Nutrition During Pregnancy and Lactation

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Nutrition During Pregnancy and Lactation

• Nutrition for Infants and Toddlers

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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 gt 50 deaths due to malaria,
  diarrhea, pneumonia

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Mothers Day Report Card

• Each year Save the Children publishes the
  Mothers 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!

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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

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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

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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

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Country Finland U.S.
Lifetime risk of female mortality due to pregnancy or child birth 12.200 2,400
Life expectancy 83 82
Under 5 mortality rate 2.9 7.5
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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

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Where is DR Congo?
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Afghanistan
10 worst countries for women and children
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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

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One island, two health stories
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Country Dominican Republic Haiti
Lifetime risk of maternal mortality, 1 in 240 83
Life expectancy (2009) 76 63
Under 5 mortality rate, per 1000 births 24.7 70
undernourished (2009) 4 22
Access to clean water (2009) 86 40
In Haiti, 73 of children 6-24 months and 60 of
pregnant women are anemic.
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Zambia Quick Facts

• 1 in 37 women die from pregnancy related
  disorders
• 1 in 82.9 children die before the age of 5

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Life-Saving Six for Keeping Babies Alive,
Nutrition Matters

• Iron (mother and child) and folate (mom)
• Breastfeeding 1st 6 months exclusively
• Complementary feeding 6 mos
• Vitamin A ( 2 doses /year, child)
• Zinc (child)
• Decreases diarrheal deaths
• Hygiene, water, sanitation

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Mortality Definitions

• Neonatal mortality rate
• death of infants in the 1st 28 days of life
• Infant mortality rate
• death of infants in the 1st year of life
• Both are reported in deaths/1000 live births

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Neonatal (lt28 days) Mortality Data
Population Neonatal mortality rate, deaths/1000 live births Year
U.S. overall 4.19 2009
Maine 4.2 2006
Black infants 8.2 2009
White infants 3.43 2009
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Infant (lt1 yr) Mortality Data
Population Infant mortality rate, deaths/1000 live births Year
U.S. overall 6.8 5.7 6.7 6.39 6.05 2001 2004 2008 2009 2011
Black 12.7 2009
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Infant (lt1 yr) Mortality Data
Population Infant mortality rate, deaths/1000 live births Year
U.S. overall 7.0 6.42 2002 2009
Black infants 14.3 12.71 2002 2009
White 5.8 5.27 2002 2009
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More Recent U.S. Data
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Infant mortality rates, by state U.S. - 2010
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Percent change in infant mortality rates, by race
and ethnicity United States, 20052011
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Leading causes of infant death in 2011 U.S.

• Congenital malformations
• Pre-term/low birthweight
• Sudden infant death syndrome (SIDS)
• Maternal complications
• Unintentional injuries
• Together, these 5 causes accounted for 56 of all
  infant deaths in the United States in 2011

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Infant Mortality

• Lowest rates for mothers in their late 20s-
  early 30s
• 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

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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

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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

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Nutrition During Pregnancy

• Time of significant growth for mother and fetus
• Goal is to start pregnancy with full nutritional
  stores

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Nutrition During Pregnancy

• Of greatest importance pre-pregnancy are having
  adequate levels of
• Folate
• Iron

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Caloric Needs and Weight Gain
Trimester Recommended Weight Gain Caloric Needs
1st 2-5 pounds total Few extra calories, make healthy choices
2nd and 3rd 1 pound/week 350 - 450 kcal/day
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Weight Gain Recommendations
Starting Weight Weight Gain, lbs
Underweight 28-40 5 lbs 1st trimester
Healthy Weight 25 - 35
Overweight 15-25
Obese Minimum 15
Teen Upper end of above ranges
Twins 35-45
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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

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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?......

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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

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Eclampsia

• At greatest risk
• Over 35 and under 17
• Carrying twins or more!
• Family/personal history of
• Diabetes
• First pregnancy
• African American descent

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Eclampsia

• Symptoms/consequences
• Edema
• Hypertension
• Protein in urine
• Kidney failure
• Liver damage
• Convulsions and death of mom and/or baby

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Eclampsia

• Treatment
• Bed rest
• Magnesium sulfate (diuretic)
• Deliver baby

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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

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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

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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

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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

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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

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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

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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

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Practices to AVOID

• Vitamin megadoses
• Alcohol
• Increases risk of fetal alcohol syndrome (FAS)

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FAS

• Brains of 6 week old infants

FAS
No FAS
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FAS

• Physical Characteristics
• Broad, short, flat nose
• No dimple above lip
• Narrow eyes
• Flat face

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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

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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

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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

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Nutrition During Lactation

• Vitamins needs go up for
• Vitamin A, E and C
• B vitamins in general

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Nutrition During Lactation

• Minerals
• Iron
• Return to pre-pregnancy levels
• Calcium
• Increased absorption takes care of needs
• Adequate fluid intake is critical

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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

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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.

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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.

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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

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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

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Breastfeeding

• Pros?
• Cons?

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Feeding Infants

• NEVER SCOLD a new mom who decides not to
  breastfeed!

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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

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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

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Adding Solids to the Diet

• At 4-6 months the babys 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

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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

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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

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Adding Solids to the Diet

• Avoid sweetened baby foods
• NO HONEY
• May carry botulism

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8-9 Months of Age

• Baby can be fed family food
• Lightly seasoned
• Cooked
• Finely chopped
• Allow some self-feeding
• Messy, but good for babys development

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Messy Babies!
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Feeding a 1 year Old

• OK to add whole cows milk to diet
• Growth rate slows and caloric needs dont go up
  much
• So dont stress if your soon to be toddler isnt
  eating as much as you think he/she should

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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

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Feeding a 1 year Old

• Remember children have small stomachs,
  therefore its 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?id805
  7

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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

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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