SUMMARY- Clinical Practice Guidelines on Maternal
Nutrition and Supplementation
Regrine B. Lagarteja, RMT, MLS(ASCPi)CM
NOMENCLATURE ON LEVELS OF EVIDENCE AND
GRADES OF RECOMMENDATION
LEVEL
I
II-1
II-2
II-3
III
GRADE
A
B
C
D
E
GPP
DEFINITION
Evidence obtained from at least one properly
randomized controlled trial
Evidence obtained from well-designed controlled
trials without randomization
Evidence obtained from well-designed cohort or
case-control analytic studies, preferably from more
than one center or research group
Evidence obtained from multiple time series with or
without the intervention
Opinions of respected authorities, based on clinical
experience; descriptive studies and case report of
expert committees.
DEFINITION
There is good evidence to support the
recommendation of the practice in maternal nutrition
and supplementation
There is fair evidence to support the
recommendation of the practice in maternal nutrition
and supplementation
There is insufficient evidence to recommend for or
against the inclusion of the practice in maternal
nutrition and supplementation
There is fair evidence to support the
recommendation that the practice be excluded in
maternal nutrition and supplementation
There is good evidence to support the
recommendation that the practice be excluded in
maternal nutrition and supplementation
A good practice point (GPP) is a recommendation
for best practice based on the experience of the
Task Force
o Maternal BMI of <20 a the start of pregnancy is
associated with increased prevalence of preterm delivery
and low birth weight infants
 For inadequate weight gain, only balanced Protein-energy
supplementation may be safe and effective
o High protein and isocaloric protein energy
supplementation may be associated with untoward fetal
effects
o For excessive weight gain, P-E restriction not significantly
effective and may adversely impact birth weight
RECOMMENDATIONS
1. Routine assessment of BMI at first visit
2. Nutrition counseling for inadequate weight gain or initial BMI
<20
3. Routine screening for inappropriate weight gain at each visit
4. Practical evaluation of weight gain at 24-28 weeks
5. Individualized weight gain based on pre-pregnancy weight
RECOMMENDED WEIGHT GAIN IN PREGNANCY
WEIGHT CLASSIFICATION
PRECONCEPTION
 IOM Pregnancy Weight Guidelines: mother’s weight at the
start of pregnancy is one of the most important modifiers of
pregnancy weight gain
 Overweight women should undertake weight reduction
program BEFORE attempting pregnancy
o Bariatric surgery is an option before pregnancy BUT has
an increased risk of Fe, B12, Vitamin D, and calcium
deficiencies
ANTEPARTUM
ASSESSMENT OF THE NUTRITIONAL STATUS OF
PREGNANT WOMEN
SUPPORTING STATEMENTS
 Screening for inappropriate weight gain allows for early
intervention to prevent complications
 Pregnant women who experience inappropriate weight gain
may be at risk for a number of complications
 Excessive Weight Gain
o Increase risk for macrosomic infants, shoulder dystocia,
operative delivery, and postpartum obesity
o BMI >30 affects approx. 1/3 of adult women
o Maternal overweight condition increases the risk of
antepartum stillbirth
 Inadequate weight gain
o Increase risk of preterm delivery, IUGR, and low birth
weight
 Pregnant women who started pregnancy as underweight or
who have not gained enough during pregnancy tend to have
increased risk for preterm pregnancy, and low birth weight
baby
 Mother who gain too much during pregnancy have higher
incidence of CS and preterm birth, and retain too much
weight even after pregnancy, and higher weight in
subsequent pregnancies
SUMMARY: Clinical Practice Guidelines on Maternal Nutrition and Supplementation
