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NUTRITION IN PREGNANCY AND LACTATION
Lingegowda Krishna1
Nageshu Shailaja 2
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: [email protected]
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 trimester of
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
CalciumN-400mgP-1000mgL-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.
PhosphorousN-800mgP-1200mgL-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
IronN-30mgP-38mgL-30mg
Combines with proteins to make hemoglobin.Provides iron for fetal storage.
Liver, red meatsEgg 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.
ZincN-12 mgP-15mgL-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
IodineN-150mcgP-175mcgL-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
MagnesiumN-280mgP-320mgL-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 AN-600mcg REP-600mcg REL-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 DN-5mcgP-10mcgL-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 EN-8mg TEαP-10mg TEαL-12mg TEα
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 KN-65mcgP-65mcgL-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 acidN-180mcgP-1400mcgL-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.
NiacinN-15mgP-17mgL-20mg
Needed for energy & protein metabolism.
Pork, organ meats, peanuts, beans, peas & enriched grains
Stable; only small amounts are lost in food preparation.
RiboflavinN-1.3mgP-1.6mgL-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-1.1mgP-1.5mgL-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-1.6mgP-2.2mgL-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-2.0mcgP-2.2mcgL-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 CN-40mgP-40mgL-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
BREAKFAST1cup milk (225ml), 2 dosas with green chutney (without coconut)
MID MORNING 1cup milk (150ml) + 1 sweet limeLUNCH 1 katori rice, 3 chapathis, 2 katori tur dal, palak fish(3 slices), French
beens bhaji, toasted saladMID AFTERNOON 1 glass buttermilk (made from skim milk)TEATIME 1cup tea with half cup skim milk (75ml), 1 katori poha with peasMID EVENING 1cup skim milk + 1 appleDINNER Mixed vegetable soup, khichidi 2 katoris, kadhi 1 ½ katori,potato
cauliflower bhaji 1 katori,pumpkin raithaBED 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
BabyPlacentaAmniotic fluidMother
Breasts Uterus Body fluids Blood Maternal stores of fat, protein
and other nutrients
3.40.70.9
0.90.91.51.53.1
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 in dehydration, 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 oral Intake 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 fat diet may be recommended in latent phase. Allow oral
fluids to maintain hydration in the active phase
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 of IUGR 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.
Nutrition is not only important for the unborn baby but is also essential for
the mother’s current and future state of health. The diet during pregnancy and
lactation is designed to promote optimal nutrition for the woman and fetus in
pregnancy and for the mother and infant during lactation.
1. A pregnant woman is always advised to eat what she wants, in amounts she
desires and food should be salted to her taste. Mothers who are in negative
energy in terms of both food storage and heavy workload deliver low birth
weight babies. Pregnant women from low socio economic group should make
efforts to ensure a healthy diet.
2. Proteins are needed for repair of the mother’s tissue as well as for added
demands of growth, increased blood volume and repair of placenta, uterus
and breast. They can be supplied from either meat, milk, eggs, pulses ,
legumes, cheese, poultry or fish. Generally if a pregnant woman consumes
enough calories in her food, her protein needs are taken care of.
3. Her weight should be checked serially with the intention of gaining about 10 –
12 kg during the whole period of 40 weeks.
4. Iron is the only nutrient for which requirements cannot be met by diet alone.
Iron deficiency anemia is a significant cause of increased maternal mortality
and has an adverse effect on the health and development of the newborn.
Tablets of simple iron salts that provide 30 – 60mg of iron/day should be
taken. Iron supplementation is not necessary in the first trimester and it also
aggravates nausea and vomiting. Recheck the hemoglobin concentration at 28
– 32wks to detect any significant decrease.
5. The increased requirements of all vitamins can be generally supplied by the
usual diet, except for folic acid, which is required more in pregnancies, that
are complicated by protracted vomiting, hemolytic anemia, multiple fetuses
and those on antiepileptic drugs. Folic acid tab of 5mg/day should be taken
not only during pregnancy but also three months before you are planning to
start a family, especially in cases with a genetic or family history of neural
tube defects.
6. Strict vegetarians may have low vitamin B12, so supplementation of vitamin
B12 may be required in such cases. Studies show that multi vitamin
supplementation for women who do not consume an adequate diet are not
really helpful.
7. Calcium is deposited in the fetus during later pregnancy. This amount
represents about 2.5% of maternal calcium, most of which is present in the
bone and can be readily used for fetal growth. So it is only in developing
countries where there is deficiency of vitamin D and calcium that
supplementation is required. One cup of cow’s milk provides approximately
1gm of calcium.
8. Iodised salt should always be used. So as you can see, pregnancy does not
require too much of extra nutrition. Rather a good balanced diet with all the
specific nutrients is required for the benefit of the mother and the growing
fetus.
Nutritional guidelines for a pregnant mother
o Drink plenty of fluids in the form of water and juices, which help increase the
volume of breast milk.
o The maximum amount of energy should be derived from whole grain cereals
rather than from fats and sugars.
o The source of carbohydrates should be mainly from the consumption of
whole grain cereals rather than from sugars and refined products.
o Non-vegetarians can get protein from meat, poultry and eggs. Vegetarians
can derive quality proteins from a combination of cereals, legumes, pulses
and nuts. Intake of sprouted pulses is desirable.
o Mineral and vitamin requirements should be met by consuming a variety of
fruits(including seasonal) and vegetables, especially those rich in vitamin C
such as orange and green leafy vegetables.
o Vegetarians should drink milk can serve as a source of calcium and vitamin
B12 and D.
o A combination of PUFA (Poly unsaturated fatty acids) and MUFA (Mono
unsaturated fatty acids) oils as a source of energy and is preferable to
saturated fats.
o Eat foods rich in vitamin C, such as citrus fruits, amla, guava, sprouts etc with
meals in order to improve the absorption of iron from the food.
o Milk and curd are the best sources of biologically available calcium.
o Foods that are not nutritious, like those that are fried or barbecued, should
be avoided, including those that can cause allergic reactions in the pregnant
woman.
o A pregnant mother may also require calcium, iron and vitamin B-12
supplements.
o Choose at least five daily servings of fruits and vegetables. Also try whole
grain foods such as ragi, dal, brown bread, whole grain pulses and lentils.
o Whenever possible eat fruits with the peel and remember that eating a fruit
is more beneficial than drinking fruit juice.
o Drink at least 12 glasses of fluid per day.
o Only take chemical laxatives prescribed by an obstetrician.
If weight gain is too rapid during any part of the pregnancy, the following guidelines
should be used to manage weight:
Avoid high-calorie, low-nutrient foods such as sweets, cakes, pastries,
desserts and fried snacks like chips, vadas, bondas etc.
Use low-fat dairy products-skimmed milk and yogurt/curd made with
skimmed milk.
Use only lean meats, poultry and fish.
Bake, broil, grill, or stir-fry instead of frying foods.
Increase physical activity.
Do not crash diet!!!
References:
1) Williams obstetrics 23rd edition
2) D.K.James - High risk pregnancy management options 4rd edition
3) Steven G Gabbe -Obstetrics 5th edition
4) Maternal nutrition: A Quintessential Guide- Kamini Rao, Vindhya Subbiah