chapter 11 maternal and infant nutrition in health and disease

Chapter 11Chapter 11

Maternal and Infant Nutrition in Health and Disease

2Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Learning ObjectivesLearning Objectives

Identify nutritional needs during Identify nutritional needs during pregnancy, lactation, and infancy.pregnancy, lactation, and infancy.

Discuss the benefits of lactation and Discuss the benefits of lactation and management techniques.management techniques.

Discuss infant feeding strategies.Discuss infant feeding strategies.


Nutrition for a Healthy Pregnancy Nutrition for a Healthy Pregnancy Begins Before ConceptionBegins Before Conception

Weight loss can increase fertility especially in those with PCOSWeight loss can increase fertility especially in those with PCOS Achieve normal BG levels before conception (with diabetes)Achieve normal BG levels before conception (with diabetes) Avoid excess vitamin A (preformed) to reduce risk of birth defects Avoid excess vitamin A (preformed) to reduce risk of birth defects Vegans require vitamins BVegans require vitamins B1212, D, and calcium, D, and calcium

BB1212 deficiency associated w/ impaired neurologic development deficiency associated w/ impaired neurologic development Deficiency issues on fetal growth and developmentDeficiency issues on fetal growth and development

Pyridoxine (vitamin BPyridoxine (vitamin B66) deficiency may lead to impaired ) deficiency may lead to impaired

learning and memory retention as well as Down syndromelearning and memory retention as well as Down syndrome Folic acid deficiency increases risk for Neural tube defects Folic acid deficiency increases risk for Neural tube defects

(spina bifida), Down syndrome and Cleft palate(spina bifida), Down syndrome and Cleft palate Rule out celiac disease if Hx of following:Rule out celiac disease if Hx of following:

Infertility or MiscarriagesInfertility or Miscarriages Low-birth-weight infantsLow-birth-weight infants Family Hx neural tube defectsFamily Hx neural tube defects


Comparison of Weight Gain GoalsComparison of Weight Gain Goals

Past Goals:Past Goals: 1960s 1960s << 20 lb 20 lb More recently:More recently:

25-35 lb (BMI 20-26)25-35 lb (BMI 20-26) 28-40 lb (BMI <20)28-40 lb (BMI <20) 15-20 lb (BMI >26)15-20 lb (BMI >26)

Current Goals:Current Goals: From Institute of Medicine From Institute of Medicine

(IOM):(IOM): Up to 30 lb normal weightUp to 30 lb normal weight Up to 25 lb overweightUp to 25 lb overweight 15 lb for obesity15 lb for obesity

For multiple births (triplets):For multiple births (triplets): 35 to 45 lb normal BMI35 to 45 lb normal BMI

Goal to prevent low birth weight and macrosomiaGoal to prevent low birth weight and macrosomia


Components of Weight GainComponents of Weight Gain

Components of weight gain during pregnancy. (From Murray SS, McKinney ES, Gorrie TM: Foundations of maternal-newborn nursing, ed 4, St Louis, 2006, Saunders.)


Prenatal Weight Gain ChartPrenatal Weight Gain Chart

Recommended prenatal weight gain. Chart to monitor weight gain throughout pregnancy. PGW, Pregestational weight (weight before conception). (From the New York State Health Department, WIC Program.)

•How many extra calories per day do you need?


Risk Factors for and Risk Factors for and Related to Macrosomia Related to Macrosomia

Birth weight >4 kg (8.8 lb)Birth weight >4 kg (8.8 lb) Women who gain >IOM weight gain recommendation are Women who gain >IOM weight gain recommendation are

three times more likely to have infant with macrosomiathree times more likely to have infant with macrosomia (Hedderson et al., 2006)(Hedderson et al., 2006)

Uncontrolled diabetes—in first trimester due to alterations in Uncontrolled diabetes—in first trimester due to alterations in

placental growth and functionplacental growth and function (Jansson et al., 2006); (Jansson et al., 2006); later later trimesters related to high glucose levels through placentatrimesters related to high glucose levels through placenta

Macrosomia increases risk of shoulder dystocia (head Macrosomia increases risk of shoulder dystocia (head normal size, shoulders too large for normal delivery) and normal size, shoulders too large for normal delivery) and

risk of birth canal injuriesrisk of birth canal injuries (Hirnle et al., 2007)(Hirnle et al., 2007)

Neonatal hypoglycemia (BG <40 mg/dL) and Neonatal hypoglycemia (BG <40 mg/dL) and hyperbilirubinemia hyperbilirubinemia

Increased risk for infant’s later development of metabolic Increased risk for infant’s later development of metabolic

syndromesyndrome (Boney et al., 2005)(Boney et al., 2005)


Risks of Low Birth Weight (LBW)Risks of Low Birth Weight (LBW)

