NUTRITION IN PREGNANCY AND LACTATION

Lingegowda Krishna1

Nageshu Shailaja2

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:

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 trimesterof 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 & RDA / Important functions / Important source / Comments
Calories
N-2200
P-2200(1st trimester)
P-2500(2nd & 3rd trimester)
L-2700 / Provide energy for tissue building & increased metabolic requirements / Carbohydrates ,fats & proteins / Calorie requirements vary according to the stage of pregnancy, size of pregnant woman, activity level, pre pregnant weight & how well nourished they are
Water or liquids
N-8 glasses
P-10 glasses
L-12-14 glasses / Carries nutrients to cells
Carries waste products away.
Provides fluid for increased blood, tissue & amniotic fluid volume.
Helps regulate body temperature.
Aids digestion. / Water, juices & milk / Liquid is often neglected, but it is an important nutrient
Protein
N-50g
P-65g
L-75g / Builds & repairs tissue.
Helps build blood, amniotic fluid & placenta.
Helps form antibodies.
Supplies energy / Meat, fish, poultry eggs, milk, cheese, dried beans & peas, peanut butter, nuts, whole grains & cereals / Fetal increase by 1/3rd in late pregnancy as the baby grows

Minerals

Key nutrient & RDA / Important functions / Important source / Comments
Calcium
N-400mg
P-1000mg
L-1000mg / Helps build bones & teeth.
Important in blood clotting.
Helps regulate use of other minerals in the body. / Milk, cheese, whole grains, vegetables, egg yolk, whole canned fish, ice cream / Fetal requirements increase in late pregnancy.
Caffeine can decrease the amount of calcium available to fetus.
Phosphorous
N-800mg
P-1200mg
L-1200mg / Helps build bones & teeth / Milk, cheese, lean meats / Calcium & phosphorous exist in a constant ratio in the blood,an excess limits the use of calcium
Iron
N-30mg
P-38mg
L-30mg / Combines with proteins to make hemoglobin.
Provides iron for fetal storage. / Liver, red meats
Egg yolk, whole grains, leafy vegetables, nuts, legumes, dried fruits, prunes & apple juice / Fetal requirements increase 10 fold in the last 6 weeks of pregnancy.
Supplement 30-60mg of iron daily is recommended by National Research Council.
Zinc
N-12 mg
P-15mg
L-19mg / Component of insulin.
Important in growth of skeleton. / Meat, liver, eggs, sea food (especially oysters & nervous system) / Deficiency can cause malformations of fetal skeleton &nervous system
Iodine
N-150mcg
P-175mcg
L-200 mcg / Helps control the rate of body’s energy use.Important in thyroxine production. / Sea foods, iodised salt / Deficiency may cause goiter in infant
Magnesium
N-280mg
P-320mg
L-355g / Helps energy, protein & cell metabolism.
Enzyme activator.
Helps tissue growth & muscle action. / 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 / Important source / Comments
Vitamin A
N-600mcg RE
P-600mcg RE
L-950mcg RE / Helps bone & tissue growth & development.
Essential in development of enamel-forming cells in gum tissue.
Helps maintain health of skin & mucous membrane. / Butter, fortified margarine, green & yellow vegetables, liver / In excess amounts ,it is toxic to fetus.
It loses its potency when exposed to light.
Vitamin D
N-5mcg
P-10mcg
L-10mcg / Needed for absorption of calcium & phosphorous, & mineralization of bones & teeth / Fortified milk, fortified margarine, fish, liver, oil , sunlight on your skin / Toxic to fetus in excess amounts.
Vitamin E
N-8mg α TE
P-10mg α TE
L-12mg α TE / Needed for tissue growth, cell wall integrity & red blood cell integrity. / Vegetable oils, cereals, meat, eggs, milk, nuts & seeds / Enhances absorption of vitamin A.
Vitamin K
N-65mcg
P-65mcg
L-65mcg / Essential for synthesis of blood clotting factors. / - / Produced in the body by the intestinal flora.

