolic requirements for folate. To prevent this anemia the DRI standard recommends 600 mcg of folate per day during pregnancy. Women with poor diets will need supplementation to reach this intake goal.
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A major food source of iron is liver; however, liver intake is often avoided during pregnancy. Other food sources include meat, legumes, dried fruit, green leafy vegetables, eggs, and enriched bread and cereals (see list of iron-containing foods in Chapter 7).
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A moderate amount of dietary sodium is needed for two essential reasons:
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A number of clinicians have presented clinical and laboratory evidence that pregnancy-induced hypertension (PIH) is a disease that principally affects young women with their first pregnancy. Although the genetic and immune-related causes of PIH are becoming clearer, diet plays a role in the risk of preeclampsia. For example, diets poor in kcalories, protein, calcium, magnesium, potassium, and dietary fiber have been associated with risk of PIH. Regardless of the underlying causes and multiorgan effects, nutritional support of the pregnancy is, as always, a primary concern. Certainly, as many practitioners have observed, PIH is classically associated with poverty, inadequate diet, and little or no prenatal care. Much of the PIH problem, which seems to develop early from the time of implantation of the fertilized ovum into the uterine lining, may be reduced by good prenatal care from the beginning of the pregnancy, which inherently includes attention to sound nutrition. It is this sound nutritional status, which a woman brings to her pregnancy and maintains throughout it, that provides her with optimal resources for adapting to the physiologic stress of gestation. Her fitness during pregnancy is a direct function of her past state of nutrition and her optimal nutrition throughout pregnancy. Clinical Symptoms
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A pregnant woman who engages in pica, regardless of cultural background, should be informed about the health consequences of pica. Although it is unclear if nutrient deficiencies precipitate pica behaviors or vice versa, many pica substances are capable of binding nutrients to render them unavailable for absorption. Nutritional anemias may occur, having adverse effects on both mother and baby. Exposure to toxins and teratogens from nonfood substances such as battery acid or ashes is also possible. Gastrointestinal perforation, constipation, and microbial infections are additional potential outcomes of pica.
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A special increased metabolic need exists for the B vitamin folate during pregnancy. Folate deficiency usually occurs in conjunction with general malnutrition, making the pregnant woman in low-socioeconomic conditions especially vulnerable. A specific megaloblastic anemia caused by maternal folate deficiency sometimes occurs and warrants supplementation of the diet with folic acid. This added amount is particularly needed in situations in which such demands are increased, such as in a multiple pregnancy.
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A special need exists for various B vitamins, including thiamin, riboflavin, niacin, pyridoxine, vitamin B12, pantothenic acid, and folate, during pregnancy. The B vitamins are important as coenzyme factors in a number of metabolic activities related to energy production, tissue protein synthesis, and function of muscle and nerve tissue; therefore they play key roles in the increased metabolic work of pregnancy.23 These B vitamins are usually supplied by a well-balanced diet that is increased in quantity and quality to supply needed energy and nutrients.
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A woman brings to each pregnancy all of her previous life experiences, including her diet and eating habits. Her general health and fitness and her state of nutrition at the time of conception are products of her lifelong dietary habits and her genetic heritage. The importance of preconception nutrition is increasingly recognized. The Maternal, Infant and Child Health Goal included in Healthy People 2010: Understanding and Improving Health (see Further Readings and Resources at the end of this chapter) addresses the need for improvements in preconception nutrition and health in women in the United States.16 Preconception counseling is an avenue to such improvements. Related to nutrition, preconception counseling may include screening for medical conditions such as iron deficiency anemia, eating disorders, drug-nutrient interactions, and genetic disorders, as well as assessment of current body weight, recent and previous weight changes, body mass index (BMI), fitness and exercise status, folate status, other nutrient intakes, eating patterns, and dietary and botanical supplement use. Evaluation of existing medical conditions such as hypertension, diabetes, thyroid disease, celiac disease, phenylketonuria (PKU), and others, is important. Inquiry about the home and family environment, including income, education, safety, lead exposure, and abuse, should also be conducted during preconception counseling so that guidance, recommendations, and referrals may be thoroughly provided. Each of these nutrition and health-related factors has documented effects on pregnancy outcome, many of which are adverse. However, preconception counseling and optimal preconception nutrition may increase the odds for a healthy pregnancy and desirable infant outcome.
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Acquired Immunodeficiency Syndrome
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Actually, investigators have been looking to breast-feeding as a possible means of preventing breast and ovarian cancer. Epidemiologic studies suggest a decreased risk for these cancers in women who breast-feed.
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Advantages and Barriers to Breast-Feeding
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Age and Parity
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Age plays a major role in pregnancy; the teenage girl adds her own growth and maturation needs to those imposed by pregnancy. In addition, the number of pregnancies (gravida) and the number of viable offspring (parity), as well as the time intervals between them, greatly influence the woman's nutrient reserves, her increased nutritional needs, and the outcome of the pregnancy.
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Age, Gravida, and Parity
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All the major and trace minerals play roles in maternal health. Four that have special functions in relation to pregnancy—(1) calcium, (2) iodine, (3) iron, and (4) zinc—deserve particular attention.
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An adequate supply of essential fatty acids is also vital throughout pregnancy. Tissue growth, especially the proper development of cell membranes in nerve and brain tissue, and development of organ function, notably cognition and visual acuity, require that essential fatty acids and their converted forms reach the developing fetus in sufficient amounts. Depending on individual needs, supplementation of the mother's essential fatty acid intake may be useful to maintain adequate levels.21 However, most pregnant women may consume adequate amounts of linoleic (13 g/day) and α-linolenic (1.4 g/day) acids through consumption of canola, soybean, and walnut oils, in addition to other dietary fat sources.10 Docosahexaenoic acid (DHA), important for visual and cognitive development, is found in salmon, mackerel, striped bass, and other fish products. Eicosapentaenoic acid (EPA), also found in fish, fish oils, flaxseed, walnuts, and canola oil is important for blood vessel dilation, blood clotting, and attenuation of inflammation. Combined DHA and EPA intake of 500 mg/d is recommended.22
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An expanding body of research and the best practices of clinicians reinforce that maternal nutrition is critically important to the mother and the newborn (Figure 11-1). It lays the fundamental foundation for the successful outcome of pregnancy—a healthy mother and infant.15 Several vital factors that determine nutritional requirements of the woman during her pregnancy are well recognized.
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An understanding by the health care practitioner regarding factors leading to pica is vital to affecting behavior change. For example, the pregnant woman who believes that a nonfood substance has an essential role in the body's balance or harmony with her environment may be less willing to avoid consumption of that nonfood substance. On the other hand, a pregnant woman who consumes eggshells because of the sensory cravings associated with the texture may be amenable to substituting a crunchy food substance for this nonfood product. Inquiry regarding the history of pica in the pregnant woman is important to identify sources of pica substances and to involve other family members or cultural leaders who may support such behavior and need counseling to facilitate appropriate behavior changes. Such nutrition counseling must be delivered in a culturally sensitive and appropriate manner, with emphasis on the importance of behavior changes for an optimal outcome for the infant. Socioeconomic Challenges
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Anemia
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Anemia caused by blood loss is more likely to occur during labor and delivery than during pregnancy. Blood loss may occur earlier, as a result of abortion or ruptured tubular pregnancy. Most women undergoing these physiologic problems receive blood via transfusion, and iron therapy may be indicated for adequate replacement for hemoglobin formation.
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Anemia is common during pregnancy. It is often associated with the normal maternal blood volume increase of 40% to 50% and a disproportionate increase in red cell mass of about 20%. Of all women in large prenatal clinics in the United States, about 10% have hemoglobin concentrations of less than 10 g/dL and a hematocrit reading less than 32%. Anemia is far more prevalent among the poor, many of whom live on diets barely adequate for subsistence. However, anemia is by no means restricted to lower economic groups.
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Approximately 67% of adults in the United States are overweight and nearly 33% are obese. Hence many women enter their pregnancies with excess body weight. This condition increases the risks of fetal mortality and malformations, excessive weight gain during pregnancy, gestational diabetes, hypertension, and preeclampsia, as well as the likelihood of preterm delivery and infant delivery by cesarean section. Pregnancy is not a time for weight loss because of the energy and nutrient requirements of the woman and fetus. Rather, a woman with excess body weight should moderately and gradually reduce her weight before pregnancy through an individualized energy-restricted diet and exercise plan. Weight gain during pregnancy should then follow recommendations based on BMI as outlined later in this chapter.Exercise
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As a result of our increased knowledge of pregnancy and nutrition, we can provide better nutritional guidance. Three basic concepts form a fundamental framework for assessing maternal nutritional needs and for planning supportive prenatal care for the woman.
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At the end of the initial counseling session, the nutritionist told the couple about a series of prenatal group discussions conducted by members of the clinic's perinatal health team, including sessions on pregnancy, labor and delivery, and the care and feeding of the infant. These are attended primarily by a mixture of experienced parents and young, first-time parents to be and are offered as a means of introducing practical aspects of pregnancy and parenting.