Low birth weight: <5.5 lb of unknown etiologyLow birth weight: <5.5 lb of unknown etiology Small-for-gestational age (SGA) <10th percentile Small-for-gestational age (SGA) <10th percentile

height or weight based on gestational age; may also height or weight based on gestational age; may also be referred to as be referred to as intrauterine growth retardationintrauterine growth retardation (IUGR)(IUGR)

SGA infants are at later risk of hypercholesterolemiaSGA infants are at later risk of hypercholesterolemia IUGR or LBW related to low-normal kidney function IUGR or LBW related to low-normal kidney function

in adulthoodin adulthood Increased risk of occurrence with poor dietary intake Increased risk of occurrence with poor dietary intake

and inadequate weight gain during pregnancyand inadequate weight gain during pregnancy


Biochemical & Nutrient IssuesBiochemical & Nutrient Issues

Increased need for protein: 75-100 g Nutrients that are often low in a pregnant woman's diet and may

require supplementation are: Omega-3 fats to promote good neurologic development of fetus and infant Calcium: Many women may not get enough calcium before conceiving and

are already at risk for bone loss. 1,300 mg/day for women 18 years of age and younger 1,000 mg/day for women >19 years

Vitamin D: 800IU/day Iron: good sources include fortified breakfast cereals & prenatal vitamin.

27 mg/day Folate:

<18 years, 800 mcg >18 years, 1,000 mcg/day (IOM 2004)

Fiber: 25-35g/day to help prevent constipation due to slower transit time


Other Nutrition Issues Other Nutrition Issues in Pregnancyin Pregnancy

Hydration: dehydration is the number one Hydration: dehydration is the number one cause of early laborcause of early labor

Safe food handling to prevent food poisoningSafe food handling to prevent food poisoning Steam or heat deli meat to lower risk ofSteam or heat deli meat to lower risk of

ListeriaListeria Avoidance of excess mercury intakeAvoidance of excess mercury intake

Decreased intake of tuna, shark, swordfish, marlin, Decreased intake of tuna, shark, swordfish, marlin, and lake troutand lake trout

Small fish generally low in mercury (e.g., sardines)Small fish generally low in mercury (e.g., sardines) Wild salmon good source of omega 3’s and low in Wild salmon good source of omega 3’s and low in

mercurymercury


Prolonged HyperemesisProlonged Hyperemesis

Can cause dehydration; hospitalization needed for IV Can cause dehydration; hospitalization needed for IV fluid replacementfluid replacement

Associated with vitamin deficiencies:Associated with vitamin deficiencies: Beriberi and Wernicke’s encephalopathyBeriberi and Wernicke’s encephalopathy

Possible fatal electrolyte imbalancePossible fatal electrolyte imbalance May cause hemorrhage due to rupture of esophageal May cause hemorrhage due to rupture of esophageal

varicesvarices Parenteral nutrition may be required via venous accessParenteral nutrition may be required via venous access Monitor for ketonesMonitor for ketones May benefit withMay benefit with

Small, frequent meals, including snacking on crackersSmall, frequent meals, including snacking on crackers Vitamin BVitamin B66 (Powers et al., 2007)(Powers et al., 2007)

GingerGinger (Ensiyeh and Sakineh, 2008)(Ensiyeh and Sakineh, 2008)


Diagnostic Screening for DiabetesDiagnostic Screening for Diabetes

100-G Glucose Load100-G Glucose Load 75-G Glucose Load75-G Glucose Load Fasting 95 (5.3)Fasting 95 (5.3) Fasting 95 (5.3)Fasting 95 (5.3) 1-hr 180 (10.0) 1-hr 180 (10.0) 1-hr 180 (10.0)1-hr 180 (10.0) 2-hr 155 (8.6)2-hr 155 (8.6) 2-hr 155 (8.6)2-hr 155 (8.6) 3-hr 140 (7.8)3-hr 140 (7.8)


Third Trimester IssuesThird Trimester Issues

Mother may experience heartburn; small frequent meals Mother may experience heartburn; small frequent meals and sitting up after eating can helpand sitting up after eating can help

Constipation can be a problem because of diminishedConstipation can be a problem because of diminishedperistalsis for increased intestinal absorption of nutrients; peristalsis for increased intestinal absorption of nutrients; include fiber, water, and exercise as toleratedinclude fiber, water, and exercise as tolerated

Restless leg syndrome: transient form found in up to 1 in 4 Restless leg syndrome: transient form found in up to 1 in 4 women during pregnancy; associated with low hemoglobinwomen during pregnancy; associated with low hemoglobin

Pregnancy-induced HTN (PIH) or gestational HTN-Pregnancy-induced HTN (PIH) or gestational HTN-preeclampsia: a leading cause of maternal and fetal preeclampsia: a leading cause of maternal and fetal morbidity and mortalitymorbidity and mortality

