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Hydration in pregnancy and breastfeeding

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A scientific review of the role and the importance of water during pregnancy and breastfeeding.

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Hydration in pregnancy and breastfeeding

  1. 1. Developed by for the Hydration for Health Initiative Hydration in pregnancy and breastfeeding Physiological changes, water balance and water needs
  2. 2. Get this content online 1 http://www.h4hinitiative.com/h4h-academy/hydration-lab/ www.h4hinitiative.com
  3. 3. Hydration and the role of water during pregnancy Body water changes Essential changes for fetus’ development and fluid supply Body water balance Adaptations to ensure body water balance Emerging science regarding water and health outcomes during pregnancy Hydration and the role of water during lactation Water in breast milk Consequences of breastfeeding for body water Guidelines for fluid intake during pregnancy and lactation Key facts References - References are sorted by slide, at the end of the presentation Content 2 www.h4hinitiative.com
  4. 4. Hydration and the role of water during pregnancy
  5. 5. Location of additional body water in pregnant women at term 4 Hydration and the role of water during pregnancy Body water changes Increase in the mother’s total body water (6 to 8L) is needed for plasma volume expansion, for constitution of the amniotic fluid and for the placenta. 10% 6% 29% 19% 14% 8% 14% Amniotic fluid Placenta Fetus, mostly composed of water (75-90%) Blood Uterus + breast Other tissue (fat) Extracellular fluid (adapted from Pitkin, 1976) www.h4hinitiative.com
  6. 6. 5 Hydration and the role of water during pregnancy Essential changes for fetus’ development and fluid supply www.h4hinitiative.com Amniotic fluid (AF) • Mainly composed of water: 500 to 1200mL • Water reservoir insuring protection and development of the fetus Plasma volume • Increases up to 40-50% above pre-pregnancy level • Osmolality decreases from 290 to 280 mosm/kg compared to non-pregnant women Placenta • 85% water (≈ 500mL of water) • Major organ supplying water to the fetus: from 100 mL/hour at 12 weeks to 3600 mL/hour at term
  7. 7. INPUTS LOSSESINPUTS LOSSES Hydration and the role of water during pregnancy Water balance in pregnant women Body water balance = (sum of water inputs) – (sum of water losses) 6 Water needs in pregnant women are increased due to the increase in energy intake and weight gain. VS Breathing + Faeces Skin Water from fluid Water from food Metabolic water Urine Non-pregnant women Pregnant women Breathing + Faeces Skin Water from fluid Water from food Metabolic water Urine Increased energy intake www.h4hinitiative.com + 6 to 8L of body water Supporting fetus + fluid environment
  8. 8. Hydration and the role of water during pregnancy Adaptations to ensure body water balance Regulation of body water balance is the same in pregnant and in non-pregnant women 7 www.h4hinitiative.com Thirst -+ AVP Stimulation of Osmoreceptors in hypothalamus - -+ Pituitary gland Water intake Permeability to water Kidneys Water deficit Water excessPLASMA OSMOLALITY Small volume of concentrated urine Water reabsorption Water reabsorption Larger volume of diluted urine - Plasma osmolality thresholds initiating thirst and arginine vasopressin (AVP) secretion are lowered during pregnancy, enabling pregnant women to achieve a normal water balance based on these new levels.