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B Vitamins
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BOX 11-1 Nutritional Risk Factors in Pregnancy
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Basic Concepts Involved
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Basic Nutrient Allowances and Individual Variation
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Before Pregnancy
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Believe it or not, it has been done. It takes time, patience, and good coordination to breast-feed twins, but it is possible. Triplets, however, are another matter altogether. Women have successfully nursed triplets, but often they did very little else until the babies were weaned. This mother will need emotional support, whether she attempts to nurse or, finding the amount of time and patience required overwhelming, prefers to bottle-feed.
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Breast Milk During Weaning
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Breast Milk and the Cesarean Section Infant
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Breast Milk for the Preterm Infant
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Breast milk can be stored for up to 5 days in the refrigerator or up to 5 months in the freezer. Many working mothers take advantage of this by expressing their milk and storing it for use by care providers. In fact, women often express milk on their breaks at school or work. (Some places of employment even have lactation rooms and provide breast pumps at the workplace.) Expressing milk not only relieves the pressure of buildup but it also allows the milk to be stored for later use at home.
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Breast-feeding might actually help a woman regain her figure more quickly. Because the caloric demand of breast-feeding exceeds that of the nonpregnant woman by about 400 to 500 kcalories, a slightly faster rate of weight loss may be expected, although hormonal adaptations may limit the extent to which weight loss is experienced during lactation. Oxytocin, the hormone manufactured to stimulate the letdown reflex, also stimulates uterine contractions, helping reduce the uterus to its prepregnancy size more rapidly.
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Breast-feeding should be encouraged in most mothers (see the Perspectives in Practice box, "Breast-Feeding: The Dynamic Nature of Human Milk"). However, some conditions exist for which it is recommended that women in the United States not breast-feed, including HIV-positive status, active untreated tuberculosis, human T-lymphocytic virus, illicit drug use, and with specific chemotherapeutic agents. Other conditions or medications should be discussed with health practitioners.84
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Calcium
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Carbohydrate intake of at least 175 g/day during pregnancy is important for an adequate supply of glucose and nonprotein energy.10 Whole grain breads and cereals, as well as fruits and vegetables, should be consumed to meet maternal and fetal glucose needs and provide fiber for satiety and bowel regulation. Currently popular low-carbohydrate "diets" are not recommended during pregnancy because various phases of these diets do not provide the minimum glucose load required by the maternal and fetal bodies. In general, total daily dietary kcalorie intake should be comprised of 15% protein, 30% fat, and 55% carbohydrate, keeping in mind the individual needs of the pregnant woman and adequate macronutrient distribution ranges. Mineral Needs
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Carefully monitored care throughout pregnancy and after birth is essential for pregnant women who are infected by the human immunodeficiency virus (HIV). Two goals are most important: (1) to reduce the rate of the disease progression in the woman through nutritional support and (2) to minimize the chance of HIV vertical transmission from mother to infant, either in the womb or after birth via breast-feeding. Poor weight gain and nutrient deficiencies during pregnancy are often found in HIV-positive patients. Although specific nutrient requirements for HIV-infected pregnant women have not been established, these patients may need up to 150% of normal pregnancy intakes of macronutrients and micronutrients. Continual individual monitoring and adjustment are essential. Infants can be infected by HIV during labor and delivery and through breast milk. Where safe alternatives to breast milk are available, such as commercial formula or banked human milk, a decision on breast-feeding depends on the HIV status of the newborn infant. In the United States, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics recommend HIV-positive mothers do not breast-feed when the infant is not infected. Eating Disorders
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Case Study
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Cigarette smoking during pregnancy is also contraindicated.45 Harmful substances in tobacco and impaired oxygen transport cause fetal damage and special problems of placental abnormalities, leading to increased risk of spontaneous abortion (miscarriage), prematurity, low birth weight, impairment of mental and physical growth, and increased potential mortality.45,46 Counseling with women and families who smoke should stress the importance of quitting for pregnancy and beyond.
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Clearly, severe kcalorie restriction is harmful to the developing fetus and the woman. It is inevitably accompanied by restriction of the vitally needed nutrients essential to the growth process.37 Moreover, weight reduction should never be undertaken during pregnancy. Sufficient weight gain should be encouraged with the use of a nourishing diet.
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Clinical observations and developing science in nutrition and medicine have provided directions for healthier pregnancies. Previous false ideas have been refuted, and a sound base for current practice has emerged. A classic report of the National Research Council (NRC) first reflected this applied scientific base and led the way. This report, Maternal Nutrition and the Course of Human Pregnancy, provided an undeniable, new direction for a positive approach to the management of pregnancy.3 Indeed, continuing research has reinforced this positive direction. On the basis of the significant NRC findings, guidelines for the nutritional care of pregnant women were then issued by the American College of Obstetrics and Gynecology and the American Dietetic Association.4,5 These reports continue to provide useful guidelines for physicians, nutritionists, dietitians, and nurses in their prenatal care. Nutritional guidelines for pregnancy and lactation for all nutrients are also included in the Dietary Reference Intake (DRI) recommendations published by the Food and Nutrition Board of the Institute of Medicine.6-10 These guidelines remind us that an infant is nutritionally 9 months old at birth, even older when we consider the significance of the mother's preconception status.
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Complex Physiologic Interactions of Gestation
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Complications of pregnancy
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Consequences of Pica and Need for Counseling
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Cultural Norm of Concern
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Current Breast-Feeding Trends
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Current practice usually follows a regular diet with moderate sodium intake, 1.5 to 2.3 g/day, with light use of salt to taste.40 Limiting sodium beyond this general use is contrary to physiologic need in pregnancy and is unfounded. The NRC and professional obstetric guidelines have labeled routine salt-free diets and diuretics as potentially dangerous.3-5 Maintaining the needed increase in circulating blood volume during pregnancy requires adequate amounts of sodium and protein, as well as adequate fluid intake to prevent dehydration and possible premature contractions.
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Data from the National Immunization Survey show that approximately 71% of mothers initiate breast-feeding.65 Several factors contribute to this rate of breast-feeding initiation:
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Despite the advantages of breast-feeding, some women do have to deal with perceived barriers associated with misinformation, personal feelings of modesty, family pressures, or outside employment, among other factors. Addressing these barriers, such as the following, before delivery rather than after will increase the likelihood that the mother breast-feeds her infant:
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Diabetes Mellitus and Gestational Diabetes Mellitus
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Dietary Patterns: General and Alternative
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Dietary Supplements
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Drug use, both recreational and medicinal, also poses numerous problems.46 Self-medication with over-the-counter drugs carries potential adverse effects. The use of illicit drugs is especially hazardous, exposing the developing fetus to the risks of addiction and possibly acquired immunodeficiency syndrome (AIDS) from the woman's use of contaminated needles during drug injections. Dangers come not only from the drug itself or contaminated needles but also from impurities contained in illicit drugs. Evaluation of the effects of street drugs (marijuana, cocaine, heroin, methadone) on nutritional status is difficult because of multiple drug use, uncertain purity, unknown dose and timing, and inadequate nutritional status of many drug users. A high incidence of meconium staining (which could relate to fetal damage), poor prenatal weight gain, very short (<3 hours) or prolonged labor, operative delivery (cesarean, forceps), and other perinatal problems among marijuana users has been reported. Such outcomes indicate that abstinence of marijuana use during pregnancy is prudent. Pica
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During Pregnancy
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During her initial nutrition interview, Mrs. Delgado indicated that the pregnancy was unplanned. She seemed especially worried about the effects of her irregular diet on the baby. As college students, she and her 21-year-old husband had erratic meals, dominated by junk food. Mrs. Delgado's 24-hour diet history revealed an inadequate intake of dark-green or red-yellow-orange vegetables and milk products, as well as meat or eggs and citrus fruits. The couple realized that these types of foods were an important part of a nutritious diet but felt inexperienced as cooks and lacked the time and money to prepare healthful meals every day.
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During normal pregnancy the maternal circulating blood volume expands by 40% to 50% and may increase more with multiple fetuses. This adaptation reduces the strain on the maternal heart, minimizes hemoglobin losses at delivery, and enhances nutrient flow to the fetus. Although red blood cell mass also increases during gestation, this change does not parallel blood volume expansion, resulting in hemodilution of red blood cell mass. Thus specific guidelines are used to determine iron deficiency anemia during pregnancy (see Anemia later in this chapter). Maternal iron is needed to supply iron to the developing placenta and fetal liver. Adequate maternal iron stores also help protect the woman against iron losses related to blood loss at delivery.
