NUTRITION IN PREGNANCY

AND LACTATION

Olufemi Aworinde

Consultant Obstetrician and Gynaecologist,

Bowen University, Iwo

Nutrition in Pregnancy• Adequate nutrition is necessary for development of the infants

metabolic pathway and future well being

• Balanced diet should contain food from all of the basic food groups

• Specifics of diet will vary according to patient's preference, family eating pattern, cultural and ethnic background and social class

• There is increased nutritional need for both fetal growth and maternal physiological needs

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Importance of Nutrition

• Underweight women & low pregnancy weight gain is associated with low birth weight infants(<2500g)

• Statistically significant relationship between low rate of maternal weight gain and preterm delivery

• Overweight women & high pregnancy weight gain are at increased risk of macrosomia(>4000g)

• Macrosomia is associated with birth injuries and caesarean section

• Pre-pregnacy obesity is associated with hypertension, diabetes and post operative wound infection

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Gestational weight gain recommendations

Pre-pregnancy BMI Total weight gain at term Rate of weight gain in the

2nd

and 3rd

trimester

Underweight

(<18.5 kg/m2)

12.5-18 kg 0.51 (0.44-0.58) kg/week

Normal weight

(18.5-24.9 kg/m2)

11.5-16 kg 0.42 (0.35-0.50) kg/week

Overweight

(25.0-29.9 kg/m2)

7-11.5 kg 0.28 (0.23-0.33) kg/week

Obesity

(≥ 30.0 kg/m2)

5-9 kg 0.22 (0.17-0.27) kg/week

Nutrition in Pregnancy

• Daily requirement related to optimal body weight• 35kcals multiplied by optimal body weight

• About 80000kcal is needed to support full term pregnancy

• These when divided into daily needs give the requirement below.

• Daily requirement• Average non-pregnant woman 2300kcals/d

• Additional 300-350kcals/d during pregnancy

• Additional 300kcals per fetus in multiple pregnancy

• Additional 500kcals/d during lactation

• Some of these nutrients need to be supplemented

• Maternal weight gain in 2nd trimester is the most important for fetal growth• Protective of fetal growth if overall weight gain is poor

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• The amount of food a woman needs during pregnancy

depends on a number of things including her age, BMI before

pregnancy, the rate at which she gains weight and appetite.

• The first trimester does not require any extra calories.

• During the second trimester, an additional 340 calories a day

are recommended.

• For the third trimester, an additional 450 calories a day are

recommended.

Nutrition in pregnancy

• Total weight gain • 11.5-16kg (ACOG recommendation)

• Average is 12kg

• Underweight need to gain more while obese need to gain less

• Contributors to the weight gain• Fetus 3.5kg

• Placenta, uterus & amniotic fluid 650-900g

• Interstitial fluid & blood volume 1.2-1.8kg

• Breast enlargement 400g

• Maternal fat 1.65kg

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Nutrients

• Nutrients• Macronutrents (protein, carbohydrate and fats & oil)

• Micronutrients (Vitamins and minerals)

• Normal pregnancy diet• Protein 20%

• Fats 30%

• Carbohydrate 50%

• Protein requirement• 1g /kg plus 20g per day in 2nd trimester

• Essential for embryonic development

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Micronutrients

• Multivitamin supplements are not routinely required in a woman eating a well balanced diet

• Iron• 30-60mg elemental iron supplementation is recommended for

pregnancy and lactation

• 60-120mg elemental iron in iron deficiency anemia

• Folic acid• 400ug daily recommendation

• 4mg per day commenced pre-conceptionally for those with previous pregnancy complicated by neural tube defects

• Calcium• 1200mg per day required during pregnancy

• Easily met in diary products

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Folic acid (Summary)

• Strong evidence that folic acid prevents preconceptionally recurrent and first occurence neural tube defects

• Increasing evidence that folic acid reduces risk of some other birth defects

• Improves the hematologic indices in women receiving routine iron and folic acid

• Recommendation• 400 g/day: All women in childbearing age

• 1 mg/day: Pregnant women

• 4 mg/day: Women with history of neural tube defect deliveries (take folic acid 1 month prior to conception and during first trimester)