Water soluble vitamins

Key nutrient & RDA / Important functions / Important source / Comments
Folic acid
N-180mcg
P-1400mcg
L-280mcg / Essential in hemoglobin synthesis.
Involved in DNA & RNA synthesis.
Needed for synthesis of amino acids. / Liver, green leafy vegetables & yeast / 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.
Niacin
N-15mg
P-17mg
L-20mg / Needed for energy & protein metabolism. / Pork, organ meats, peanuts, beans, peas & enriched grains / Stable; only small amounts are lost in food preparation.
Riboflavin
N-1.3mg
P-1.6mg
L-1.8mg / Essential for energy & protein metabolism. / Milk, lean meat, enriched grains, green leafy vegetables / Oral contraceptives may reduce serum concentration of riboflavin.
Thiamin (B1)
N-1.1mg
P-1.5mg
L-1.6mg / Important for energy metabolism. / Pork, beef, liver, whole grains & legumes / Essential for conversion of carbohydrates into energy in the muscular & nervous systems.
Pyridoxine(B6)
N-1.6mg
P-2.2mg
L-2.1mg / Important in aminoacid metabolism & protein synthesis required for fetal growth. / Unprocessed cereals, grains, wheat germ, nuts, seeds, legume & corn / Excessive amounts may reduce milk supply in lactating women.
May help reduce nausea in early pregnancy.
Cobalamin (B12)
N-2.0mcg
P-2.2mcg
L-2.6mcg / Essential in protein metabolism.
Important in formation of red blood cells. / Milk,eggs,meat,liver, cheese / Deficiency leads to anemia & CNS damage.
It is manufactured by microorganisms in the intestinal tract.
Oral contraceptives may reduce serum concentration.
Vitamin C
N-40mg
P-40mg
L-45mg / Helps tissue formation & integrity.
It is “cement” substance in connective & vascular tissue.
Increases iron absorption. / Citrus fruits, berries, melons,tomatoes, chilly, pepper, green vegetables & potatoes / 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

Note: N – Nonpregnant P – Pregnant L - Lactation

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
Placenta
Amniotic fluid
Uterus
Blood
Extra cellular fluid
Total / 3.4
0.7
0.9
0.9
1.5
1.5
8.9 / 0.44
0.1
0.003
0.166
0.081
0.135
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 of Fats and Lipid (ISSFAL) / Adequate intake for adults to be at least 220mg per day and 300mg per day for pregnant and lactating women
Committee On Medical Aspects Of Food Policy (COMA) / 1.5g EPA plus DHA per week(i.e 214mg mg per day)
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 Academy of Nutrition Sciences held in 1997(EANS) / “ People who do not eat fish should consider consuming marine n-3 PUFA equivalent to the amount obtained 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 / 1cup milk (225ml), 2 dosas with green chutney (without coconut)
MID MORNING / 1cup milk (150ml) + 1 sweet lime
LUNCH / 1 katori rice, 3 chapathis, 2 katori tur dal, palak fish(3 slices), French beens bhaji, toasted salad
MID AFTERNOON / 1 glass buttermilk(made from skim milk)
TEATIME / 1cup tea with half cup skim milk(75ml), 1 katori poha with peas
MID EVENING / 1cup skim milk + 1 apple
DINNER / Mixed vegetable soup, khichidi 2 katoris, kadhi 1 ½ katori,potato cauliflower bhaji 1 katori,pumpkin raitha
BED TIME / 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 / In Kg
Baby
Placenta
Amniotic fluid
Mother
  • Breasts
  • Uterus
  • Body fluids
  • Blood
  • Maternal stores of fat, protein and other nutrients
/ 3.4
0.7
0.9
0.9
0.9
1.5
1.5
3.1
Total / 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 indehydration,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 oralIntake 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 fatdiet may be recommended in latent phase.Allow oral fluids to maintain hydration in the activephase
  • 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 ofIUGR 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.