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During pregnancy the DRI recommendation for zinc increases from 8 to 11 mg/day.9 Zinc is vital for enzymatic reactions and is essential to growth and development because of its role in deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) synthesis and protein production. Inadequate zinc consumption during gestation has been associated with low birth weight and congenital malformations. Iron supplementation may inhibit zinc absorption; thus additional dietary sources of zinc are critical when maternal iron supplementation is prescribed. Seafood, eggs, and meat are primary sources of zinc.
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During pregnancy, glycosuria is not uncommon because of the increased circulating blood volume and its load of metabolites. Routine screening protocols, typically conducted between the twenty-fourth and twenty-eighth week of gestation, are used during pregnancy to detect gestational diabetes mellitus (GDM). GDM is an intolerance of carbohydrate such that blood glucose concentration increases during pregnancy. In 95% of cases this carbohydrate or glucose intolerance resolves after delivery. Treatment during pregnancy is important because of the increased risk these women carry for fetal damage during this gestational period.57 The most common outcome for an infant born to a mother with GDM is macrosomia, a larger than normal body size. Other infant complications include hypoglycemia, jaundice, and trauma at birth. Although GDM occurs in 2% to 13% of the pregnant population, up to 50% of women with pregnancy-induced abnormal glucose tolerance subsequently develop overt diabetes. Team management is required for adequate care of gestational and preexisting types 1 and 2 diabetes mellitus.58,59 (See Chapter 22 for a detailed discussion of diabetes care.)
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Eating disorders, specifically anorexia nervosa (AN) and bulimia nervosa (BN), have been previously described (see Chapter 8). Diagnosis and treatment of these disorders in the nonpregnant state require multidisciplinary approaches, and even greater consideration with further specialized care is required for a pregnant woman with AN or BN. AN is uncommon during pregnancy, because amenorrhea is a diagnostic criteria for the disorder; however, ovulation and subsequent conception has been reported.62 Compared with AN, pregnancy in a woman with BN is more likely, because of more typical menstrual patterns, weight status, and less restrictive eating. BN has been linked to spontaneous abortion, poor weight gain, low infant birth weight, premature deliveries, and congenital malformations.63 A team approach that emphasizes nutritional needs of the growing fetus, anticipated maternal body size and shape changes, and postpartum care is critical to a successful course and outcome.63,64
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Effects of Iron Supplements
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Energy
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Even premature infants can thrive on human milk. Mothers and physicians have sometimes been reluctant to consider breast-feeding for infants born prematurely or delivered by cesarean section, fearing that the early birth or surgical procedure may have some negative effect on the quantity or quality of human milk. This uncertainty about the nutritional quality of mother's milk has also led physicians to encourage adding formula or solid foods (or both) to the diet to make sure the infant is well fed. These practices are usually unnecessary. They often contribute to allergies, obesity, and digestive problems because of the extra stress placed on an immature gut.
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Evidence-Based Practice
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Excess Body Weight
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Excessive consumption of retinol and retinoic acid, two forms of vitamin A, has been associated with fetal malformations such as heart, facial, and ear defects. Overconsumption is generally related to the use of supplements or medications such as Accutane. Harmful effects are most damaging during the first few months of pregnancy, again emphasizing the need for prenatal counseling and appropriate preconception nutrition.
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Exclusive breast-feeding by well-nourished mothers can be adequate for periods ranging from 2 to 15 months.81-84 Exclusive breast-feeding is strongly encouraged for at least 6 months. Unfortunately, exclusive breast-feeding declines to less than 43% and less than 14% of mothers by 3 months and 6 months, respectively.65 Solid foods are usually added to the baby's diet at about 6 months of age; the American Dietetic Association's position is that breast-feeding should continue for at least the first 12 months of the infant's life Nutritional Needs
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FIGURE 11-2 Physical activity during pregnancy benefits both the pregnant woman and the fetus.
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FIGURE 11-3 Food intake plan for a pregnant woman based on trimester of pregnancy, age, height, prepregnancy weight, and physical activity using the MyPyramid for Moms program (www.mypyramid.gov/).
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Focus on Culture
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Folate Deficiency Anemia
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Foods that were eaten during pregnancy may be consumed during lactation. Some women report that after they eat onions, cauliflower, cabbage, or other foods that their infants do not like the taste of their breast milk. Other women say that eating chocolate or drinking coffee, for example, "makes their babies fussy" when breast-feeding. Scientific evidence does not discourage moderate intake of these foods or drinks. A well-balanced diet that includes a variety of colorful foods and fluids is encouraged during breast-feeding.
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For centuries in all cultures, a great body of folklore has surrounded pregnancy. Various traditional practices and diets have been followed, many of which have had little factual basis, and much clinical advice has been based only on supposition. For example, early obstetricians even held the notion that semistarvation of the pregnant woman was really a blessing in disguise because it produced a small baby of light weight who would be easier to deliver. To this end, they used diets restricted in kilocalories (kcalories or kcal), protein, water, and salt. Despite the lack of any scientific evidence to support such ideas, two assumptions, now known to be false, governed practice: (1) the parasite theory (i.e., whatever the fetus needs, it draws from maternal stores despite the maternal diet) and (2) the maternal instinct theory (i.e., whatever the fetus needs, the pregnant woman instinctively craves and consumes it).
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Functional Gastrointestinal Problems
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General Amount of Weight Gain
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General Daily Food Pattern
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General dietary problems
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Gestation is characterized by exceedingly rapid growth and development. During this 38- to 42-week period, a single fertilized egg cell (ovum) grows into a fully developed infant
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Health promotion
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Healthy women produce healthy babies across a wide range of total weight gain. Therefore during pregnancy the nutritional focus should always be on an individualized assessment of need and the quality of the weight gain. An average weight gain during normal pregnancy is about 11 to 16 kg (25 to 35 lb).35 Around this average, many individual variations occur. No specific rigid norm or restriction exists to which all women should be held, regardless of individual needs; therefore such a course is obviously unwise and unscientific. Current recommendations are therefore usually stated in terms of ranges to accommodate variances in needs. An initial base for evaluation, however, may be the average weight of the products of pregnancy as shown in Table 11-2. In addition to the components of growth and development usually attributed to a pregnancy, an important part is maternal stores. This laying down of extra adipose fat tissue is necessary for maternal energy reserves to sustain rapid fetal growth during the latter half of pregnancy, for labor and delivery, and for maintaining lactation after birth. Approximately 1.8 to 3.6 kg (4 to 8 lb) of adipose tissue is commonly deposited for these needs. The Institute of Medicine updated weight gain guidelines for pregnancy in May 2009, using the World Health Organization's (WHO's) classifications for prepregnancy BMI. The guidelines are as follows35: • Normal-weight women with a BMI of 18.5 to 24.9 should gain from 11.5 to 16 kg (25 to 35 lb).
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Heartburn or Gastric Pressure
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Hemorrhagic Anemia
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Hemorrhoids
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Herbal and botanical supplement use during pregnancy is discouraged because of the potentially harmful or unknown effects on the woman and fetus. However, based on cultural and traditional medicine practices and emerging trends, pregnant women may include such products in their daily routines (see the Case Study box, "Nutrition Counseling in Pregnancy"). Several reference materials are available regarding the risks associated with use of specific herbals and botanicals during pregnancy (see Further Readings and Resources at the end of this chapter).32-34
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High-risk pregnancies
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Human milk is the ideal first food for human infants. Its dynamic nature changes to match growth needs. The mother's choice to breast-feed her infant depends on a number of factors, however, especially for new mothers, who often need information and counseling from early pregnancy.
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Hyperemesis
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Hypertension
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Identify Risk Factors Involved
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In a group of women living in Kenya from a variety of ethnic and religious backgrounds, more than 80% reported consumption of approximately 1 cup of soil on a daily basis. Soil intake was more common in the latter part of pregnancy. In these cultures, pica represents a cultural norm that may increase in prevalence during pregnancy.
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In a real sense, throughout her life a woman is providing for the ongoing continuum of life through the food that she eats. Each offspring obviously becomes a part of this continuing process during the pregnancy, when the mother's diet directly sustains growth and development. However, in the broader sense, the mother transfers her nutritional heritage, practices, and beliefs to her growing children, who in the next generation pass on this heritage genetically and culturally. Other family members also play important roles in this generational sustenance of the life continuum.
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In a small number of pregnant women, about 3.5:1000 pregnancies, a severe form of persistent nausea and vomiting occurs that does not respond to usual treatment. This condition, hyperemesis, begins early in the pregnancy and may last throughout it. It may develop into the more serious pernicious form of hyperemesis gravidarum. This persistent condition causes severe alterations in fluids and electrolytes, weight loss, and nutritional deficits, sometimes requiring hospitalization and alternative feeding by enteral or parenteral methods to sustain the pregnancy (see Chapter 19). Pyridoxine supplementation has been suggested as a preventive measure to abate nausea and vomiting, along with an increased protein and lower carbohydrate content of the diet.41 Some prescription medications may also be useful but require physician supervision.41 Continued personal support and reassurance are important. Constipation
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In addition to the increased diet, the nursing mother requires rest, moderate exercise, and relaxation. Both parents may benefit from counseling focused on reducing the stresses of their new family situation, as well as meeting their own personal needs. Postpartum depression is increasingly recognized as a specific, and sometimes very serious, condition in mothers. Ranging from "baby blues" to postpartum psychosis, the relationship of this condition with nutritional status requires further investigation.91,92 For example, iron-deficiency anemia may be a risk factor for postpartum depression (see Evidence-Based Practice box, "Iron and Postpartum Depression"). The connections among nutrient needs, postpartum depression, and breast-feeding duration will be of future interest.