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Iron supplementation (Summary)

• Iron requirements:• Average non-pregnant adult:

• 800 g iron lost/day

• + 500 g iron lost/day during menses

• Pregnant woman: Increased need

• Expanded blood volume

• Fetal and placental requirements

• Blood loss during delivery

• Routine vs. selective iron supplementation:• Prevalence of nutritional anemia

• Routine iron and folate supplementation where nutritional anemia is prevalent

• Recommended dose: 60 mg elemental iron + 5 g folic acid

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Iodine deficiency• Iodine deficiency is a preventable cause of mental

impairment

• Not common with iodinized salt consumption

• Iodine supplementation and fortification programs have been largely successful in decreasing iodine deficiency conditions

• Population with high levels of mental retardation (e.g., some parts of China):• Supplementation may be effective at preconception up to mid-

pregnancy period

• Form of iodine supplementation (iodinating food or oral/injectable iodine) depend on:

• Severity of iodine deficiency

• Cost

• Availability of different preparation

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Vitamin A supplementation

• Indications for vitamin A supplementation:

• Vertical transmission of HIV (ongoing)

• Infant survival

• Maternal anemia: Positive interaction with iron in reducing anemia

• Infection

• Potential adverse effects of Vitamin A and related substances:

• Excessive doses of Vitamin A (>10,000 IU/day) have been associated with cranial-facial (face, palate, ears) and cardiac birth defects.

• The maximal supplement in pregnancy is 8000 IU/day.

• Offspring of mothers with vitamin A deficiency (which is rare), have a higher mortality rate, which may be associated with decreased immune function.

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Calcium Supplementation

• Calcium decreases risk of hypertension, pre-eclampsia, low birth weight, and chronic hypertension in children

• Recommend for high risk women with low calcium intake, if pre-eclampsia is important in the population

• Calcium has other health benefits not related to pregnancy:• Maintaining bone strength

• Proper muscle contraction

• Blood clotting

• Cell membrane function

• Healthy teeth

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Summary of nutritional review findings

• Evidence of nutritional intervention effectiveness

• Iron supplementation

• Periconceptional folic acid intake

• Iodine use

• Balanced energy/protein supplementation

• Calcium

• Confirmatory studies to examine effectiveness

• Vitamin A

• Zinc

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Breast Feeding

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BREAST

18

19

LYMPHATIC

DRAINAGE

• Lymph nodes

draining the

breast are

located in the

axilla.

Physiology of lactation Stage Duct system Major hormones

Pre-pubertal None

Pubertal Growth, division and elongation of the tubular duct system

Estradiol

Adult True alveolar development at the ends of the ducts

Oestrogen: Progesterone

1:20 – 1:100

Pregnancy Priming, preparation for milk production

Oestrogen

Progesterone

Prolactin

Human Placental lactogen

Lactation Prolactin

Oxytocin

The control and production of human milk • Milk is produced as a result of the action of hormones and reflexes

• During pregnancy, hormone changes prepare the gland tissue to make milk. More gland tissue develops and breasts become bigger

• Immediately after delivery, hormone changes make the breasts begin to produce milk (prolactin and oxytocin)

• When baby begins to suckle, two reflexes make the milk come in the right quantity and at the right time

• Prolactin reflex or milk secretion reflex

• Oxytocin reflex or the milk ejection reflex

The control and production of human milk Prolactin – The milk secreting hormone

• Produced by pituitary gland at base of the brain

• Suckling stimulates the nerve endings in the nipples which carries messages to the anterior part of the pituitary gland

• Works after the baby suckles and makes milk for the next feed

• Production based on supply and demand

• Pituitary secretes more prolactin during the night –breast feeding at night helps to keep up a good supply

• Prolactin suppresses the activity of the ovaries –contraception and delays menstruation

The control and production of human milkOxytocin – The milk ejecting hormone

• Makes small muscle cells around the breast glands contract and increase the pressure on the milk inside

• Produced when the baby suckles and stimulates the sensory nerves in the nipple

• Secreted by the posterior part of the pituitary gland

• Works while the baby is suckling and makes milk flow for this feed

• Makes uterus to contract – helps to deliver placenta

• Helps to stop bleeding immediately after delivery - Shortens time mother loses lochia

The control and production of human milk

Oxytocin – The milk ejecting hormone…

• Mother’s thoughts, feelings and sensations can affect the oxytocin’s reflex.