  9. 9. Hydration and the role of water during pregnancy Main adaptations of the urinary tract in pregnancy 8 Adaptations to ensure body water balance www.h4hinitiative.com Kidney • Length increases by approx. 1% • Volume increases by up to 30% • Renal plasma flow increases by 50-85% • Increase in GFR by 40-65% Bladder • Doubling of the bladder capacity (1 000 mL) Ureters • Dilatation of the ureters
  10. 10. Hydration and the role of water during pregnancy Potential consequences of maternal fluid intake on fetal well-being Emerging science regarding water and health outcomes First evidence in pregnant women seems to indicate a potential benefit of increased water intake on amniotic fluid volume in women with low amniotic fluid volume. Fluid intake www.h4hinitiative.com Amniotic fluid volume • Recognized as a predictor of fetal well-being and subsequently of poor perinatal outcome • Can be evaluated using the amniotic fluid index (AFI) Amniotic fluid index (AFI) • In pregnant women with low amniotic fluid volume, maternal fluid intake may influence AFI 9
  11. 11. Hydration and the role of water during pregnancy Emerging science regarding water and health outcomes Constipation and Urinary tract infections in pregnant women 10 As in non-pregnant women, hydration might be beneficial against constipation and urinary tract infections recurrence. However more research is needed to clearly establish these relationships. www.h4hinitiative.com Constipation • Affects up to 40% of pregnant women • A high fiber diet, combined with drinking more water, could prevent or relieve constipation Urinary tract infection (UTI) • Most common bacterial infection • In 2 to 10% of pregnancies, UTI is asymptomatic • Up to 2% of pregnant women will experience pyelonephritis due to untreated asymptomatic bacteria • Preliminary evidence in non-pregnant women suggest that: o fluid restriction might increase susceptibility to UTI o increasing water intake might help decrease the risk of recurrence of UTI
  12. 12. Hydration and the role of water during lactation
  13. 13. Milk production gradually increases across the lactating period, averaging 750mL/d at 6 months postpartum (in exclusively breastfeeding women) 12 Hydration and the role of water during lactation Water in breast milk Breast milk contains, on average, 87% of water. Since breast milk production uses maternal body water, 750mL of milk per day at 87% of water represents a significant extra water loss for the mother. (adapted from Neville et al. 1988) www.h4hinitiative.com 550 600 650 700 750 800 7-14 15-28 30-59 60-150 Days postpartum BreastMilkproduction(mL/d)
  14. 14. INPUTS LOSSES 13 Hydration and the role of water during lactation Water balance in breastfeeding women The mother needs to compensate the quantity of water lost with maternal milk production (estimated at 600 to 700 mL/d) by drinking sufficient water. Milk production: • Is not affected, within normal limits, by maternal fluid intake volume • Usually meets infants needs even if it puts the mother at risk of dehydration VS Breathing + Faeces Skin Water from fluid Water from food Metabolic water Urine Non-breastfeeding women Breastfeeding women Breathing + Faeces Skin Water from fluid Water from food Metabolic water Urine Milk output www.h4hinitiative.com INPUTS LOSSES
  15. 15. Reference values for total water intake vary greatly among countries because of the methodological differences used to establish references Guidelines for total water intake* during pregnancy and lactation 14 Country (References) World (WHO, 2003) USA & Canada (IoM, 2004) Australia & New Zealand (NHMRC, 2006) Europe (EFSA, 2010) Adult women 2200 mL/d 2700 mL/d 2800 mL/d 2000 mL/d Pregnant women 4800 mL/d 3000 mL/d 3100 mL/d 2300 mL/d Breastfeeding women 5500 mL/d 3800 mL/d 3500 mL/d 2700 mL/d Additional amounts of water recommended during pregnancy and lactation are globally consistent, about +300 mL per day in pregnant women and +700 mL per day in breastfeeding women. *total water intake includes drinking water, water in other beverages, and water in food. It is estimated that 80% of total water intake comes from fluid sources (Institute of Medicine, Dietary Reference Intakes for Water, Sodium, Potassium, Sodium, Chloride and Sulfate. National Academies Press, 2004). www.h4hinitiative.com
  16. 16. Key facts to keep in mind 15 Body water increases by 6 to 8L Increased water needs in healthy pregnant women vs adult women o Against constipation o Against urinary tract infections recurrence To compensate water lost in milk output RECOMMENDATIONS FOR TOTAL WATER INTAKE VS ADULT WOMEN (IOM, NHMRC, EFSA) Pregnant women + 300 mL/d Breastfeeding women + 700 mL/d ADAPTATIONS FOR BODY WATER REGULATION: o Reduction of plasma osmolality thresholds and AVP secretion o Adaptations of the urinary tract WATER INTAKE COULD BE BENEFICIAL: www.h4hinitiative.com To compensate for the increased energy intake and weight gain Increased water needs in healthy breastfeeding women vs adult women Breast milk production averages 750ml/d at 6 month postpartum, containing on average 87% of water Supports: amniotic fluid constitution, placenta, and higher blood volume.