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In early counseling, mothers express a variety of concerns about breast-feeding. Following are a few such statements:
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Increased amounts of vitamins A, B complex, and C are needed during pregnancy. If these needs are met, then sufficient amounts of vitamins E and K are also available. The recommended amount of vitamin D does not increase during pregnancy but is important to fetal skeletal development.
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Infants with Down syndrome can be nursed; however, it does require time, patience, and the use of slightly different nursing techniques. The mother should be told about the special nursing needs of infants with Down syndrome to avoid disappointment or a feeling of failure should breast-feeding become impractical for her particular living situation.
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Iodine
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Iron
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Iron Deficiency Anemia
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Iron and Postpartum Depression
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Is it possible that clinical deficiencies of nutrients cause postpartum depression? Iron-deficiency anemia is common among women, particularly postpartum women because of iron losses with delivery and mobilization of iron stores to support fetal growth, development, and iron storage during the latter stages of pregnancy. An association between low hemoglobin concentration (≤12 g/dL) and increased self-rated symptoms of depression were reported in eight postpartum women within the first month after delivery. This was significantly different from lower self-rated symptoms of depression in 29 postpartum women with hemoglobin concentration greater than 12 g/dL. One randomized controlled trial found that self-reported depression and stress significantly decreased in 30 postpartum women with iron-deficiency anemia who were treated with 125 mg ferrous sulfate (along with folate and vitamin C), compared with 21 untreated anemic postpartum women (supplemented with only folate and vitamin C) and 30 nonanemic control women. Breast-Feeding
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It may be painful in the first few days or even weeks as mother and baby establish a pattern of feeding and proper latch and release techniques. Milk should not be allowed to collect in the breast to the point of engorgement, the nipples should be kept clean and dry, and a variety of feeding positions may be used while nursing to decrease the chances of having a painful experience. Mastitis is a painful infection of the breast that requires medical attention and often antibiotic treatment.
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Lean meats and poultry, fish, dried beans, and nuts provide dietary protein, iron, zinc, and B vitamins for growth of muscles, bones, blood, and nerves; vegetable protein foods also contribute fiber. Fluid milk and dairy products provide dietary protein, calcium, and vitamin D to build strong bones, teeth, and healthy nerves and muscles and to promote normal blood clotting. Grains provide carbohydrates and B vitamins for energy and healthy nerves, as well as iron for healthy blood. At least one half of these grains should be whole grain cereal and bread products to provide fiber. Vitamin C-rich fruits and vegetables assist in preventing infection and promoting healing; they also promote iron absorption and act as sources of fiber. Vitamin A-rich fruits and vegetables contribute β-carotene and vitamin A to prevent infection, promote night vision, and prevent constipation. Other fruits and vegetables contribute energy and fiber to the diet. Oils provide vitamin E and essential fatty acids.
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Levels of nutrients in mother's milk shift according to the gestational age of the infant at birth. The preterm infant is often denied its mother's milk by some hospital workers because they think of it as mature milk having too little protein and too much lactose to meet the child's needs. An analysis of the nutritional quality of preterm milk, however, reveals energy and fat concentrations that are 20% to 30% greater, protein levels 15% to 20% greater, and lactose levels 10% lesser than those found in mature milk. Premature milk can meet the preterm infant's needs.
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Life Continuum Concept
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Many nutritional, physiologic, psychologic, and practical advantages to breast-feeding exist; six are identified as follows:
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Maternal Disease Conditions
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Maternal Medical Conditions
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Maternal Phenylketonuria
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Milk, egg, cheese, and meat are complete protein foods of high biologic value. Protein-rich foods also contribute other nutrients, such as calcium, iron, and B vitamins. Additional protein may be obtained from legumes and whole grains, with lesser amounts in other plant sources.
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Mother's milk changes to meet the infant's needs at all stages of development.
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Mrs. Delgado is a 19-year-old married primigravida, who tested positive for urinary human chorionic gonadotropin (hCG) 2 weeks earlier. Mrs. Delgado is 160 cm (5 feet, 3 inches) tall with an average pregravid weight of 57 kg (125 lb). Her current gestational age is 6 weeks. Her history for chronic disorders and other serious health problems is negative.
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Ms. McLane has a positive family history for diabetes, and her mother had gestational diabetes. Ms. McLane should have been screened for gestational diabetes between the twenty-fourth and twenty-eighth weeks of her current pregnancy; however, this was not done. She experienced frequent urination and fatigue that she reported as "different" from her first pregnancy. This prompted her to return to her obstetrician. The obstetrician completed a full examination and administered an oral glucose tolerance test. One hour after consuming a 100-g solution of glucose, Ms. McLane's blood glucose concentration was 218 mg/dL. She was scheduled for follow-up testing, and gestational diabetes was confirmed. A 2200-kcal/day diabetic diet was prescribed to allow Ms. McLane to control this condition through diet.
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Ms. McLane has been referred to you for nutrition counseling. This is now the thirty-first week of her pregnancy, and she shares with you that a friend suggested that she "use some natural products to help her high blood sugar." In addition to consuming her prenatal supplement on a daily basis, she takes 500 mg of burdock root and 1 tbsp of flaxseed and drinks 3 cups of hot fenugreek tea per day. Her prenatal supplement contains 400 mcg of folate, 250 mg of calcium, 40 mg of iron, 100 mg of vitamin C, 5 mcg of vitamin D, 3 mg of thiamin, 3 mg of riboflavin, 4 mg of pyridoxine, 40 mg of niacin, 10 mg of vitamin E, 5 mcg of vitamin B12, 30 mg of zinc, and 10 mg of copper. Completion of a dietary intake analysis shows that Ms. McLane's kcalorie intake is 1750 per day. She reported that she has been nauseated for about 2 weeks, so she also added 300 mg of powdered ginger to each cup of the fenugreek tea. She reported some diarrhea and Braxton Hicks contractions during the last week, as well a lack of desire to be physically active. Quality of Weight Gain
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Ms. McLane is a 33-year-old Caucasian woman who is in her twenty-ninth week of pregnancy. This is her second pregnancy. During her first pregnancy (at age 29), she gained 24 lb during a normal pregnancy and had a delivery without complications. She is presently 165.1 cm (5 feet, 5 inches) tall and weighs 81.8 kg (180 lb). Her prepregnancy weight was 72.7 kg (160 lb). Ms. McLane visited her obstetrician before her second pregnancy for prepregnancy planning. She has been consuming a healthy diet and a prenatal vitamin supplement every day. After her first visit to the obstetrician during the current pregnancy (at week 10), Ms. McLane did not return for any further appointments, because of her prior positive experience with pregnancy and belief that she "didn't need anything because the first pregnancy went so well."
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Much of our knowledge regarding the importance of sufficient energy intake during pregnancy arose from records of pregnancy and infant statistics through periods of famine during World War II. Insufficient kcalorie intake during the first trimester of pregnancy was associated with infertility and increased incidence of neural tube defects and other metabolic changes, whereas inadequate kcalorie consumption in the second and third trimesters of pregnancy was associated with increased numbers of congenital abnormalities, infants of low birth weight, and infant mortality. Current famine and food insecurity in various locations around the world continue to support these earlier findings regarding the essential need for adequate kcalories during pregnancy to support an optimal infant outcome. Energy needs of pregnancy may be met through a balanced intake of macronutrients.Protein, Fat, and Carbohydrate Needs
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Multiple Fetuses
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Nausea and Vomiting
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Nearly 45% of women born and living in western Mexico engaged in pica during pregnancy, whereas only about 30% of Mexican-born women currently residing in California practiced pica during pregnancy. Although pica may be a culturally accepted norm, changes in prevalence may be induced with acculturation into a society where this behavior is less common.
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Nipple jewelry appears to interfere with breast-feeding; however, a mother who wishes to maintain her piercing while breast-feeding may use retainers. Women should be made aware that serious complications because of nipple piercing have been reported, requiring pharmaceutical or surgical treatments that have required up to 12 months for resolution. Very little is known about later breast-feeding successes or complications after earlier removal of a nipple piercing. Breast augmentation and reduction surgeries have shown mixed results related to successful breast-feeding; however, this issue has not been adequately investigated. At least one retrospective study shows that previous breast reduction did not impair the ability to breast-feed. Women should be informed about the current lack of knowledge surrounding these issues but presented with guidance for decision making.
