NUTRITION IN PREGNANCY AND LACTATION Lingegowda Krishna1 Nageshu Shailaja 2 Namrata Kulkarni3 1- Professor and Head, Department of Obstetrics and Gynaecology, PES Institute of Medical Sciences and Research, Kuppam. 2-Associate Professor, Department of Obstetrics and Gynaecology, PES Institute of Medical Sciences and Research, Kuppam. 3- Assistant Professor, Department of Obstetrics and Gynaecology, PES Institute of Medical Sciences and Research, Kuppam. *Corresponding Author: Address: Dr.L Krishna, Professor and Head of the Department, Obsterics and Gynaecology, Medical Superintendent PESIMS&R, Kuppam-517425, Chittoor(Dt), Andhra Pradesh, India. Phone:+9391833730, E- mail: drlkrishnas@gmail.com Introduction A critical element of the health care system is the health of women in the childbearing age and children under five. A child’s nutritional well-being begins with the mother’s nutritional status during adolescence and pregnancy. Pregnancy is a critical period during which good maternal nutrition is a key factor influencing the health of both mother and child. The vast majority of them die from complications, which could be reduced through better nutrition. Consequences of Maternal Nutritional Deficiency Inadequate intake of the micronutrients may have a profound impact on both the mother and fetus during pregnancy. Vitamin A deficiency is linked to maternal death. Inadequate folate during preconceptional period and the first trimester of pregnancy can cause birth defects like neural tube defects, such as spina bifida and anencephaly. Folate deficiency can also increase the risk of low birth weight (LBW) and maternal mortality. Iodine deficiency increases the risk of still birth and miscarriage and can cause severe learning disabilities in children. Zinc deficiency can result in prolonged labour, which increases the odds of the mother dying and can impair fetal development. LBW babies tend to have slower growth rate and stunting, unless there is an early intervention. Energy requirements during pregnancy and lactation Pregnant and lactating women require additional dietary intake, as they have to meet their own nutritional requirements and also supply nutrients to the growing fetus and the infants. The Indian Council of Medical Research has recommended an additional intake of 300kcals /day during the second and third trimester of pregnancy. According to dietary guidelines women should consume a variety of foods to meet the additional nutrient needs and achieve the recommended weight gain. Key nutrient & Important functions Important source Comments Calories Provide energy for Carbohydrates ,fats Calorie N-2200 tissue building & & proteins P-2200(1st increased metabolic according to the trimester) requirements stage of pregnancy, RDA requirements vary P-2500(2nd & 3rd size of pregnant trimester) woman, activity L-2700 level, pre pregnant weight & how well nourished they are Water or liquids Carries nutrients to Water, juices & Liquid is often N-8 glasses cells milk neglected, but it is P-10 glasses Carries waste an important L-12-14 glasses products away. nutrient Provides fluid for increased blood, tissue & amniotic fluid volume. Helps regulate body temperature. Aids digestion. Protein Builds & repairs Meat, fish, poultry Fetal increase by N-50g tissue. eggs, milk, cheese, 1/3rd in late P-65g Helps build blood, dried beans & peas, pregnancy as the L-75g amniotic fluid & peanut butter, placenta. nuts, whole grains Helps form antibodies. & cereals Supplies energy baby grows Minerals Key nutrient & RDA Calcium N-400mg P-1000mg L-1000mg Phosphorous N-800mg P-1200mg L-1200mg Important functions Important source Helps build bones & teeth. Important in blood clotting. Helps regulate use of other minerals in the body. Helps build bones & teeth Milk, cheese, whole grains, vegetables, egg yolk, whole canned fish, ice cream Iron N-30mg P-38mg L-30mg Combines with proteins to make hemoglobin. Provides iron for fetal storage. Zinc N-12 mg P-15mg L-19mg Iodine N-150mcg P-175mcg L-200 mcg Magnesium N-280mg P-320mg L-355g Component of insulin. Important in