  17. 17. Pitkin RM. Nutritional support in obstetrics and gynecology. Clin Obstet Gynecol. 1976; 19(3):489-513. Chesley LC. Hypertensive Disorders in Pregnancy. New York: Appleton- Century-Crofts; 1978. Hytten FE. Weight gain in pregnancy. In: Hytten FE, Chamberlain G, eds. Clinical Physiology in Obstetrics, Blackwell Scientific 1980: Oxford, pp. 193-230. Beall MH, van den Wijngaard JPHM, van Gemert MJC, Ross MG. Amniotic Fluid Water Dynamics. Placenta 2007; 28(8- 9):816-23. Larciprete G, Valensise H, Vasapollo B, Altomare F, Sorge R, Casalino B, De Lorenzo A, Arduini D. Body composition during normal pregnancy: reference ranges. Acta Diabetol. 2003; 40 Suppl 1:S225-32. Bibliographic references 16 Slide 4 – Hydration and the role of water during pregnancy – Body water changes www.h4hinitiative.com
  18. 18. Clapp JF, Seward BL, Sleamaker RH, Hiser J. Maternal physiologic adaptations to early human pregnancy. Am J Obstet Gynecol. 1988; 159:1456-60. Metcalfe J, Ueland K. Maternal cardiovascular adjustments to pregnancy. Prog Cardiovasc Dis. 1974; 16:363. Ueland, K. Cardiorespiratory physiology of pregnancy. In: Gynecology and Obstetrics, Vol 3. Harper and Row, Baltimore 1979. Davison JM, Vallotton MB, Lindheimer MD. Plasma osmolality and urinary concentration and dilution during and after pregnancy: evidence that lateral recumbency inhibits maximal urinary concentrating ability. BJOG 1981; 88(5):472-9. Goodwin JW, Godden JO, Chance GW. Perinatal medicine: the basic science underlying clinical practice. Baltimore: The Williams and Wilkins Co 1976, 617 pp. Barker G, Boyd RD, D’Souza SW, Donnai P, Fox H, Sibley CP. Placental water content and distribution. Placenta 1994 Jan; 15(1):47- 56. Meschia G (1983). Circulation to female reproductive organs. In Handbook of Physiology, Sect. 2, Vol. III, part 1, ed. ShepherdJT &AbboudFM, pp. 241–269. American Physiological Society, Bethesda , MD. Reynolds LP and Redmer DA (1995). Utero-placental vascular development and placental function. J Anim Sci. 73, 1839–1851. Hutchinson Dl, Gray Mj, Plentl Aa, Alvarez H, Caldeyro-Barcia R, Kaplan B, Lind J. The role of the fetus in the water exchange of the amniotic fluid of normal and hydramniotic patients. J Clin Invest. 1959 Jun;38(6):971-80. Bibliographic references 17 Slide 5 – Hydration and the role of water during pregnancy – Essential changes for fetus’ development and fluid supply www.h4hinitiative.com
  19. 19. Shirreffs SM. Markers of hydration status. Eur J Clin Nutr. 2003; 57 Suppl 2:S6-9. Benelam B, Wyness L. Hydration and health: a review. Nutr Bull. 2010; 35(1):3-25. Grandjean AC, Reimers KJ and Buyckx ME. Hydration: issues for the 21st century. Nutr Rev. 2003; 61:261-71. EFSA, EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA). Scientific Opinion on Dietary reference values for water. EFSA Journal 2010; 8(3):1459, 48 pp. Bibliographic references 18 Davison JM. The kidney in pregnancy: a review. J R Soc Med. 1983 June; 76(6): 485–501. Brenner BM, Rector S. ed. Brenner and Rector’s The Kidney. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2008. Slide 7 – Hydration and the role of water during pregnancy – Adaptations to ensure body water balance Slide 6 – Hydration and the role of water during pregnancy – Water balance in pregnant women www.h4hinitiative.com
  20. 20. Brenner BM, Rector S. ed. Brenner and Rector’s The Kidney. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2008. Jeyabalan A, Lain KY. Anatomic and functional changes of the upper urinary tract during pregnancy. Urol Clin North Am. 2007 Feb;34(1):1-6. Bibliographic references 19 Slide 8 – Hydration and the role of water during pregnancy – Adaptations to ensure body water balance www.h4hinitiative.com
