Chapter 11

1. Chapter 11 Maternal and Infant Nutrition in Health and Disease

2. Nutrition for a Healthy Pregnancy Begins Before Conception Achieve normal BG levels before conception (with diabetes) Women with PKU need to adhere to low phenylalanine diet Goal to meet the DRI for nutrients without excess or deficiency Avoid excess vitamin A (preformed) to reduce risk of birth defects (as found in certain acne creams) Vegans require vitamins B12, D, and calcium B12 deficiency associated with impaired neurologic development of the fetus and/or infant Deficiency issues on fetal growth and development Pyridoxine (vitamin B6) deficiency may lead to impaired learning and memory retention (women who used anovulatory steroids prepregnancy are most at risk of B6 deficiency); Down syndrome associated with pyridoxine deficiency(Baggot et al., 2008)

3. Folic Acid Needed before or at time of conception and throughout pregnancy for following benefits: Reduced risk of neural tube defects (spina bifida), alongwith possible role of choline (B vitamin) Decreased homocysteine level for reduced risk of Down syndrome Decreased risk of fetal loss Decreased risk of cardiac malformation Decreased risk of small birth size Decreased risk of orofacial clefts (along with vitamins B1,B3, B6, E, and zinc) Prevention of one form of anemia

4. Other Nutrition Issues in Pregnancy Safe food handling to prevent food poisoning Steam or heat deli meat to lower risk ofpathogens Avoidance of excess mercury intake Decreased intake of tuna, shark, swordfish, marlin, and lake trout Small fish generally low in mercury (e.g., sardines)

5. Trimester Physiologic Changes FIRST TRIMESTER (EMBRYO; CRITICAL STAGE) Organs develop (4 to 12 weeks) Central nervous system develops (4 to 12 weeks) Skeletal structure hardens from cartilage to bone (4 weeks) SECOND TRIMESTER (FETUS) Growth and development continue (13 to 40 weeks) Teeth calcify (20 weeks) Fetus can survive outside womb (24 weeks) THIRD TRIMESTER TO BIRTH Growth and development continue Storage of iron and other nutrients (36 to 40 weeks; premature babies often deficient in iron) Development of necessary fat tissue (36 to 40 weeks)

6. Comparison of Weight Gain Goals Past Goals: 1960s < 20 lb More recently: 25-35 lb (BMI 20-26) 28-40 lb (BMI <20) 15-20 lb (BMI >26) Current Goals: From Institute of Medicine (IOM): Up to 30 lb normal weight Up to 25 lb overweight 15 lb for obesity For multiple births (triplets): 35 to 45 lb normal BMI Goal to prevent low birth weight and macrosomia

7. Risks of Low Birth Weight (LBW) Low birth weight: <5.5 lb of unknown etiology Small-for-gestational age (SGA) <10th percentile height or weight based on gestational age; may also be referred to as intrauterine growth retardation (IUGR) SGA infants are at later risk of hypercholesterolemia IUGR or LBW related to low-normal kidney function in adulthood Increased risk of occurrence with poor dietary intake and inadequate weight gain during pregnancy

8. First Trimester Issues Prepregnancy BMI determines weight goals: Overweight/obese women weight gain goal related only to the products of conception Underweight woman increased weight gain goal to increase blood volume and promote normal fetal growth Morning sickness and hyperemesis (>5% weight loss) May benefit from small, frequent meals, especially including CHO (crackers) before getting out of bed in the morning Choline (B vitamin) appears important for brain development and enhanced memory throughout life (high amounts found in liver, eggs, and peanut butter) Early screen for gestational diabetes for those at high risk Anemia screening and treated prn; Fe+ used to help prevent

9. Prolonged Hyperemesis Can cause dehydration; hospitalization needed for IV fluid replacement Associated with vitamin deficiencies: Beriberi and Wernicke’s encephalopathy Possible fatal electrolyte imbalance May cause hemorrhage due to rupture of esophageal varices Parenteral nutrition may be required via venous access Monitor for ketones May benefit with Small, frequent meals, including snacking on crackers Vitamin B6(Powers et al., 2007) Ginger(Ensiyeh and Sakineh, 2008)

10. Second Trimester Issues At approximately week 24, the placenta is large enough to release significant amounts of hormones that work counter to insulin Weeks 24 to 28—glucose tolerance test to rule out gestational diabetes Kilocalorie intake needs to increase; these needs are individual and based on weight goals Protein intake should be 60 to 100 g Source of omega-3 fats now recommended andavailable in some prenatal vitamins; vegans may be fine with plant forms: walnuts, canola oil, flax, seaweed

11. FYI Childhood asthma may be prevented by Supplementing mother’s diet with fish oil Increasing intake of zinc and vitamins D and E during pregnancy (Devereux, 2007; Litonjua et al., 2006)

12. Third Trimester Issues Ensure adequate calcium and vitamin D to allow for fetal bone and tooth development to occur Mother may experience heartburn; small frequent meals and sitting up after eating can help Constipation can be a problem because of diminishedperistalsis for increased intestinal absorption of nutrients; include fiber, water, and exercise as tolerated Restless leg syndrome: transient form found in up to 1 in 4 women during pregnancy; associated with low hemoglobin Pregnancy-induced HTN (PIH) or gestational HTN-preeclampsia: a leading cause of maternal and fetal morbidity and mortality