growth of skeleton. Helps control the rate of body’s energy use. Important in thyroxine production. Helps energy, protein & cell metabolism. Enzyme activator. Helps tissue growth & muscle action. Comments Fetal requirements increase in late pregnancy. Caffeine can decrease the amount of calcium available to fetus. Milk, cheese, lean Calcium & meats phosphorous exist in a constant ratio in the blood,an excess limits the use of calcium Liver, red meats Fetal requirements Egg yolk, whole increase 10 fold in grains, leafy the last 6 weeks of vegetables, nuts, pregnancy. legumes, dried fruits, Supplement 30prunes & apple juice 60mg of iron daily is recommended by National Research Council. Meat, liver, eggs, sea Deficiency can cause food (especially malformations of oysters & nervous fetal skeleton & system) nervous system Sea foods, iodised Deficiency may salt cause goiter in infant Nuts ,cocoa, green vegetables, whole grains & direct beans & peas Most is stored in bones. Deficiency may cause dysfunction. Fat soluble vitamins Key nutrient & RDA Important functions Vitamin A Helps bone & tissue N-600mcg RE growth & P-600mcg RE development. L-950mcg RE Essential in development of enamel-forming cells in gum tissue. Helps maintain health of skin & mucous membrane. Vitamin D Needed for N-5mcg absorption of P-10mcg calcium & L-10mcg phosphorous, & mineralization of bones & teeth Vitamin E Needed for tissue N-8mg α TE growth, cell wall P-10mg α TE integrity & red blood L-12mg α TE cell integrity. Vitamin K Essential for N-65mcg synthesis of blood P-65mcg clotting factors. L-65mcg Important source Comments Butter, fortified margarine, green & yellow vegetables, liver In excess amounts ,it is toxic to fetus. It loses its potency when exposed to light. Fortified milk, Toxic to fetus in fortified margarine, excess amounts. fish, liver, oil , sunlight on your skin Vegetable oils, cereals, meat, eggs, milk, nuts & seeds - Enhances absorption of vitamin A. Produced in the body by the intestinal flora. Water soluble vitamins Key nutrient & RDA Folic acid N-180mcg P-1400mcg L-280mcg Niacin N-15mg P-17mg L-20mg Riboflavin N-1.3mg P-1.6mg L-1.8mg Thiamin (B1) N-1.1mg P-1.5mg L-1.6mg Pyridoxine(B6) N-1.6mg P-2.2mg L-2.1mg Cobalamin (B12) N-2.0mcg P-2.2mcg L-2.6mcg Vitamin C N-40mg P-40mg L-45mg Important functions Essential in hemoglobin synthesis. Involved in DNA & RNA synthesis. Needed for synthesis of amino acids. Needed for energy & protein metabolism. Essential for energy & protein metabolism. Important for energy metabolism. Important in aminoacid metabolism & protein synthesis required for fetal growth. Essential in protein metabolism. Important in formation of red blood cells. Important source Liver, green leafy vegetables & yeast Pork, organ meats, peanuts, beans, peas & enriched grains Milk, lean meat, enriched grains, green leafy vegetables Pork, beef, liver, whole grains & legumes Unprocessed cereals, grains, wheat germ, nuts, seeds, legume & corn Milk, eggs, meat, liver, cheese Helps tissue formation Citrus fruits, & integrity. berries, melons, It is “cement” tomatoes, chilly, substance in pepper, green connective & vascular vegetables & tissue. potatoes Increases iron absorption. Note: N – Nonpregnant P – Pregnant L - Lactation Comments Deficiency leads to anemia, neural tube defects. Can be destroyed in cooking & storage. Supplement of 400 mcg/day is recommended by National Research Council. Oral contraceptives may reduce blood level of folic acid. Stable; only small amounts are lost in food preparation. Oral contraceptives may reduce serum concentration of riboflavin. Essential for conversion of carbohydrates into energy in the muscular & nervous systems. Excessive amounts may reduce milk supply in lactating women. May help reduce nausea in early pregnancy. Deficiency leads to anemia & CNS damage. It is manufactured by microorganisms in the intestinal tract. Oral contraceptives may reduce serum concentration. Large supplementary doses in pregnancy may create a larger than normal need in infant. Benefits of large doses in preventing cold have not been