  21. 21. Bibliographic references 20 Beall MH, van den Wijngaard JPHM, van Gemert MJC, Ross MG. Amniotic Fluid Water Dynamics. Placenta 2007; 28(8- 9):816- 23. Fok WY, Chan LY, Lau TK. The influence of fetal position on amniotic fluid index and single deepest pocket. Ultrasound Obstet Gynecol. 2006; 28(2):162-5. Borges VT, Rososchansky J, Abbade JF, Dias A, Peraçoli JC, Rudge MV. Effect of maternal hydration on the increase of amniotic fluid index. Braz J Med Biol Res. 2011; 44(3):263-6. Fait G, Pauzner D, Gull I, Lessing JB, Jaffa AJ, Wolman I. Effect of 1 week of oral hydration on the amniotic fluid index. J Reprod Med. 2003; 48(3):187-90. Kilpatrick SJ, Safford KL, Pomeroy T, Hoedt L, Scheerer L, Laros RK. Maternal hydration increases amniotic fluid index. Obstet Gynecol. 1991; 78(6):1098-102. Hofmeyr GJ, Gülmezoglu AM, Novikova N. Maternal hydration for increasing amniotic fluid volume in oligohydramnios and normal amniotic fluid volume. Cochrane Database Syst Rev. 2002; (1):CD000134. Slide 9 – Hydration and the role of water during pregnancy – Emerging science regarding water and health outcomes www.h4hinitiative.com
  22. 22. Bibliographic references 21 Brenner BM, Rector S. ed. Brenner and Rector’s The Kidney. 8th ed. Philadelphia, Pa: Saunders Elsevier; 2008 Anderson AS. Constipation during pregnancy: incidence and methods used in its treatment in a group of Cambridgeshire women. Health Visitor 1984; 57:363-64. Cullen G, O’Donoghue D. Constipation and pregnancy. Best Pract Res Clin Gastroenterol. 2007; 21(5):807-18. Cranston D, McWhinnie D, Collin J. Dietary fibre and gastrointestinal disease. Br J Surg. 1988; 75:508-12. Trottier M, Erebara A, Bozzo P. Treating constipation during pregnancy. Can Fam Physician 2012; 58(8):836-8. Schnarr J, Smaill F. Asymptomatic bacteriuria and symptomatic urinary tract infections in pregnancy. Eur J Clin Invest. 2008 Oct;38 Suppl 2:50-7. doi: 10.1111/j.1365-2362.2008.02009.x. Dwyer PL, O’Reilly M. Recurrent urinary tract infection in the female. Curr Opin Obstet Gynecol. 2002 Oct;14(5):537-43. Beetz R. Mild dehydration: a risk factor of urinary tract infection? Eur J Clin Nutr. 2003; 57 Suppl 2:S52-8. Eckford SD, Keane DP, Lamond E, Jackson SR and Abrams P. Hydration monitoring in the prevention of recurrent idiopathic urinary tract infections in pre-menopausal women. Br J Urol. 1995; 76:90-3. Nygaard I, Linder M. Thirst at work--an occupational hazard? Int Urogynecol J Pelvic Floor Dysfunct. 1997;8(6):340-3. Pitt M. Fluid intake and urinary tract infection. Nursing Times 1989; 85:36-8. Slide 10 – Hydration and the role of water during pregnancy – Emerging science regarding water and health outcomes www.h4hinitiative.com
  23. 23. EFSA, EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA). Scientific Opinion on Dietary reference values for water. EFSA Journal 2010; 8(3):1459, 48 pp. Neville MC, Keller R, Seacat J, Lutes V, Neifert M, Casey C, Allen J, Archer P. Studies in human lactation: milk volumes in lactating women during the onset of lactation and full lactation. Am J Clin Nutr. 1988; 48(6):1375-86. Bibliographic references 22 EFSA, EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA). Scientific Opinion on Dietary reference values for water. EFSA Journal 2010; 8(3):1459, 48 pp. Slide 12 – Hydration and the role of water during lactation – Water balance in breast milk Slide 13 – Hydration and the role of water during lactation – Consequences of breastfeeding for body water www.h4hinitiative.com
  24. 24. WHO (World Health Organization). Domestic water quantity, service level and health. 2003. WHO/SDE/WSH/3.02. IoM (Institute of Medicine) National Academies of Science. Dietary reference intakes for water, potassium, sodium, chloride and sulfate. The National Academies Press, Washington DC, 2004. NHRMC (National Health and Medical Research Council). Nutrient Reference Values for Australia and New Zealand Including Recommended Dietary Intakes. 2006. Reference number: N35. EFSA (European Food Safety Authority), EFSA Panel on Dietetic Products, Nutrition, and Allergies (NDA). Scientific Opinion on Dietary reference values for water. EFSA Journal 2010; 8(3):1459, 48 pp. Bibliographic references 22 Slide 15 – Guidelines for total water intake during pregnancy and lactation www.h4hinitiative.com
  25. 25. Access Hydration in pregnancy and breastfeeding Monograph online To learn more 23 http://www.h4hinitiative.com/h4h-academy/hydration- lab/hydration-pregnancy-and-breastfeeding Visit the H4H website http://www.h4hinitiative.com/everyday- hydration/different-needs-different-life-stages www.h4hinitiative.com
  26. 26. Developed by for the Hydration for Health Initiative

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