Eclampsia can lead to convulsions and coma. Treated with Eclampsia can lead to convulsions and coma. Treated with magnesium sulfatemagnesium sulfate


Other ConcernsOther Concerns

Avoid alcohol to prevent fetal alcohol syndrome, Avoid alcohol to prevent fetal alcohol syndrome, mental retardation and deformities such as wide set mental retardation and deformities such as wide set eyeseyes

Avoid caffeine, a vasoconstrictor to ensure good Avoid caffeine, a vasoconstrictor to ensure good oxygen uptake by fetusoxygen uptake by fetus

Physiologic AnemiaPhysiologic Anemia——may be caused by increased may be caused by increased blood volume, but in the United States is still treated blood volume, but in the United States is still treated with iron supplementswith iron supplements

Pica– eating non nutritive items such as dirt or paint Pica– eating non nutritive items such as dirt or paint chips and may be associated with iron deficiencychips and may be associated with iron deficiency


Lactation GoalsLactation Goals

The American Academy of Pediatrics The American Academy of Pediatrics recommends exclusive breastfeeding/nursing for recommends exclusive breastfeeding/nursing for 6 months and continued nursing through the first 6 months and continued nursing through the first year of life or longer, as desiredyear of life or longer, as desired


Benefits of LactationBenefits of Lactation

Colostrum and milk provide antibodies and immunity factors Colostrum and milk provide antibodies and immunity factors to the breastfed infantto the breastfed infant

Hormones promote uterine contractions that aid return toHormones promote uterine contractions that aid return toprepregnancy size and promote weight loss by motherprepregnancy size and promote weight loss by mother

Babies’ “chewing” action promotes strong jaw muscles and Babies’ “chewing” action promotes strong jaw muscles and helps prevent baby-bottle mouth (tooth decay)helps prevent baby-bottle mouth (tooth decay)

Baby becomes a “gourmet” eater with increased Baby becomes a “gourmet” eater with increased acceptance of variety of foods later in lifeacceptance of variety of foods later in life

DHA (omega-3 fat) promotes brain development and DHA (omega-3 fat) promotes brain development and increased visual acuityincreased visual acuity

Reduced risk for later obesity of the childReduced risk for later obesity of the child


Ten Steps to Promote LactationTen Steps to Promote Lactation

1.1. Maintain a written breastfeeding policy that is Maintain a written breastfeeding policy that is routinely communicated to all health care staff.routinely communicated to all health care staff.

2.2. Train all health care staff in skills necessary to Train all health care staff in skills necessary to implement this policy.implement this policy.

3.3. Inform all pregnant women about the benefits Inform all pregnant women about the benefits and management of breastfeeding.and management of breastfeeding.

4.4. Help mothers initiate breastfeeding within one Help mothers initiate breastfeeding within one hour of birth.hour of birth.

5.5. Show mothers how to breastfeed and how to Show mothers how to breastfeed and how to maintain lactation even if they are separated maintain lactation even if they are separated from their infants.from their infants.


6.6. Give infants no food or drink other than breast Give infants no food or drink other than breast milk, unless medically indicated.milk, unless medically indicated.

7.7. Practice “rooming in”—allow mothers and infants Practice “rooming in”—allow mothers and infants to remain together 24 hours a day.to remain together 24 hours a day.

8.8. Encourage unrestricted breastfeeding.Encourage unrestricted breastfeeding.9.9. Give no pacifiers or artificial nipples to Give no pacifiers or artificial nipples to

breastfeeding infantsbreastfeeding infants10.10. Foster the establishment of breastfeeding Foster the establishment of breastfeeding

support groups and refer mothers to them on support groups and refer mothers to them on discharge from the hospital or clinicdischarge from the hospital or clinic (BFUSA, 2004).(BFUSA, 2004).

Ten Steps to Promote Ten Steps to Promote Lactation (continued)Lactation (continued)


Support Woman’s ConfidenceSupport Woman’s Confidence

Eight to 12 feedings per 24-hour period a sign of good Eight to 12 feedings per 24-hour period a sign of good intake (may be spread evenly over this time or increased intake (may be spread evenly over this time or increased frequency in days and less at night)frequency in days and less at night)

Six or more wet diapers per 24-hour period indicate good Six or more wet diapers per 24-hour period indicate good milk production (assuming no water bottles)milk production (assuming no water bottles)

Remind women during periods of growth spurts that “supply Remind women during periods of growth spurts that “supply and demand” will result in increased milk production and demand” will result in increased milk production

Refer any woman having or perceiving lactation difficulty to Refer any woman having or perceiving lactation difficulty to La Leche League (local chapter representative can be La Leche League (local chapter representative can be found on-line) or to an International Board-Certified found on-line) or to an International Board-Certified Lactation Consultant (IBCLC) at a local hospitalLactation Consultant (IBCLC) at a local hospital