confirmed Protein requirement during pregnancy and lactation: During pregnancy, the expansion of blood volume and the growth of maternal tissues requires substantial amount of protein. Growth of the fetus and placenta also places protein demand on the pregnant woman. Thus an additional protein intake is essential for the maintenance of a successful pregnancy. Factorial Estimate of Protein Components of Weight Gain in a Normal Full-Term Pregnancy Component Weight (in kg) Protein (in kg) Fetus 3.4 0.44 Placenta 0.7 0.1 Amniotic fluid 0.9 0.003 Uterus 0.9 0.166 Blood 1.5 0.081 Extra cellular fluid 1.5 0.135 Total 8.9 0.925 The deposition of protein is not linear throughout pregnancy. Early during pregnancy the protein requirement for fetal development is minimal, whereas the requirement for maternal volume expansion and tissue growth may be substantial. Late in pregnancy the fetus may account for a major increase in protein needs. Safe Level of Additional Protein During Pregnancy Trimester Additional Protein Required(g/day) 1 1.2 2 6.1 3 10.7 An extra 25 gram/day of protein with a chemical score of 70 is recommended during lactation by FAO/WHO. A safe level of extra protein intake during lactation is 16g/day during the first 6 months of lactation, 12g/day during the second 6 months and 11g/day thereafter. The protein content of pulses is twice that of cereals (22-25%) and almost equal to that of meat and poultry but the quality of protein is inferior to animal protein. Recommended Essential Fatty Acid Intake Adequate intakes (AI) have been set for Linoleic acid(LA) and Alpha Linolenic acid(ALA) The AI for LA is 17 and 12g/d for men and women aged 19 – 50yrs, respectively. The AI for ALA is 1.6 and 1.1g/d for men and women aged 19 to > 70yrs, respectively. Recommendations Concerning Essential Fatty Acid Intakes: The ratio of linoleic to alpha-linolenic acid in the diet should be between 5:1 and 10:1 Individuals with a ratio in excess of 10:1 should be encouraged to consume more n-3 rich foods such as green vegetables, legumes, fish and other seafood. Particular attention must be paid to promoting adequate maternal intakes of essential fatty acids throughout pregnancy and lactation to meet the requirements of fetal and infant development Emerging role of Docosahexaenoic acid (DHA): DHA is an omega 3 fatty acid, the predominant fatty acid in the brain and retina. Due to low conversion rate of alpha linolenic acid (ALA) to DHA, it is important to directly consume DHA, especially during pregnancy and lactation. The brain has its growth spurt in the third trimester of pregnancy and during early childhood. Therefore, an appropriate pre-and post-natal supply of these LCPs or their precursors is thought essential for normal fetal and neonatal growth, neurologic development and function, learning and behavior. DHA also has an important role in fetal retinal function and in prevention of maternal postpartum depression. Dietary sources of DHA: fish and fish oil, present in fatty fish and algae Recommendations on DHA intake: Organization DHA Recommendations International society for the study Adequate intake for adults to be at least 220mg per day of Fats and Lipid (ISSFAL) and 300mg per day for pregnant and lactating women Committee On Medical Aspects Of 1.5g EPA plus DHA per week(i.e 214mg mg per day) Food Policy (COMA) British Nutrition Foundation(BNF) 8g EPA plus DHA per week for women(i.e 1145 mg per day) 10g EPA plus DHA per week for men(i.e 1430 mg per day) Expert workshop of the European “ People who do not eat fish should consider consuming Academy of Nutrition Sciences held marine n-3 PUFA equivalent to the amount obtained in 1997(EANS) from fatty fish, namely 200mg EPA plus DHA daily”. EPA- Eicosapentaenoic acid Importance of dietary fibre: Dietary fibre consists of the remnants of edible plant cells, polysaccharides, lignin and associated substances resistant to digestion. Modest increases in the intake of fruits, vegetables, legumes and whole and high-fiber grain products, would bring the majority of the Indian pregnant women close to the