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Normal Cultural Behavior or Pregnancy-Induced Disorder
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Nutrient levels continue to change with time to match changing growth patterns and developing digestive abilities. Mother's milk does provide sufficient kcalories and nutrients to keep babies well fed without supplemental formula or food. Even when the infant is being weaned, the nature of human milk ensures adequate nutrients, just in case the new, solid-food diet cannot meet the child's needs. Human milk collected during gradual weaning has been found to have increased concentrations of protein, sodium, and iron. Lactose levels are lower, possibly so that increased amounts of kcalories can be supplied by fats, a more concentrated source.
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Nutrition Counseling in Pregnancy
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Nutrition during lactation
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Nutritional demands of pregnancy
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Often, "prenatal vitamins" are prescribed for pregnant women. These supplements include a variety of vitamins and minerals and are intended to add to nutrient intake from foods rather than replace food and nutrient consumption. Iron and folate are generally the two nutrients that require supplementation during pregnancy. Some women may need additional nutrients, however.31 For example, pregnant women who follow vegan diets, have one or more nutritional deficiencies, smoke cigarettes, use or abuse drugs or alcohol (or both), or have multiple fetuses, need prenatal vitamin and mineral supplements that include additional nutrients.
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On the whole, about 0.5 to 2.0 kg (1.1 to 4.4 lb) is a target for average weight gain during the first trimester for all pregnant women.35 Thereafter, the target for average weight gain per week is 0.5 kg (1 lb) for underweight and normal-weight women, 0.3 kg (0.6 lb) for overweight women, and 0.23 kg (0.5 lb) for obese women. No scientific justification exists for routinely limiting weight gain to lesser amounts. Moreover, an individual woman who needs to gain more should not have unrealistic patterns imposed on her. It is only unusual patterns of gain, such as a sudden sharp increase in weight after the twentieth week of pregnancy that may signal abnormal water retention, which should be monitored closely, especially if it occurs in conjunction with blood pressure elevation and proteinuria. Conversely, an insufficient or low maternal weight gain during the second or third trimester increases the risk for intrauterine growth retardation.3 Weight Gain and Sodium Intake
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Other women would like to breast-feed but are worried about special "what if" situations, such as the following: "What if I Need a Cesarean Section?"
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PIH is defined according to its manifestations, which generally occur in the third trimester toward term. These symptoms are hypertension, abnormal and excessive edema, albuminuria, and, in severe cases, convulsions or coma, a state called eclampsia.
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Perinatal Concept
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Pica During Pregnancy
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Pica is the craving and consumption of unusual nonfood substances such as laundry starch, clay, dirt, or ice. This practice during pregnancy is more widespread than health care workers have believed, particularly in southern regions of the United States and among specific ethnic and cultural groups. Some pica practices have been associated with iron deficiency anemia, although the direction of causality is unknown.51,52 Where these unusual practices exist, they must be appreciated as cultural patterns that require a respectful approach and understanding by health workers who seek to negotiate appropriate behavior changes (see the Focus on Culture box, "Pica During Pregnancy: Cultural Norm of Concern").53
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Pica is the ingestion of nonfood substances or food components including but not limited to clay, dirt, chalk, cornstarch, laundry starch, baking powder, baking soda, ice, and freezer frost. These substances are often craved with subsequent consumption. Approximately 20% of pregnant women engage in pica, and the prevalence of this psychobehavioral disorder is increased in rural (compared with urban) areas and in certain cultures.
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Preconception Nutrition
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Preconception folic acid supplementation has been shown in randomized clinical trials to greatly reduce a woman's risk of bearing an infant with a neural tube defect, which is the source of the serious defects of spina bifida and anencephaly. These congenital defects in the formation of the spine develop in the first few weeks of pregnancy, when the neural tube, which forms the spinal cord, does not close completely, leaving part of one or more vertebrae of the spinal cord exposed at birth. Each year in the United States approximately 3000 infants are born with spina bifida and anencephaly, and an estimated 1500 affected fetuses are spontaneously aborted.24 Since 1992 the U.S. Public Health Service has recommended that all women of childbearing age who are capable of becoming pregnant consume from food or supplementation 400 mcg of folic acid per day to prevent such deficiencies. This recommendation continues in the latest DRI guidelines, which recommend 400 mcg/day for nonpregnant women, rising to 600 mcg/day during pregnancy and 500 mcg/day during lactation.7 The U.S. Food and Drug Administration (FDA), acting to increase folic acid consumption nationally, mandated in 1998 that enriched cereal grain products be fortified with folic acid.25,26 These fortified foods are good sources of folic acid in addition to orange and pineapple juices, oranges, and dried beans.27 (Review Chapter 6 for more discussion on neural tube defects and their prevention.)Vitamin C
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Preexisting clinical conditions in the woman further complicate pregnancy. In each case, management of these conditions is based on general principles of care related to pregnancy and to the particular disease involved. Examples of such maternal conditions are reviewed here; they are hypertension, diabetes mellitus, PKU, AIDS, and eating disorders.
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Preexisting hypertension in the pregnant woman can cause considerable maternal and fetal consequences. Many of these problems can be prevented by initial screening and continued monitoring by the prenatal nurse, with referral to the clinical nutritionist for a plan of care. The hypertensive disease process begins long before signs and symptoms appear, and later symptoms are inconsistent. Risk factors for hypertension before and during pregnancy are listed in Box 11-2. Nutritional therapy centers on the following three principles: Risk Factors for Pregnancy-Induced Hypertension
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Pregnancies at either age extreme of the reproductive cycle pose special problems. The National Center for Chronic Disease Prevention and Health Promotion reported that approximately 415,000 live births occurred annually to female teenagers during the years 2004 to 2006.42 The adolescent pregnancy carries many social and nutrition-related risks associated with increased incidence of low birth weight and perinatal mortality, among other poor outcomes. The obstetric history of a woman is expressed in terms of number and order of pregnancies, or her gravida status. A nulligravida (no prior pregnancy) who is 15 years of age or younger is especially at risk because her own growth is incomplete; therefore sufficient weight gain and the quality of her diet are particularly important.38 Nutrients of particular concern are those for which the adolescent female requirements are greater than the adult requirements, including calcium, magnesium, phosphorus, and zinc. These nutrients are critical for growth and development of the adolescent, as well as for her fetus. Sensitive counseling provides information and emotional support; it should involve family members or other persons significant to the adolescent. On the other hand, the older primigravida (first pregnancy), older than 35 years, also requires special attention. She may be more at risk for hypertension, either preexisting or pregnancy induced, and may need more attention to the rate of weight gain and amount of sodium used, as well as any drug therapy prescribed. In addition, several pregnancies within a limited number of years leave a mother drained of nutritional resources and entering each successive pregnancy at increased risk.
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Pregnancy-Induced Hypertension
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Pregnant women sometimes voice the related complaints of heartburn or a full feeling. These discomforts occur especially after meals and are usually caused by the pressure of the enlarging uterus crowding the stomach. Gastric reflux of some of the food mass, now a liquid chyme mixed with stomach acid, may occur in the lower esophagus, causing an irritation and a burning sensation. Obviously this common complaint has nothing to do with heart action but it receives the name because of the close proximity of the lower esophagus to the heart. The full feeling comes from general gastric pressure, lack of normal space in the area, a large meal, or gas formation. These complaints are usually remedied by dividing the day's food into a series of small meals, avoiding eating large meals at any time, and not lying down after a meal. Comfort is also improved by wearing loose-fitting clothing.
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Rate of Weight Gain
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Relation to Nutrition
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Rest and Relaxation
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Risk Factors Occurring During Pregnancy
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Risk Factors Present at the Onset of Pregnancy
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Several special needs require sensitive counseling. These areas of need include the age and parity of the woman; any use of harmful agents such as alcohol, cigarettes, drugs, or pica; and socioeconomic problems.
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Social Habits: Alcohol, Cigarettes, and Drugs
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Sodium intake may be moderate but should not be unduly restricted because of its relation to fluid and electrolyte balances during pregnancy. Initial and continuing client education and a close relationship with the nurse-nutritionist care team contribute to successful management of the hypertension and prevent problems that may occur. (For a more detailed discussion of vascular disease, see Chapter 21.)
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Some general dietary problems temporarily interfere with food and nutrient intake. Most are easily resolved through dietary counseling and with medical attention and have no long-term adverse effect on the quality of maternal weight gain. Symptoms of nausea and vomiting are usually mild and short term, the so-called morning sickness of early pregnancy, because it occurs more often on arising than later in the day. At least 50% of all pregnant women, most of them in their first pregnancy, experience this condition, beginning during the fifth or sixth week of the pregnancy and usually ending about the fourteenth to sixteenth week. A number of factors may contribute to the situation. Some factors are physiologic, with causal factors based on hormonal changes that occur early in pregnancy or on low blood sugar, which can be relieved by carbohydrate foods but that will return within 2 to 3 hours after a meal. Others may be psychologic, based on situational tensions or anxieties about the pregnancy itself. Still others may be dietary problems, based on poor food habits. Simple treatment generally improves food tolerance. Frequent small low-fat meals and snacks, which are fairly dry and consist chiefly of easily digested energy-yielding foods such as carbohydrates (mainly starches), are usually more readily tolerated. In addition, it may help to avoid cooking odors as much as possible. Liquids are best taken between meals instead of with meals.
