Nutrition During
Pregnancy and
Lactation
Nutrition for Infants and
Toddlers
Health Threats to Children
The most critical threats to the lives of children
under age five globally are:
 Pneumonia
(18%)
 Diarrheal diseases (15%)
 Pre-term birth complications (12%)
 Birth asphyxia (9%)
 Under-nutrition is an underlying cause of ~1/3 U5M
Sub-Saharan Africa > 50% deaths due to malaria,
diarrhea, pneumonia
Mother’s Day Report Card
Each year Save the Children publishes the
Mother’s Day Report Card which includes
data on the health of women and children
worldwide
 Highly recommended reading for anyone
who works with children
 2013 Report released this morning!

Best country for women & children
Finland



Life expectancy girl born today = 83
Under 5 mortality rate: 2.9 deaths/1000 live
births
Lifetime risk of dying as a result of pregnancy or
childbirth: 1 in 12,200
 many
countries are lower
 E.g. 1/25,500 in Greece

Save the Children, May 2013 Report
United States Data (2010 data)
Life expectancy girl born today = 82
 Under 5 mortality rate: 7.5 deaths/1000
live births
 Lifetime risk of dying as a result of
pregnancy or childbirth, 1 in 2,400 women

United States Data
Childhood Obesity begins young in the US
 9.5 % of children under the age of 2 are
overweight, 11.5 % are obese
 23.3 % of children ages 2 – 5 are
overweight or obese
Country
Finland
Lifetime risk of
12.200
female mortality due
to pregnancy or child
birth
U.S.
2,400
Life expectancy
83
82
Under 5 mortality
rate
2.9
7.5
Worst country for women & children –
DR Congo
Lifetime risk of dying as a result of
pregnancy or childbirth: 1 in 30
 1 in 6 babies born will die before age 5
 90% of women will have a child die befor
age 5
 Life expectancy girl born today = 45

Where is DR Congo?
Afghanistan
10 worst countries for
women and children
Somalia
Life expectancy girl born today = 52
 Under 5 mortality rate: 180 deaths/1000
live births
 1 in 16 women die during pregnancy or
childbirth
 36% of children under 5 are underweight
for their age
 70% lack access to clean water

One island, two health stories
Dominican
Republic
Haiti
Lifetime risk of maternal
mortality, 1 in:
240
83
Life expectancy (2009)
76
63
24.7
70
4
22
86%
40%
Country
Under 5 mortality rate, per
1000 births
% undernourished (2009)
Access to clean water
(2009)
In Haiti, 73% of children 6-24 months and 60% of pregnant
women are anemic.
Zambia – Quick Facts
1 in 37 women die from pregnancy related
disorders
 1 in 82.9 children die before the age of 5

“Life-Saving Six” for Keeping
Babies Alive, Nutrition Matters
1.
2.
3.
4.
5.
Iron (mother and child) and folate (mom)
Breastfeeding – 1st 6 months exclusively
Complementary feeding – 6 mos +
Vitamin A ( 2 doses /year, child)
Zinc (child)

6.
Decreases diarrheal deaths
Hygiene, water, sanitation
“Mortality” Definitions

Neonatal mortality rate


death of infants in the 1st 28 days of life
Infant mortality rate
 death
 Both
of infants in the 1st year of life
are reported in deaths/1000 live births
Neonatal (<28 days) Mortality Data
Population
Neonatal mortality rate,
Year
deaths/1000 live births
U.S. overall
4.19
2009
Maine
4.2
2006
Black infants
8.2
2009
White infants
3.43
2009
Infant (<1 yr) Mortality Data
Population
Infant mortality rate,
Year
deaths/1000 live births
U.S. overall
Black
6.8
5.7
6.7
6.39
6.05
12.7
2001
2004
2008
2009
2011
2009
Infant (<1 yr) Mortality Data
Population
Infant mortality rate,
Year
deaths/1000 live births
U.S. overall
Black infants
White
7.0
6.42
14.3
12.71
5.8
5.27
2002
2009
2002
2009
2002
2009
More Recent U.S. Data
Infant mortality rates, by state: U.S. - 2010
Percent change in infant mortality rates, by
race and ethnicity: United States, 2005–2011
Leading causes of infant death in 2011
U.S.
Congenital malformations
2. Pre-term/low birthweight
3. Sudden infant death syndrome (SIDS)
4. Maternal complications
5. Unintentional injuries
Together, these 5 causes accounted for
56% of all infant deaths in the United States
in 2011
1.
Infant Mortality
Lowest rates for mothers in their late 20’searly 30’s
 Adolescent mothers have the highest
infant mortality rate in US
 Infant mortality is