Nutritional Concerns with LactationNutritional Concerns with Lactation

Mother’s diet must be adequateMother’s diet must be adequate B vitaminsB vitamins Vitamins A and D Vitamins A and D Minerals: calcium, iodine, seleniumMinerals: calcium, iodine, selenium Nursing infant further advised to take vitamin D Nursing infant further advised to take vitamin D

supplement especially in high-risk populations (lack of supplement especially in high-risk populations (lack of sunshine, darker skin color)sunshine, darker skin color)

Vegans and women with hx bariatric weight loss Vegans and women with hx bariatric weight loss surgery need supplement of vitamin Bsurgery need supplement of vitamin B1212

No excess weight loss to ensure adequate No excess weight loss to ensure adequate kilocalories for milk production needs (½ lb/week kilocalories for milk production needs (½ lb/week appropriate; initial rapid weight loss result of fluid appropriate; initial rapid weight loss result of fluid loss after delivery)loss after delivery)


Breastfeeding versus Breastfeeding versus Bottle-Feeding IssuesBottle-Feeding Issues

FrequencyFrequency Breastfeeding required every 2 to 3 hours or 8 to 12 times perBreastfeeding required every 2 to 3 hours or 8 to 12 times per

24 hours for the young infant (older infants can go longer 24 hours for the young infant (older infants can go longer periods with lower frequency)periods with lower frequency)

• Formula is more difficult to digest; baby may go longer Formula is more difficult to digest; baby may go longer stretches between feeds but not receive adequate stretches between feeds but not receive adequate nutritional intake for optimal growth and developmentnutritional intake for optimal growth and development

BreastfeedBreastfeed——no preparation, “ready to go”; bottle requiresno preparation, “ready to go”; bottle requiressterilization and heating sterilization and heating

Vitamin D may be needed by infant with either methodVitamin D may be needed by infant with either method Breast milk can be pumped or hand-expressed by working moms; 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-breast milk or soy milk formula can be given in a bottle after breast-feeding well established (>1 month of age)feeding well established (>1 month of age)


Bottle-Feeding ConcernsBottle-Feeding Concerns

Iron-fortified formula advisedIron-fortified formula advised Formulas now available with added omega-3 Formulas now available with added omega-3

fatsfats Powdered form needs careful measuring, Powdered form needs careful measuring,

mixingmixing Liquid (concentrated) diluted 1:1 with waterLiquid (concentrated) diluted 1:1 with water Need safe water source and sterile bottlesNeed safe water source and sterile bottles Refrigeration required after mixing or opened Refrigeration required after mixing or opened

liquid concentrateliquid concentrate


Introduction to SolidsIntroduction to Solids

No solids until ages 4 to 6 months when GI tract is No solids until ages 4 to 6 months when GI tract is ready and the baby has the ability to indicate ready and the baby has the ability to indicate satietysatiety

Start with low allergenic foodsStart with low allergenic foods——baby rice cereal baby rice cereal with ironwith iron to maintain iron statusto maintain iron status

Add new foods one at a time to rule out allergies; Add new foods one at a time to rule out allergies; vegetables before fruits may allow better vegetables before fruits may allow better acceptance of veggiesacceptance of veggies

Add pureed meats after age 6 monthsAdd pureed meats after age 6 months Pincer grasp by approximately age 9 months; add Pincer grasp by approximately age 9 months; add

water by cup; solids in small pieces to prevent water by cup; solids in small pieces to prevent chokingchoking


Critical ThinkingCritical Thinking

What can a nurse do to support breastfeeding in the hospital setting?

What are the immediate and long-term concerns about breastfeeding and their possible resolutions?


Study GuideStudy Guide

• What vitamin may cause birth defects if in excess?

• What B vitamin is needed to prevent neural tube defects?

• What two B vitamins may play a role in preventing Down Syndrome?


Study Guide (continued)Study Guide (continued)

What can help increase fertility in a woman with PCOS?

Current weight gain goals for pregnancy How many extra calories per day does a pregnant

woman need? What problems are associated with macrosomia? What problems are associated with low birth weight? Why are women’s blood sugars screened during

pregnancy? What nutrients may need to be supplemented in

pregnancy? (see slide 10)

What is the number one cause of early labor?


Study Guide (continued)Study Guide (continued)

Why are pregnant women concerned about listeria and mercury and what foods are they found in?

Why avoid alcohol and caffeine? How long are women encouraged to breast feed? Lactation benefits Approximately how many kcal are used to produce milk? What is an appropriate rate of weight loss after birth? Why

not more? Compare breastfeeding and bottle feeding issues What age is appropriate to start solid food? Why give infant rice cereal?

chapter 11 maternal and infant nutrition in health and disease

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