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Some women may purposefully choose to breast-feed to avoid pregnancy, but this is not a dependable contraception method. Well-nourished women of the world tend to be more fertile and may find themselves pregnant and breast-feeding at the same time. Women who breast-feed must understand that the lack of a menstrual period during lactation (lactational amenorrhea) does not mean they cannot become pregnant. Contraceptives may be required if another pregnancy is not desired at the current time. If pregnancy occurs, then the woman should discuss appropriate infant-feeding solutions with her health care team.
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Special counseling is required for women and young girls facing economic challenges. Numerous studies and clinical observations indicate that lack of prenatal care, often associated with racial prejudices and fears, as well as a lack of adequate financial resources, places the expectant mother in grave difficulty. Special counseling that is sensitive to personal needs is required to help plan resources for care and financial assistance. Resources include programs such as the federally funded Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), described in Appendix F, as well as numerous state and local programs. An example of a community partnership program promoting prenatal care is Stork's Nest, sponsored by the March of Dimes in affiliation with a national women's organization and local community service agencies. Another successful program targeted for low-income women is BabyCare, administered by the Virginia Department of Health (see Further Readings and Resources at the end of this chapter).
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Special emphasis must be given to the pregnant woman's need for ascorbic acid. Vitamin C is essential to the formation of intercellular cement substance in developing connective tissues and vascular systems. It also increases the absorption of iron, which is needed for the increasing quantities of hemoglobin. The DRI standard recommends 85 mg/day for the pregnant woman, an increase of 10 mg/day beyond the regular female adult need of 75 mg/day.8 Additional food sources such as citrus fruit and other vegetables and fruits should be included in the woman's diet.
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Specific treatment varies according to the individual patient's symptoms and needs. Optimal nutrition is a fundamental aspect of therapy in any case. Emphasis is given to a regular diet with adequate dietary protein and calcium, as well as to a diet that is rich in fruits and vegetables, providing magnesium, potassium, and dietary fiber. Correction of plasma protein deficits stimulates the capillary fluid shift mechanism and increases circulation of tissue fluids, with subsequent correction of the hypovolemia. In addition, adequate salt and sources of vitamins and minerals are needed for correction and maintenance of metabolic balance.
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Synergism Concept
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The DRI standard recommends an additional amount of energy of approximately 340 kcal/day during the second trimester and 452 kcal/day during the third trimester of pregnancy to supply needs during this time of rapid growth.10 Total daily kcalorie intake during middle and late- pregnancy should be based on the woman's nonpregnant estimated energy requirement plus the additional energy need and will typically increase about 15% to 20% beyond the woman's general prepregnancy need. This primary emphasis on sufficient kcalories is critical to ensure nutrient and energy needs to positively support the pregnancy. Appropriate weight gain during pregnancy indicates whether sufficient kcalories are being provided.
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The Delgados attended every prenatal group meeting and kept all consequent diet-counseling sessions. Their food choices improved in time, and Mrs. Delgado's weight gain progressed normally, to a total of 13 kg (28.5 lb) by the time of delivery. The Delgados had a healthy 4 kg (8 lb, 13 oz) baby girl. Alternative Food Patterns
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The Dynamic Nature of Human Milk
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The complaint of constipation is seldom more than minor, but it contributes to discomfort and concern. Placental hormones relax the gastrointestinal muscles, and the pressure of the enlarging uterus on the lower portion of the intestine may make elimination somewhat difficult. Increased fluid intake and the use of naturally laxative foods containing dietary fiber, such as whole grains, fruits and vegetables, dried fruits (especially prunes and figs), and other fruits and juices, generally promote regularity. Laxatives should be avoided. Appropriate daily exercise is essential for overall health during pregnancy.
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The daily amount of vitamin A recommended for pregnancy is 770 mcg of retinol activity equivalents (RAE), a slight increase beyond the woman's regular need.9 For most women in the United States, no extra amount is needed. However, malnourished, underweight women and those with multiple pregnancies need more. Vitamin A is an essential factor in cell differentiation, organ formation, maintenance of strong epithelial tissue, tooth formation, and normal bone growth. Liver, egg yolk, butter and fortified margarine, dark-green and yellow vegetables, and fruits are good food sources.
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The effects of an iron supplement may include gray or black stools and sometimes nausea, constipation, or diarrhea. To help avoid food-related effects, the iron supplement should be taken 1 hour before a meal or 2 hours after it, with liquid such as water or orange juice but not with milk or tea. The absorption of iron is increased with vitamin C and decreased with milk, other dairy foods, eggs, whole grain bread and cereal, and tea. Ferrous fumarate and ferrous gluconate are alternate forms of iron supplements with good absorption properties that tend to result in less gastrointestinal distress.
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The energy cost of exercise influences the kcalorie needs of the pregnant woman. Kcalories must be consumed to meet the energy cost of exercise and to promote appropriate maternal weight gain and fetal growth and development. Adequate hydration is also vital, and the woman should increase fluid intake during exercise.
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The fetal origins hypothesis supports the notion that nutrition during gestation, or the lack thereof, sets the course for chronic disease in adulthood.11 Development of cardiovascular disease, hypertension, obesity, type 2 diabetes, metabolic syndrome, and gestational diabetes, among other chronic diseases, has been shown in the offspring of animals for which maternal dietary intakes of macronutrients and micronutrients were manipulated, as well as in human epidemiologic studies of the relationship between infant anthropometric measurements and adult disease incidence.12,13 In these epidemiologic studies, infant body size, shape, and weight measurements served as indicators of maternal nutrition. Changes in maternal nutrition during pregnancy require that the fetus adapt. These adaptations to nutrient supplies may lead to programming, or the mechanism (or mechanisms) through which permanent changes in organ system structures and functions occur, leading to risk of chronic disease. This hypothesis presumes that nutritional insults that occur during critical stages of embryonic and fetal development are most harmful, leading to future disease risk. The merits of the fetal origins hypothesis have been debated, and much remains to be discovered.14 Although research regarding the influence of nutrition on fetal growth and development has unique ethical and moral considerations, outcomes-based research is essential for appropriate evidence-based practice for healthy pregnancies.Factors Determining Nutritional Needs
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The important consideration lies in the nutritional quality of the gain. Specifically, the foods consumed should be nutrient dense, not full of empty kcalories, to meet nutrient requirements. In addition, in some cases clinicians have failed to distinguish between weight gained as a result of edema and that as a result of deposition of fat—maternal stores for energy to sustain rapid fetal growth during the latter part of pregnancy and energy for lactation to follow.37 Analysis of the total tissue gained in an average pregnancy shows that the largest component, 62%, is water. Fat accounts for 31% and protein for 7%. Water is also the most variable component of the tissue gained, accounting for a range of 8 kg (18 lb) to as much as 11 kg (24 lb). Of the 8 kg of water usually gained, about 5.5 kg (12 lb) is associated with fetal tissue and other tissues gained in pregnancy. The remaining 2.5 kg (6 lb) accumulates in the maternal interstitial tissues.38 Gravity causes the maternal tissue fluids to pool more in the lower extremities, leading to general swelling of the ankles, which is seen routinely in pregnant women. This fluid retention is a normal adaptive phenomenon designed to support the pregnancy and to exert a positive effect on fetal growth. Connective tissue becomes more hygroscopic as a result of the estrogen-induced changes in the ground substance and thus becomes softer and more easily distended. This facilitates delivery of the infant through the cervix and vaginal canal. In addition, the increased tissue fluid during pregnancy provides a means for handling the increased metabolic work and circulation of numerous metabolites necessary for fetal growth.
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The incidence of multifetal pregnancies has increased in recent decades and presents unique concerns. Infants born from a multifetal pregnancy are more likely to have lower-than-average birth weights and are at risk for preterm delivery.36 Thus nutritional needs of these women must be given special attention. Energy intake must be increased beyond the needs of a single fetus pregnancy so that the recommended weight gain for multiple fetuses is achieved. This increase in energy intake often provides for the additional nutrient demands that exist. Attention to adequate folate intake is critical to reduce risks of low birth weights and preterm delivery. Supplemental iron may be necessary to reduce the incidence of anemia, more commonly found in women with multiple fetuses. Additional calcium and vitamin D are needed with multiple fetuses to promote adequate calcium absorption for optimal bone mineralization in utero. Zinc, copper, and pyridoxine supplementation may also be required to support multifetal growth and development.