83% higher in unmarried mothers
 Higher in smokers
 Higher in pre-term infants
Maternal Mortality

All US women: ~12.7 deaths/100,000 live
births
 White
women: 10.5 (risen)
 Black women: 28.4
 Hispanic: 8.9
 2007
data
Infant Mortality

Many of the deaths can be attributed to:

Poor maternal nutrition
 Low birth weight/pre-term babies
 Lack of prenatal care



Lack of health insurance
SIDS
Nutrition before and during pregnancy is
critical to the health of baby
Nutrition During Pregnancy
Time of significant growth for mother and
fetus
 Goal is to start pregnancy with full
nutritional stores

Nutrition During Pregnancy

Of greatest importance pre-pregnancy are
having adequate levels of:
 Folate
 Iron
Caloric Needs and Weight Gain
Trimester
1st
2nd and 3rd
Recommended Caloric Needs
Weight Gain
2-5 pounds total
Few extra
calories, make
healthy choices
~1 pound/week
+ 350 - 450
kcal/day
Weight Gain Recommendations
Starting Weight
Weight Gain, lbs
Underweight
28-40
5 lbs 1st trimester
25 - ~35
Healthy Weight
Overweight
Obese
15-25
Minimum 15
Teen
Upper end of above ranges
Twins
35-45
Weight Gain

Insufficient maternal weight gain increases
risk of low birth weight baby (LBW)
 LBW
= birth weight less than 5 ½ pounds
 LBW are 40x more likely to die in the first year
of life than healthy weight baby
 1 in 12 babies in US are of LBW

Black 2x as likely to have a LBW baby as
white/Hispanic
“Morning” Sickness (MS)

~75% of women experience MS during the
first months of pregnancy
 May
be triggered by foods, smells, thought of
food

May be related to enhanced sense of smell
 Iron
supplements may trigger nausea in some
 May occur any time of day

Suggestions?......
Weight Gain

Sharp weight gains may signal:
 Water
retention
 Pregnancy induced hypertension ~7%
pregnancies
May be associated with low vitamin D levels
 Preclampsia – mild hypertension
 Eclampsia – more serious


Previously called toxemia
Eclampsia

At greatest risk:
 Over
35 and under 17
 Carrying twins or more!
 Family/personal history of
 Diabetes
 First pregnancy
 African American descent
Eclampsia

Symptoms/consequences
 Edema
 Hypertension
 Protein
in urine
 Kidney failure
 Liver damage
 Convulsions and death of mom and/or baby
Eclampsia

Treatment
 Bed
rest
 Magnesium sulfate (diuretic)
 Deliver baby
Nutritional Needs - Pregnancy

Protein
 Needs
increase by 25 g/day
 1.1 g protein/kg body weight
 Page
521 has a good summary of all
nutritional needs
Minerals

Minerals
 Calcium,
no increase
The number of calcium binding proteins increases
in the SI. This results in increases absorption.
 Critical that diet includes 3-4 servings of calcium
rich foods each day.

 Iron
needs nearly double
 Zinc needs go by ~30%

Zinc is found in proteins
Vitamins

B Vitamins
 RDA
for all goes up by ~30%
 Folate needs go up by 50%
 Eat more vegetables and select whole grain
products.

Vitamin C
 Need
a little extra
Vitamins

NO EXTRA needed for:
 Vitamin
D
 Vitamin A in the form of active vitamin A

DO NOT TAKE VITAMIN A SUPPLEMENTS
DURING PREGNANCY


Increases the risk of serious birth defects
Extra beta-carotene (plant form of vitamin A) is fine
and probably good for you
Practices to AVOID

Smoking
 Increases
risk of LBW, miscarriages, infant
death

Caffeine (?)
 Heavy
coffee drinking may lead to and
increased risk of LBW
 High levels of caffeine may increase the risk
of miscarriage
Practices to AVOID

Fasting or low/no carbohydrate diets
 Ketones

may slow fetal brain development
Aspartame (?)
 Probably
OK as long as mom does not have
PKU
 Recommend no more than 1 Liter of diet soda
per day
Practices to AVOID

Eating unpasteurized dairy products, raw
cabbage, raw meats
 Brie,
feta, blue cheeses, goat cheeses
 Increased risk of Listeria
Flu-like symptoms
 May cause miscarriage and death of mom

Practices to AVOID
Vitamin megadoses
 Alcohol

 Increases
risk of fetal alcohol syndrome (FAS)
FAS

Brains of 6 week old infants
No FAS
FAS
FAS

Physical Characteristics
 Broad,
short, flat nose
 No dimple above lip
 Narrow eyes
 Flat face
Practices to AVOID