recommended range of dietary fiber intake of 20 – 35 g/day. An intake of food high in fiber is likely to be less calorically dense and is lower in fat and added sugar. Dietary fiber intake should be considered while counseling patients about the management of gestational diabetes, constipation and other problems like hemorrhoids, bowel distress and elevated blood pressure. Food guide pyramid during pregnancy Everyday use nine servings of cereals, four servings of vegetables, three servings of fruit, milk and meat. Use fats sparingly. An increased amount of calcium can be obtained from low fat milk, low fat cheese, yogurt, dark green vegetables or fruit juices with calcium added. Sample menu for a pregnant lady BREAKFAST MID MORNING LUNCH MID AFTERNOON TEATIME MID EVENING DINNER BED TIME 1cup milk (225ml), 2 dosas with green chutney (without coconut) 1cup milk (150ml) + 1 sweet lime 1 katori rice, 3 chapathis, 2 katori tur dal, palak fish(3 slices), French beens bhaji, toasted salad 1 glass buttermilk (made from skim milk) 1cup tea with half cup skim milk (75ml), 1 katori poha with peas 1cup skim milk + 1 apple Mixed vegetable soup, khichidi 2 katoris, kadhi 1 ½ katori,potato cauliflower bhaji 1 katori,pumpkin raitha 1 cup milk(225ml) & papaya (2 slices) Weight gain during pregnancy: The pre-pregnancy weight, socioeconomic status, genetics, health condition, parity, and nutritional factors affect maternal weight during pregnancy. The components of weight gain can be divided into 2 parts – the products of conception and maternal tissue accretion. The products of conception comprise of the fetus, placenta and amniotic fluid. Cross-sectional data indicate that fetal growth follows a sigmoid curve with growth slowing in the final week of gestation. The rate of placental growth also declines towards the end of pregnancy. The expansion of maternal tissue accounts for approximately two-thirds of the total gain. In addition to increases in uterine and mammary tissue mass, there is also an expansion of maternal blood volume, extracellular fluid, fat stores and possibly other tissues. Components of weight gain Component Baby Placenta Amniotic fluid Mother Breasts Uterus Body fluids Blood Maternal stores of fat, protein and other nutrients Total In Kg 3.4 0.7 0.9 0.9 0.9 1.5 1.5 3.1 12.9 Weight – for – height and Recommended Weight gain Weight – for – height category Recommended total gain, kg(lb) Normal (BMI 19.1 – 24.9kg/m2) 11.5 – 16(25 – 35) High (BMI > 25 – 29.9kg/m2) 7 – 11.5 (15 – 25 ) Obese (BMI > 30kg/m2) No more than 7 Twin Gestation(any BMI) 23 Medical conditions where consultation with registered dietician is advisable: Multiple gestation Frequent gestation (<3months interpregnancy interval) Tobacco, alcohol of chronic medicinal or illicit drug use Severe nausea and vomiting Eating disorders Inadequate weight gain during pregnancy Adolescents Restricted eating Food allergies/intolerances GDM/prior history of GDM Prior history of LBW babies/other obstetrical complications Social factors that may limit appropriate intake(Eg.religion,poverty) Nutrition during labour Withholding food and drink inappropriately from women in labour may result in dehydration, ketosis, fatigue and can increase levels of stress which in turn can affect the Neuro-hormonal balance that enables labour to progress unhindered. The prophylactic use of antacids or reduction of the volume of stomach contents by restricted oral Intake has not been shown to be successful in preventing Mendelson’s syndrome. For those women for whom a general anaesthetic is not anticipated a light, low residue, low fat diet may be recommended in latent phase. Allow oral fluids to maintain hydration in the active phase For those women for whom a general anaesthetic is anticipated allow only clear liquids. The administration of opioids delays stomach emptying. So, allow only liquid diet. Suggested drinks for women in labour: Low fat yoghurt drinks Fresh fruit juices(avoid apple, pineapple, mango and lemon as they tend to be more acidic) Coffee/Tea with skimmed milk Soups (cream of tomato or vegetable