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The kcalories must be sufficient to perform the following two functions:
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The management of preexisting diabetes in pregnancy presents special problems. Today, however, improved expectations for the diabetic woman's pregnancy constitute one of the success stories of modern medicine.54 Contributing factors to this improved outlook include advances in technology for monitoring fetal development, increased knowledge of nutrition and diabetes, and management refinements in tight blood glucose control through self-monitoring.55,56 (Chapter 22 details the care of persons with types 1 and 2 diabetes mellitus.)
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The method of delivery does not affect the quality or quantity of milk produced. The baby can be held in such a way (the "football hold") that he or she does not rest on the mother's abdominal stitches.
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The physiologic needs of lactation are different from those of pregnancy, and they demand adequate nutritional support (see Table 11-1). The basic nutritional needs for lactation include the following additions to the mother's prepregnancy needs.
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The prefix peri- comes from the Greek root meaning around, about, or surrounding. Thus the word perinatal refers more broadly to the scope of factors that surround a birth than merely the 9 months of the physical gestation. Certainly, as nutrition knowledge and understanding have increased, health professionals realize that all of a woman's life experiences surrounding her pregnancy must be considered. Her nutritional status and food patterns, which have developed during a number of years, and the degree to which she has established and maintained nutritional reserves are all important factors. Cultural and social influences have shaped beliefs and values of the woman about pregnancy. All of these influences come to bear on any pregnancy.
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The pregnant woman needs 27 mg of iron per day, a substantial increase beyond her general needs.9 Some pregnant women may need supplementary iron in addition to increased dietary sources to meet the additional requirement of pregnancy. The iron cost of pregnancy is high. With increased demands for iron, often insufficient maternal stores, and inadequate provision through the usual diet, a daily supplement of 30 to 60 mg of iron per day is generally prescribed. If a woman has iron deficiency anemia at conception, then a larger therapeutic amount of 60 to 120 mg/day of iron may be necessary to reduce the risk of a preterm delivery or low-birth-weight baby (or both).
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The pregnant woman's DRI recommendation is 1000 mg of calcium per day, the same as the general recommendation for all women ages 19 to 50.6 Calcium is the essential element for the construction and maintenance of bones and teeth. It is also an important factor in the blood-clotting mechanism and is used in normal muscle action and other essential metabolic activities. Improved absorption of calcium supplies the needs arising from the accelerated fetal mineralization of skeletal tissue during the final period of rapid growth. Dairy products are a primary source of calcium. Consumption of milk or equivalent milk foods (cheese or nonfat milk powder used in cooking) is recommended. Additional calcium is obtained in whole or fortified cereal grains and in green leafy vegetables.
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The quality of human milk is not influenced by the way the baby comes into the world. Many women fear that a baby born by cesarean section cannot be nursed because they think that this method of delivery delays or prevents the production of mature milk. Milk production is stimulated by the release of the placenta, which occurs whether the delivery is vaginal or not. Studies confirm that no significant difference exists in the length of time it takes for mature milk to come in after vaginal or cesarean deliveries.
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The recommendation for iodine increases by 70 mcg/day during pregnancy.9 Iodine is vital for thyroid hormone synthesis and prevention of goiter. The need increases during gestation to support changes in maternal thyroid economy, increased maternal renal clearance, and fetal uptake of iodine. An inadequate supply of iodine to the fetus may lead to hypothyroidism in the newborn and is often associated with poor and abnormal growth, deficits in cognitive development, and poor motor function. Although infrequently encountered in the United States, infant hypothyroidism continues to be found in many developing countries. Iodine consumption is critical in the first half of pregnancy, and programs designed to provide oil- and water-based iodine supplements to women in preconception and prenatal periods in developing countries have been successful in reducing the incidence of infant hypothyroidism. Iodized salt is the primary dietary source for women in developed countries. Seafood is also a noted source of iodine.
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The recommended caloric increase is 330 kcal/day (plus 170 kcal/day from maternal stores) in the first 6 months and 400 kcal/day in the second 6 months of breast-feeding (beyond the usual adult allowance). This makes a daily total of about 2700 to 2800 kcal/day for milk production and maternal energy needs.10 This additional energy need for the overall total lactation process is based on the following four factors:
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The successful detection and management of infants with PKU through newborn screening programs in all states have ensured their normal growth and development to adulthood. PKU is a genetic metabolic disease caused by a missing enzyme for the metabolism of the essential amino acid phenylalanine. It is controlled by a special low-phenylalanine diet initiated at birth. Now a new generation of young women with PKU since birth are beginning to have children of their own. However, maternal PKU presents potential fetal hazards. Experience has shown how crucial it is for the woman to follow a strict low-phenylalanine diet before conception, whenever possible, to minimize risks of fetal damage in the early cell differentiation weeks of pregnancy.
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The thin, bluish appearance of breast milk has some women convinced that it is no more nourishing than water. Let them look at Table 11-3; they will be pleasantly surprised at how well breast milk meets the nutritional needs of the infant.
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The total amount of protein recommended for a pregnant woman is 71 g/day, an increase of 25 g/day.10 Protein, with its essential nitrogen, is the nutrient basic to tissue growth. Nitrogen balance studies suggest that a large amount of nitrogen is used by the woman and fetus during pregnancy and emphasize the importance of preconception maternal reserves to meet initial pregnancy needs. More protein is necessary for demands posed by the following:
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The two key factors that predict infant birth weight are (1) maternal preconception weight and (2) weight gain during pregnancy.2 Nutrition and other lifestyle factors affect maternal weight and weight gain; many of these factors, particularly nutrition, are modifiable or may be controlled by the pregnant woman. Healthy pregnancy may also be described in broader terms of mother, infant, and family. Clinicians are beginning to understand more about what this really means, especially as they observe fetal damages from malnutrition, drug abuse, and other factors. It is clear that we must assess and support more fully the quality of life of each mother and her family if we are to achieve healthy pregnancy outcomes among women.
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The word synergism is a term used to describe biologic systems in which the cooperative action of two or more factors produces a total effect greater than and different from the mere sum of the parts. In short, a new whole is created by the unified, joint effort of blending the parts in which each part makes more powerful the action of the others. Of the many biologic and physiologic examples of synergism, pregnancy is a prime case in point. Maternal organism, fetus, and placenta combine to produce a new whole, a system not existing before and producing a total effect greater than and different from the sum of the parts, all for the sole purpose of sustaining and nurturing the pregnancy and its offspring. Physiologic measures change. Blood volume and cardiac output is increased; ventilation rate and tidal volume of breathing are increased; and basal metabolic rate (BMR) is increased. The physiologic norms of the nonpregnant woman do not apply.Thus the normal physiologic adjustments of pregnancy cannot be viewed as pathologic with application of treatment procedures for that same type of response in the nonpregnant state. For example, a normal physiologic generalized edema of pregnancy is a protective response. It reflects the normal increase in total body water necessary to support the increased metabolic work of pregnancy and is associated with enhanced reproductive performance.
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These factors need to be reviewed with each individual mother in her particular situation. Only on this basis, can she make the informed decision that is best for the infant and for herself.
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These three personal habits may cause fetal damage and are contraindicated during pregnancy. No safe level of alcohol consumption has yet been found for pregnant women. Extensive or habitual alcohol use may lead to one of the fetal alcohol spectrum disorders known as fetal alcohol syndrome (FAS), which is currently a leading cause of mental retardation.43 FAS is characterized by growth retardation, malformed facial features, joint and limb abnormalities, cardiac defects, mental retardation, and in serious cases, death. FAS signs have been seen in tests with rats as early as the human equivalent of the third week of gestation, when most women are unaware of their pregnancies. Thus moderate-to-heavy drinking among sexually active women of childbearing age may carry potential danger. Even moderate prenatal alcohol exposure has been associated with low birth weight and has effects on a child's psychomotor and cognitive development in the absence of malformations, known as fetal alcohol effects (FAE).44
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Three distinct biologic entities are involved during gestation: the woman, the fetus, and the placenta, which nourishes fetal growth. Together they form a unique biologic whole. Constant metabolic interactions occur among them. Their functions, although unique, are at the same time interdependent. It is this unique biologic synergism that nourishes and sustains the pregnancy.