• Helping milk ejection

• Love thoughts

• Cry of baby

• Perceived confidence

• Hindering milk ejection

• Worries and fears

• Pain especially painful breastfeeding

• embarrassment

The control and production of human milk • How milk “comes in”

• 1st few day – breast secretes colostrum

• Next few days (2-7days) – breast begins to feel full

and produce a lot of milk (“milk comes in”). This

happens more quickly if feeding is unrestricted or on

demand

• Next few days – breast feels less full and softer but

continues to produce plenty of milk

Breast feeding

• A healthy full-term baby has three reflexes which help

him to feed

• Rooting reflex

• Helps baby to find the nipple - baby turns towards

the nipples when something touches the baby near

its mouth

• Suckling reflex

• When something goes into baby’s mouth far

enough and touches his palate, he sucks it

• Swallowing reflex

• If a baby’s mouth fills with milk, he swallows it

Breast feeding (Benefits)

• Cheap, accessible

• Bonding

• Reduced juvenile-onset diabetes mellitus, inflammatory bowel disease and neoplastic disease in childhood

• Fertility regulation • Child spacing

• Contraception• Within six months of delivery

• Exclusive breastfeeding

• amenorrhoea

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Breast feeding (Benefits)

• Nutritional benefits

• Protection against infections• Reduced incidences of vomiting and diarrhoea

• Protection against respiratory tract infections

• Has high amount of lactoferrin, which binds iron required for growth by E Coli

• Encourages growth of non-pathogenic organisms in gut

• Ig A not absorbed in gut and then binds offending organisms

• Contains polymorphs, lymphocytes and plasma cells

• Neurological benefit• Improved cognition

• Reduced atopic illnesses

• Reduced breast cancer among mothers who breastfed

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Breast feeding

• Exemption from breastfeeding• Drugs & alcohol abuse

• Infant with galactosemia

• HIV infected mother

• Active untreated tuberculosis

• Women being treated for breast cancer

• Some drugs contraindicated during breastfeeding• Cyclophosphamide, doxorubicin,

• Phencyclidine

• Lithium

• Cyclosporin

• Radioactive iodine

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Suppression of lactation

• Tight breast binding

• Avoidance of tactile breast stimulation

• Ice packs

• Mild analgesics

• Aspirin

• ibuprofen

• Drugs

• Bromocriptine (10-14 days)

• Oestrogen

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Problems with lactation

• Psychological stress

• Breasts engorgement

• Mastitis

• Breast abscess

• Nipple retraction

• Inadequate milk production

• Excretion of drugs in breast milk

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Breast feeding and mothers medicines

• Drugs that decrease milk supply

• Oestrogens

• Thiazide diuretics

• Bromocriptine

• Drugs that increase milk supply

• Chlorpromazine – 25mg dly for a week

• Metoclopramide – 10-15mg three time a day for up to 3 months

Myths and taboos

• No breast feeding when there is breast abscess

• Don’t breast feed when pregnant with another baby

• Sexual intercourse harms milk

• Dangerous to breast feed during menstrual period

• Mother believes she cannot breast feed when ill

Counselling and support

• Concern for well being of the mother

• Antenatal preparation

• Psychological

• Physical preparation

• Family preparation for support especially husbands

• Postpartum advice

• Preparing mother to leave hospital

• Concern at postnatal appointment

Conclusion

Breastfeeding…..

• Best and safest way of feeding infants

• Sweet and plentiful breastmilk is the perfect food;

always ready, warm and delicious. And it comes

in an attractive and time-tested package; that of

the woman’s breast; firmly attached to the warm,

soft, breathing, beating body of the mother.

THANK YOU!

THANK

YOU!THANK

YOU!