Illegal Drugs
 Marijuana
and cocaine can increase risk of:
LBW
 Nervous system disorders
 Irregular heart rate
 Drug withdrawal symptoms in infant
 Neonatal death

Practices to AVOID

Over the Counter Medications (most)
 Can
cause complications during pregnancy
and increase risk of birth defects
 No aspirin or ibuprofen in the last trimester

Both interfere with blood clotting
Nutrition During Lactation

Energy needs
 ~+500

kcal/day for the first 6 months
Maternal weight loss during lactation
 Recommend
a loss of a maximum of 1-2
pounds/month
Nutrition During Lactation

Vitamins needs go up for:
 Vitamin
A, E and C
 B vitamins in general
Nutrition During Lactation

Minerals
 Iron

Return to pre-pregnancy levels
 Calcium


Increased absorption takes care of needs
Adequate fluid intake is critical
Breast Feeding Benefits



First 2-3 days breast milk contains colostrum
 Contains antibodies that protect baby from
infection
Reduces incidence of allergies and eczema.
Lowers risk of obesity later in life
Breast Feeding Benefits

Reduces the risk of urinary tract infections,
inflammatory bowel disease, gastroenteritis, ear
infections, and respiratory infections.
 Formula-fed
infants are three times more likely to
suffer from ear infections than breastfed babies, and
up to five times more likely to suffer from pneumonia
and lower respiratory-tract infections.
Breast Feeding Benefits

Causes less stomach upset, diarrhea, and
constipation than formula.

Lessens the risk of SIDS.
 Although the connection is unclear, breastfed
infants account for only half as many SIDS
cases as formula-fed infants do.
Feeding Infants

Breast milk is best source of nutrition for
an infant
 Assumes
mom is well fed
 Can be the only source of nutrients for the 1st
4-6 months
Infants

Breast fed babies are generally given
vitamin D supplements
 Especially
important if limited sun exposure or
if mom is vitamin D deficient
 Issues occur most often with dark-skinned
mom/baby
Breastfeeding
Pros?
 Cons?

Feeding Infants

NEVER SCOLD a new mom who decides
not to breastfeed!
Feeding Infants

A baby grows faster in the first year of life
than ever again
 Birth
weight doubles by 4-6 months
 Birth weight triples by age 1
Formula

Formula guidelines:
 Should
be iron enriched
 Never water down
 Do not add cereal to the formula
Infants cannot digest starch
 Cereal acts as a fiber and not a source of nutrition

Adding Solids to the Diet

At ~4-6 months the baby’s iron store will
be depleted
 At
this time (usually) the baby:
can sit up on his/her own
 has doubled his/her birth weight

 Any
earlier introduction of solid foods can
increase the risk of allergies and obesity later
in life
Adding Solids to the Diet

Start with iron enriched rice cereal first
 Fewer

allergies to rice than other grains
Add foods one at a time
 Vegetables
and fruits first
Adding Solids to the Diet
8-10 months add: egg (?) and potato, meat
(last)
Eggs are controversial! I checked a number of
resources. Many list adding cooked eggs to the
diet at this point.
 Most recommend adding eggs to the diet at 12
months


Concern is that baby will develop an allergy to the
proteins in the egg white
Adding Solids to the Diet
Avoid sweetened baby foods
 NO HONEY

 May
carry botulism
8-9 Months of Age

Baby can be fed “family food”
 Lightly
seasoned
 Cooked
 Finely chopped

Allow some self-feeding
 Messy,
but good for baby’s development
Messy Babies!
Feeding a 1 year Old
OK to add whole cow’s milk to diet
 Growth rate slows and caloric needs don’t
go up much

 So
don’t stress if your soon to be toddler isn’t
eating as much as you think he/she “should”
Feeding a 1 year Old

Need increased muscle and bone
strength to support walking
 Protein
needs go up
 Calcium and phosphorus needs go up
2-3 glasses of milk are sufficient
 More may lead to “milk anemia”

Feeding a 1+ year Old

Remember – children have small
stomachs, therefore it’s important that all
that goes in be of high quality
 All
foods should be nutrient dense
 Tips for feeding a strong-willed toddler/child

http://www.eatright.org/Public/content.aspx
?id=8057
Foods to avoid – due to high risk of choking








Popcorn
Peanuts
Raisins, whole grapes
Uncut, stringy meats
Hot dog pieces
Hard, raw fruits or vegetables such as apples, green
beans, carrots
Chunks of meat, cheese or any other hard-to-chew foods
Sticky foods, such as peanut butter, which can get stuck
in the back of the mouth
Ask the Dietician: Feeding Infants and Toddlers
This site has terrific information. I highly recommend it.
Tips for Feeding Toddlers
This site has links to nutrition during pregnancy, lactation