By Regrine B. Lagarteja, RMT, MLS(ASCPi)CM
1/5
 Gestational weight gain below IOM among overweight does
not appear to have negative effect on fetal growth or
neonatal outcomes
3. To apply DBW to Filipino status, deduct 10% (or multiply by
90%)
 Nurtiture (Nutritional Status) of pregnant women is
determined through BMI
Multiple Pregnancy
 Weight gain of 1.4 lb/wk during the 2nd and 3rd trimester has
been associated with reduced risk of preterm and low birth
weight delivery in twin pregnancy
RECOMMENDATIONS
Preconception
 RENI of a woman should be based on physical stature and
physical activity level
 Underweight:
 Triplets: overall gain should be around 50 lbs with a steady
rate of gain of approx. 1.5 lb/wk
 Women with multiple pregnancy consume about 500 more
calories a day than usual (ACOG)
POSTCONCEPTION
 Assistance to help women return to their prepregnancy
weight within the first year following delivery
 Normal Weight:
RENI
 RENI
o Levels of intakes of energy and nutrients which are
considered adequate for the maintenance of health and
well-being of nearly all healthy persons in the population
o Nutrients: equal to average physiologic requirement (AR)
+2SD or 3CV to cover the needs of almost all individuals
in the population
 Adequate Intake (AI)
o For nutrients with insufficient AR data
o Based on experimentally observed average intake of
healthy individuals
 Additional requirements during pregnancy are based on
estimates of amounts laid down in fetal and maternal tissues
 Lactating: based on amounts secreted in breastmilk
 These values are added to the requirements of
nonpregnant, nonlactating women
Energy allowance based on activity levels
 Overweight:
 Computation of total energy intake is done using DBW
multiplied by the calories
Prenatal
 TER per day does not change for the first trimester
 For a pregnant woman in 2nd and 3rd trimester, 300 kcal/day
is added to the total computed energy intake
o Additional 2g or 9g of protein per day is needed also
 For women with multifetal pregnancy, 450 kcal/day is added
to compute total energy intake
Postpartum
 Lactating women require additional 500 kcal/day over the
basal energy requirement during the first 6 months and in
the last second 6 months if lactation is continued
MEASURING DBW


1.
2.
Use Tannhauser’s Method
Steps
Measure Height in cm
Deduct 100 from computed Ht in cm
IRON, FOLIC ACID, AND IODINE SUPPLEMENTATION
IRON SUPPLEMENTATION
 Recommended as part of antenatal care to reduce the risk
of low birth weight, maternal anemia and iron deficiency (IA)
SUMMARY: Clinical Practice Guidelines on Maternal Nutrition and Supplementation
By Regrine B. Lagarteja, RMT, MLS(ASCPi)CM
2/5
 Women taking daily iron supplement were less likely to have
low birth weight babies compared with controls
 Daily iron supplementation reduced the risk of maternal
anemia at term by 70%
o 8.8. g/L more Hb than those who did not take iron
Table: Suggested Scheme for Daily Iron Supplementation in
Pregnant women
 Prevalence of anemia <40%
o 30-60 mg of elemental iron with 400 ug for minimum 6
months
 Avoiding iron supplementation during 1st trimester
o avoids the risk of aggravating nausea and vomiting
o supplementation is started after 14 weeks
o consumed for a minimum duration of 6 months
o iron supplementation is continued up to 3 months
postpartum
 Anemia in pregnant women is a severe public health
problem
o Daily dose of 60 mg of elemental iron with 400 ug f folic
acid preferred over lower dose (30 mg)
 Diagnosed with anemia in clinical setting
o Daily iron (120 mg elemental iron) and folic acid (400 ug)
supplementation until Hb rises to normal
 IF iron supplements containing 400 ug of folic acid are
not available