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Throughout the pregnancy an increased need exists for most of the basic nutrients, as indicated by the DRI guidelines from the Food and Nutrition Board of the Institute of Medicine (Table 11-1).6-10 However, it is important to remember that these are guidelines; individual variances in nutrient needs must be examined for each pregnancy. Individual variations such as BMR, BMI, physical activity, and health status must be considered. In addition, the quantitative need for nourishment of pregnant adolescents and multifetal pregnancies must be noted. Individual counseling and correct use of nutritional guidelines is imperative.20 In considering the nutritional needs of the healthy pregnant woman, we will review here the macronutrients and selected micronutrients with increased needs, rationale for increased needs, and how such nutrients may be obtained from foods.Energy Needs
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Thus premature or cesarean deliveries should not discourage women from breast-feeding. Mothers should not underestimate the nutritive quality of their milk simply because it does not appear as rich and thick as cow's milk. After all, cow's milk is made for young calves, who are up and running around after birth and have a much shorter, faster growth period. For the human infant, in nutritional and immunologic terms, breast milk remains the best milk. Mothers' Facts and Fancies About Breast-Feeding
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To avoid the consequences of sustained poor nutrition during pregnancy, a first procedure is to identify women at risk. In a joint report, the American College of Obstetrics and Gynecology and the American Dietetic Association issued a set of risk factors, as shown in Box 11-1, that identify women with special nutritional needs during pregnancy.5 These nutrition-related factors are based on clinical evidence of inadequate nutrition. However, rather than waiting for clinical symptoms of poor nutrition to appear, a better approach would be to identify poor food patterns that will induce nutritional problems and to prevent these problems from developing. On this basis, three types of dietary patterns predict failure to support optimal maternal and fetal nutrition: (1) insufficient food intake, (2) poor food selection, and (3) poor food distribution throughout the day. These patterns, added to the list of risk factors in Box 11-1, are much more sensitive for nutritional risk. Once early assessment identifies risk factors, practitioners can then give more careful attention to these women. By working closely with each woman and her personal food pattern and living situation, a food plan can be developed with her to ensure an optimal intake of energy and nutrients to support her pregnancy and its successful outcome.
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To obtain the needed amount of iron, check the percentage of elemental iron in the iron preparation being used. For example, the commonly used compound ferrous sulfate is a hydrated salt (FeSO4 7H2O), which contains 20% iron. It is usually dispensed in tablets containing 195, 300, or 325 mg of the ferrous sulfate compound. Each tablet, then, would contain 39, 60, or 65 mg of iron, respectively. Thus to supply a regular daily supplement of 60 mg of iron, one 300-mg tablet of ferrous sulfate is required (300 mg FeSO4 7H2O × 20% = 60 mg iron); for a therapeutic dose of 120 mg iron, two 300-mg tablets are required. Problems with routine iron supplementation for pregnant women include unpleasant gastrointestinal side effects (see Effects of Iron Supplements later in this chapter) and less motivation to maintain a good diet. Of major concern are imbalances with other trace elements, such as zinc and copper, that compete with iron for absorption. Excess iron intake, when not needed, may actually mask inadequate pregnancy-induced hemodilution. Thus some prenatal clinics follow protocols that prescribe regular prenatal vitamins with iron at the first clinic visit, adding additional iron supplementation only if hemoglobin falls to 10.5 g/dL or less at any time during the pregnancy.
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Treatment
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Two useful general principles concerning eating habits for all persons also apply during pregnancy, as follows:
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Until recently much of the counsel given to pregnant women during the past few decades has been based more on tradition than on scientific fact. Increasing evidence indicates that positive nutritional support of pregnancy, rather than past negative restrictions born of limited knowledge and false assumptions, promotes a successful outcome with increased health and vigor of mothers and their infants. This struggle during the past few decades, particularly to define the "healthy pregnancy," has not been easy. A healthy pregnancy has often been defined by the birth weight of the newborn, because infant mortality, or death, is low for infants with birth weights of 3500 to 4500 g.1
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Vitamin A
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Vitamin D
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Vitamin Needs
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Weight gain during pregnancy
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When it comes to breast-feeding, all women are created equal. The only parts of the breast that participate in milk production are the glandular and nervous tissue and the nipple; these are basically the same in healthy women. The only difference between a size 32A and a size 42DD is the amount of fat tissue the breast contains.
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With the increasing ethnic diversity in the United States, it is especially important to use the woman's personal cultural food patterns in dietary counseling. We are ethnocentric if we rigidly adhere to a single dietary pattern for all pregnant women, because intake differs among women from various cultures, belief systems, and lifestyles. We must always remember that specific nutrients, not specific foods, are required for a successful pregnancy and that these nutrients are found in a wide variety of food choices. If we are wise, we will encourage our clients to use foods that serve their nutritional needs, whatever those foods might be (see the Case Study box, "A Baby for the Delgados"). A number of resources are available as guides for cultural, religious, and vegetarian food patterns. Suggestions for improving transcultural nutrition counseling skills are also available.28-30
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Women who exercise before pregnancy should continue a reasonable exercise regimen during pregnancy.17 In fact, women who engage in prenatal exercise have been shown to have health benefits compared with nonexercising women.18 Moderate-intensity physical activity may also be beneficial to the woman and fetus, even if the woman was sedentary before conception. Each day, a pregnant woman should strive to achieve approximately 20 to 22 minutes of aerobic activity to meet a goal of approximately 150 minutes per week.17 As the woman's body size and shape change throughout the course of pregnancy, exercise type, duration, intensity, and frequency should be adjusted to promote safety for the woman and her fetus (Figure 11-2). Physical activities that are not recommended during pregnancy include scuba diving and those with risk of trauma to the abdominal area.19
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Women who have adequate exposure to sunlight probably need little additional vitamin D. During pregnancy, because of the need for calcium and phosphorus presented by the developing fetal skeletal tissue, vitamin D is used to promote the absorption and use of these minerals. The daily recommended amount for pregnancy is 5 mcg cholecalciferol
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Zinc
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weighing about 3500 g, on average. What nutrients must the woman supply to support this intense period of fetal growth and development? What must her diet provide to meet fetal nutritional demands and her own needs during this critical period?
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• Abuse of nicotine, alcohol, or drugs
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• Age extremes (≤20 years old, ≥35 years old)
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• Age: ≤15 yr or ≥35 yr
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• Bizarre or faddist food habits
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• Diabetes
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• Diagnosis of pregnancy-induced hypertension (PIH) in a previous pregnancy
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• Dietary deficiencies
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• Excessive weight gain: >1 kg (2 lb)/week after the first trimester Recognize Special Counseling Needs
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• Family history of hypertension or vascular disease
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• Fetal hydrops
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• Frequent pregnancies: three or more during a 2-year period
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• Glomerulonephritis
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• Hydatidiform mole
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• Hydramnios
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• Inadequate weight gain: any weight loss or weight gain of <1 kg (2 lb)/month after the first trimester
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• Large fetus
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• Low hemoglobin (HGB) or hematocrit (HCT): HGB <12 g/dL, HCT <35%
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• Multiple gestation
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• Nulligravida
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• Poor obstetric history or poor fetal performance
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• Poverty
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• Preexisting condition (hypertension, renal or vascular disease)
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• Primigravida
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• Therapeutic diet required for a chronic disorder
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• Weight: <85% or >120% of standard weight
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•Community support is increasingly available, even in workplaces.71,72
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•Enlargement of the uterus, mammary glands, and placenta.
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•Family pressures, especially from the husband, not to breast-feed have strong influences on the mother, even though she may want to do so. Initial counseling and education about breast-feeding should include both parents whenever possible. Reasons for negative attitudes can be explored and misinformation clarified with sound education.
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•Formation of amniotic fluid.
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•Increase in maternal circulating blood volume and subsequent demand for increased plasma proteins to maintain colloidal osmotic pressure and circulation of tissue fluids to nourish cells.
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•Maternity wards and alternative birth centers have been modified to facilitate successful lactation.
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•Misinformation, a major barrier, creates negative impressions and ideas. Women in today's world often lack positive role models in extended families or experienced friends with whom they can discuss their feelings and obtain much practical guidance. Experienced breast-feeding mothers or lactation consultants can fill this need, especially for young first-time mothers.
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•More mothers are informed about the benefits of breast-feeding (Figure 11-4).66,67
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•Outside employment, with a limited maternity leave and job loss if the mother does not return to work at that time, can complicate the mother's decision, even though she may want to breast-feed her baby. However, if the mother does have the will, then it is possible to breast-feed and be employed. After breast-feeding is well established, she can regularly express milk by hand or with a breast pump into sterile disposable nursing bags to use with disposable holder, cap, and nipple ensemble. Rapid chilling and strict sanitation are required, but it can be planned, given the commitment. Some companies provide child care facilities for their employees, recognizing that helping employees with this modern need is good business. The mother can plan occasional formula feeds to fill in with the sustained breast-feeding.
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•Personal modesty and anxiety, or a fear of appearing immodest in breast exposure, may hinder some mothers from breast-feeding. Sensitive counseling, especially with a positive role model as described previously, can help to allay some of these personal fears. Most of women's breast-feeding is done in the privacy of the home rather than around others; therefore early support during initial experiences would be helpful.
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•Practitioners recognize the ability of human milk to meet infant needs (Table 11-3) and promote immune function.68-70
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•Programs that promote breast-feeding are increasingly responsive to a wider range of maternal socioeconomic conditions and cultural backgrounds.73-80
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•Rapid fetal growth.
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•Storage reserves for labor, delivery, and lactation.
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Healthy Pregnancy
good birth weight
Directions for Current Practice
what is best to the baby