etc) Squash drinks – not too concentrated Water and ice Naturally carbonated mineral water Suggested foods for women in labour: Idli Toast with low fat spread, jam/honey Cereals with skimmed milk/ganji Plain sweet biscuits Smooth soup Low fat, smooth yoghurt Guidelines for diet in gestational diabetes mellitus Energy (Calories): Carbohydrates: 55-60% of total calories. Encourage complex carbohydrates i,e grains, cereals, pulses, beans, vegetables and salads. Avoid simple and refined carbohydrates like sugar , honey, maida and jaggery. Foods with low glycemic index is advised. Breakfast is 10-15%, Lunch and dinner 25-30% and 4 snacks of 5-10% of total calories required per day. Proteins: 1gm/kg body weight + 14 grams. Avoid red meat and egg yolk. Fats: 22-15% of total calories. Saturated fat should be 6-7% of total calories. Fruits: Consume one fresh fruit per day. Avoid juices. Ideal fruits are citrus fruits, guava, apple, papaya and watermelon Dietary fibres: 30-40 gram/day. Indian diet is rich in fibre. Avoid the loss of fibre by refining and processing the food. Condiments and spices: Include in diet plan. Provide antioxidants, trace elements, minerals and omega 3 fatty acids. Artificial sweeteners: Use of aspartame and artificial sweeteners is prohibited in pregnancy and lactation. Role of nutrition in IUGR: Nutrition is the major intrauterine environmental factor that alters expression of the fetal genome and may have life long consequences (Barker hypothesis).Protein energy supplementation decreases the risk of IUGR by 30% in those with inadequate nutritional intake. Mothers with decreased serum zinc concentration benefit from zinc supplementation. Zinc is recognized as an important factor for normal fetal growth and development. Nutritive needs in Pregnancy induced hypertension: Nutritional interventions such as calcium supplementation, antioxidants like Vitamin C & E and fish oil have shown promise in the prevention and reduction of PIH , especially in high risk groups, teenage pregnancies and in women with diets low in calcium. Maternal nutrition – tips to give your patient Pregnancy is very special moment in someone’s life, it includes the joys and challenges of motherhood and requires that your patient is given adequate information with the best possible care, essential for a healthy pregnancy. It is undoubtedly a very exciting time, but is also a period of great psychological stress for a woman as she nurtures a growing fetus in her body. Fetal development is accompanied by many physiological, biochemical and hormonal changes which occur in the maternal body and influence the need for nutrients and the efficiency with which the body uses them. Nutrition is not only important for the unborn baby but is also essential for the mother’s current and future state of health. The diet during pregnancy and lactation is designed to promote optimal nutrition for the woman and fetus in pregnancy and for the mother and infant during lactation. 1. A pregnant woman is always advised to eat what she wants, in amounts she desires and food should be salted to her taste. Mothers who are in negative energy in terms of both food storage and heavy workload deliver low birth weight babies. Pregnant women from low socio economic group should make efforts to ensure a healthy diet. 2. Proteins are needed for repair of the mother’s tissue as well as for added demands of growth, increased blood volume and repair of placenta, uterus and breast. They can be supplied from either meat, milk, eggs, pulses , legumes, cheese, poultry or fish. Generally if a pregnant woman consumes enough calories in her food, her protein needs are taken care of. 3. Her weight should be checked serially with the intention of gaining about 10 – 12 kg during the whole period of 40 weeks. 4. Iron is the only nutrient for which requirements cannot be met by diet alone. Iron deficiency anemia is a significant cause of increased maternal mortality and has an adverse effect on the health and development of the newborn. Tablets of simple iron salts that provide 30 – 60mg of iron/day should be taken. Iron supplementation is not necessary in the first trimester and it also aggravates nausea and vomiting. Recheck the hemoglobin concentration at 28 – 32wks to detect any significant decrease. 