o Iron supplement with less folic acid may be used
 Double dose of iron supplementation
o Pregnant is large
o Twin fetus
o Begins supplementation late in pregnancy
o Irregularly takes iron
o 0.4-1 mg folic acid daily, prior to conception, throughout,
and during postpartum period
Benefits Of Folic Acid Supplementation During Pregnancy
 protection against fetal structural anomalies (like NTD) and
congenital heart defect
 key nutrient for active erythropoiesis because of its role in
DNA synthesis prevent anemia
 important in the timing of labor
 regulation of trophoblast invasion
o folate deficiency may interfere with early stages of
placental development
IODINE SUPPLEMENTATION
 x250 ug intake met by diet; no additional supplementation
required
 associated with stillbirths, miscarriages, poor growth, and
cognitive impairment
 Cretinism is the most extreme manifestation
o More subtle manifestation: poor school performance,
reduced intellectual ability, impaired work capacity
 Iodine supplementation is the world’s greatest single
cause of preventable brain damage
FOLIC ACID SUPPLEMENTATION
 Essential for DNA replication and is a substrate for
enzymatic reactions involved in AA synthesis and vitamin
metabolism
 Also required for the development and growth of fetus
 L-5-methyl-tetrahydrofolate
o Metabolically active form
o Predominant micronutrient form of folate that circulates
in plasma
 At high risk of having a child with NTD or on
anticonvulsant medications
o 5 mg daily prior to conception, throughout pregnancy, and
post partum
 Other reproductive-aged women
SUMMARY: Clinical Practice Guidelines on Maternal Nutrition and Supplementation
By Regrine B. Lagarteja, RMT, MLS(ASCPi)CM
3/5
THIAMINE (B1)
 Based on requirement for normal erythrocyte transketolase
(ETK) activity and urinary thiamine excretion and twice an
assumed CV of 10% to cover 97.5% of individuals
Stage
RNI
Preconception
13-15: 1.0 mg
16-49: 1.1 mg
Prenatal
1.4 mg
Lactating
1.5 mg
RIBOFLAVIN (B12)
 Categories of countries based on national salt
iodization coverage
o Category 1
 Iodine deficiency is under control in a sustained way
 Iodization of salt for >2 years
 Iodized salt is consumed by >90% of households
o Category 2
 Not all salt is iodized, iodization not regulated,
distribution of salt not even
 Consumed y <90% of household
o Category 3
 Countries or region within countries in which iodized
salt is either not available or available only to a
negotiable extent
 <20% of the households consumed iodized oil and
iodine nutrition is inadequate
o in Philippines, median concentration of iodine is 200-299
ug (Category I with risk of iodine induced
hyperthyroidism)
MICRONUTRIENT SUPPLEMENTATION: VITAMINS,
MINERALS, AND ELECTROLYTES
WATER AND ELECTROLYTES
 Based on the amount of riboflavin intake to maintain
riboflavin status of satisfactory erythrocyte glutathione
reductase activity (EG-AC) level
Stage
RNI
Preconception
13-15: 1.0 mg
16-49: 1.1 mg
Prenatal
1.7 mg
Lactating
1.7 mg
NIACIN
 Based on the amount of niacin intake corresponding to an
excretion of N’ methylnicotinamide that is above the minimal
excretion at which deficiency symptoms occur
 No correction made for bioavailability
Stage
RNI
Preconception
14 mg
Prenatal
18 mg
Lactating
17 mg
PYRIDOXINE (VITAMIN B6)
 Based on the amount required for normalization of
tryptophan load test
 RNI for adults: 1.3 mg/day
Stage
RNI
Preconception
13-18: 1.2 mg
19-49: 1.3 mg
Prenatal
1.9 mg
Lactating
2.0 mg
COBALAMIN (B12)
 based on recommended intake of 1 mL per kcal of energy
per day
 average conditions: 2500 mL/day
 may be increased to 3735 (1.5 mL/kcal) to cover variations
in activity level, sweating, and solute load
 infants: 1.5 mL/kcal which corresponds to the water-toenergy ratio in breast milk