13. Signs and Symptoms of PIH Proteinuria High blood pressure; Rx advised if systolicBP >155 mm Hg Decreased risk with following: Good selenium and magnesium status Control of blood glucose Physical activity

14. Other Concerns Avoid alcohol to prevent fetal alcohol syndrome Avoid caffeine, a vasoconstrictor to ensure good oxygen uptake by fetus Anemia—may be caused by increased blood volume, but in the United States is still treated with iron supplements Pica—based on old cultural practices of eating clay in Africa (traditionally a source of trace minerals, but the risk of toxins outweighs possible benefits in modern times) For women on Rx for epilepsy: increased intake of folate, vitamin B6, biotin, vitamin D (Gaby, 2007), and adequate intake of vitamin K four weeks before delivery (Montouris, 2007)

15. Lactation Goals The American Academy of Pediatrics recommends exclusive breastfeeding/nursing for 6 months and continued nursing through the first year of life or longer, as desired Healthy People 2010’s goal to increase the number of women who breastfeed to 75% Baby-Friendly Hospital Initiative (BFHI), a worldwide program sponsored by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to encourage and recognize hospitals and birthing centers that provide high-quality care in support of lactation

16. Ten Steps to Promote Lactation Maintain a written breastfeeding policy that is routinely communicated to all health care staff. Train all health care staff in skills necessary to implement this policy. Inform all pregnant women about the benefits and management of breastfeeding. Help mothers initiate breastfeeding within one hour of birth. Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants.

17. Give infants no food or drink other than breast milk, unless medically indicated. Practice “rooming in”—allow mothers and infants to remain together 24 hours a day. Encourage unrestricted breastfeeding. Give no pacifiers or artificial nipples to breastfeeding infants Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic(BFUSA, 2004). Ten Steps to Promote Lactation (continued)

18. Cited Reasons for Early Lactation Cessation Lack of confidence Problems with infant latching or suckling Lack of individualized encouragement within 2 weeks after birth 50% receive help with breastfeeding after hospital discharge (Lewallen et al., 2006) Adolescent mothers report inadequate information on benefits of lactation and expressed desire for increased professional follow-up (Spear, 2006)

19. Benefits of Lactation Colostrum and milk provide antibodies and immunity factors to the breastfed infant Hormones promote uterine contractions that aid return toprepregnancy size and promote weight loss by mother Babies’ “chewing” action promotes strong jaw muscles and helps prevent baby-bottle mouth (tooth decay) Baby becomes a “gourmet” eater with increased acceptance of variety of foods later in life DHA (omega-3 fat) promotes brain development and increased visual acuity; human milk also high in alpha linoleic acid unless other mammal milk Reduced risk for later obesity of the child

20. Lactation Management La Leche League—books and personal support for breastfeeding “Supply and demand”—prolactin production from tactile stimulation allows for milk production; due to supply and demand, multiples can be at least partially breastfed; pumps can be used to express milk for preemies Let-down reflex—oxytocin production allows “hind” milk to be released (“fore” milk is the equivalent of skim; hind milk is the equivalent of cream); mother needs to be relaxed for production of oxytocin; “pins and needle” sensation confirms let-down reflex

21. Support Woman’s Confidence Eight to 12 feedings per 24-hour period a sign of good intake (may be spread evenly over this time or increased frequency in days and less at night) Six or more wet diapers per 24-hour period indicate good milk production (assuming no water bottles) Remind women during periods of growth spurts that “supply and demand” will result in increased milk production Refer any woman having or perceiving lactation difficulty to La Leche League (local chapter representative can be found on-line) or to an International Board-Certified Lactation Consultant (IBCLC) at a local hospital

22. Prevention and Management of Cracked or Sore Nipples Change infant’s feeding position to help get tongue off of sore spot (e.g., football hold, lying down with baby’s feet toward mother’s head) Relaxation techniques to encourage let-down reflex; use warm compresses before putting infant to breast Nurse on less sore side first Aim for short, frequent nursings <10 minutes Remove baby from breast with mother’s finger inserted near baby’s mouth to break suction Air dry nipples after nursing; use cold compresses between nursings

23. Breastfeeding versus Bottle-Feeding Issues Frequency Breastfeeding required every 2 to 3 hours or 8 to 12 times per24 hours for the young infant (older infants can go longer periodswith lower frequency) Formula is more difficult to digest; baby may go longer stretches between feeds but not receive adequate nutritional intake for optimal growth and development Breastfeed—no preparation, “ready to go”; bottle requiressterilization and heating Vitamin D may be needed by infant with either method Breast milk can be pumped or hand-expressed by working moms; breast milk or soy milk formula can be given in a bottle after breast-feeding well established (>1 month of age)

24. Bottle-Feeding Concerns Iron-fortified formula advised Formulas now available with added omega-3 fats Powdered form needs careful measuring, mixing Liquid (concentrated) diluted 1:1 with water Need safe water source and sterile bottles Refrigeration required after mixing or opened liquid concentrate

25. Introduction to Solids No solids until ages 4 to 6 months when GI tract is ready and the baby has the ability to indicate satiety Start with low allergenic foods—baby rice cereal with iron to maintain iron status Add new foods one at a time to rule out allergies; vegetables before fruits may allow better acceptance of veggies Add pureed meats after age 6 months Pincer grasp by approximately age 9 months; add juice by cup; solids in small pieces to prevent choking