5. The increased requirements of all vitamins can be generally supplied by the usual diet, except for folic acid, which is required more in pregnancies, that are complicated by protracted vomiting, hemolytic anemia, multiple fetuses and those on antiepileptic drugs. Folic acid tab of 5mg/day should be taken not only during pregnancy but also three months before you are planning to start a family, especially in cases with a genetic or family history of neural tube defects. 6. Strict vegetarians may have low vitamin B12, so supplementation of vitamin B12 may be required in such cases. Studies show that multi vitamin supplementation for women who do not consume an adequate diet are not really helpful. 7. Calcium is deposited in the fetus during later pregnancy. This amount represents about 2.5% of maternal calcium, most of which is present in the bone and can be readily used for fetal growth. So it is only in developing countries where there is deficiency of vitamin D and calcium that supplementation is required. One cup of cow’s milk provides approximately 1gm of calcium. 8. Iodised salt should always be used. So as you can see, pregnancy does not require too much of extra nutrition. Rather a good balanced diet with all the specific nutrients is required for the benefit of the mother and the growing fetus. Nutritional guidelines for a pregnant mother o Drink plenty of fluids in the form of water and juices, which help increase the volume of breast milk. o The maximum amount of energy should be derived from whole grain cereals rather than from fats and sugars. o The source of carbohydrates should be mainly from the consumption of whole grain cereals rather than from sugars and refined products. o Non-vegetarians can get protein from meat, poultry and eggs. Vegetarians can derive quality proteins from a combination of cereals, legumes, pulses and nuts. Intake of sprouted pulses is desirable. o Mineral and vitamin requirements should be met by consuming a variety of fruits(including seasonal) and vegetables, especially those rich in vitamin C such as orange and green leafy vegetables. o Vegetarians should drink milk can serve as a source of calcium and vitamin B12 and D. o A combination of PUFA (Poly unsaturated fatty acids) and MUFA (Mono unsaturated fatty acids) oils as a source of energy and is preferable to saturated fats. o Eat foods rich in vitamin C, such as citrus fruits, amla, guava, sprouts etc with meals in order to improve the absorption of iron from the food. o Milk and curd are the best sources of biologically available calcium. o Foods that are not nutritious, like those that are fried or barbecued, should be avoided, including those that can cause allergic reactions in the pregnant woman. o A pregnant mother may also require calcium, iron and vitamin B-12 supplements. o Choose at least five daily servings of fruits and vegetables. Also try whole grain foods such as ragi, dal, brown bread, whole grain pulses and lentils. o Whenever possible eat fruits with the peel and remember that eating a fruit is more beneficial than drinking fruit juice. o Drink at least 12 glasses of fluid per day. o Only take chemical laxatives prescribed by an obstetrician. If weight gain is too rapid during any part of the pregnancy, the following guidelines should be used to manage weight: Avoid high-calorie, low-nutrient foods such as sweets, cakes, pastries, desserts and fried snacks like chips, vadas, bondas etc. Use low-fat dairy products-skimmed milk and yogurt/curd made with skimmed milk. Use only lean meats, poultry and fish. Bake, broil, grill, or stir-fry instead of frying foods. Increase physical activity. Do not crash diet!!! References: 1) Williams obstetrics 23rd edition 2) D.K.James - High risk pregnancy management options 4rd edition 3) Steven G Gabbe -Obstetrics 5th edition 4) Maternal nutrition: A Quintessential Guide- Kamini Rao, Vindhya Subbiah