VITAMIN C
 based on intake associated with adequate liver stores and
antioxidant protection
 Recommendation
Stage
RNI
Preconception
70 mg
Prenatal
80 mg
Lactating
1st 6 months- 105
2nd 6 months- 100
 Amount needed to maintain adequate hematological status
Stage
RNI
Preconception
2.4 ug
Prenatal
2.6 ug
Lactating
2.8 ug
FOLATE
 Amount of folate that will maintain adequate folate stores
based on erythrocyte folate and plasma homocysteine levels
 Best source: vegetables and fruits
Stage
RNI
Preconception
400 ug
Prenatal
600 ug
Lactating
500 ug
VITAMIN A
 Based on average amounts of vitamin A required to
maintain a given body pool size in well-nourished individuals
 Estimated average requirement + 2SD
Stage
RNI
Preconception
13-18: 450 ug
19-49: 500 ug
SUMMARY: Clinical Practice Guidelines on Maternal Nutrition and Supplementation
By Regrine B. Lagarteja, RMT, MLS(ASCPi)CM
4/5
 Maintain amount of vitamin D indicated by satisfactory level
of 25-OH-D
 RNI: 5 ug
 Based on intake required to maintain serum inorganic
phosphate within the normal range
Stage
RNI
Preconception
13-18: 1250 mg
19-49: 700 mg
Prenatal
700 mg
Lactating
200 ug
VITAMIN E
SELENIUM
 Safe level for intake: 12 mg/day
 Based on US data whose mean PUFA intake can be
presumed to be higher than that of Filipinos
 High intake of PUFA are typically accompanied by increased
Vit E intakes
 Based on intake that provides adequate reserves based on
satisfactory levels of plasma selenium and of glutathione
peroxidase activity
Stage
RNI
Preconception
13-15: 31 ug
16-18: 36 ug
19-49: 31 ug
Prenatal
35 ug
Lactating
40 ug
Prenatal
Lactating
800 ug
900 ug
VITAMIN D
VITAMIN K
 All breastfed infants should receive vitamin K
supplementation at birth
Stage
RNI (ug/kg)
Preconception
13-15: 49
16-18: 50
19-49: 51
Prenatal
51
Lactating
51
CALCIUM
 Based on theoretical Ca requirement estimates
 Developed countries: 60-80 g protein per capita
 Developing countries: 20-40 g per capita
Stage
RNI
Preconception
13-18: 1000 mg
19-49: 750 mg
Prenatal
750 mg
Lactating
750 mg
IRON
 Based on dietary iron needed to meet absorbed iron
requirements
o Amount needed to cover menstrual losses for women of
reproductive age, adjusted for bioavailability of iron in
typical complete meals consumed
 The estimated iron requirement during 1st trimester of
pregnancy and 1st 6 months of lactation are lower than that
of menstruating nonpregnant
Stage
RNI
Preconception
13-15: 21 mg
16-49: 27 mg
Prenatal
1st trimester: 27 mg
2nd trimester: 34 mg
3rd trimester: 38 mg
Lactating
1st 6 months: 27 mg
2nd 6 months: 30 mg
IODINE
 Intake necessary to maintain plasma iodide level above
critical limit likely to be associated with the onset of goiter
 Daily urinary excretion of 100 ug/L
Stage
RNI
Preconception
150 ug
Prenatal
200 ug
Lactating
200 ug
MAGNESIUM
 4 mg/kg/ body weight for adults to achieve a positive
magnesium balance
Stage
RNI
Preconception
13-15: 220 mg
16-18: 240 mg
19-49: 205 mg
Prenatal
205 mg
Lactating
250 mg
MANGANESE
 based on the median intake of Americans derived from USFDA Total Diet Study
Stage
RNI
Preconception
13-18: 1.6 mg
19-49: 1.8 mg
Prenatal
2.0 mg
Lactating
2.6 mg
ZINC
 based on daily absorbed zinc requirements of 0.072 and
0.059 mg/kg for adult males and females, and adjusted for
bioavailability of 30%
Stage
RNI
Preconception
13-15: 7.9 mg
16-18: 7 mg
19-49: 4.5 mg
Prenatal
1st trimester: 5.1 mg
2nd trimester: 6.6 mg
3rd trimester: 9.6 mg
Lactating
11.5 mg
FLUORIDE
 based on “adequate intakes” that have been found to
prevent dental caries
 2.5 mg
PHOSPHORUS
SUMMARY: Clinical Practice Guidelines on Maternal Nutrition and Supplementation
By Regrine B. Lagarteja, RMT, MLS(ASCPi)CM
5/5