Chapter 11

1,376 views

Published on

Published in: Health & Medicine
  • Be the first to comment

Chapter 11

  1. 1. CHAPTER 11Nutrition During Pregnancy and Lactation Sharon M. Nickols-Richardson Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
  2. 2. Maternal Nutrition and the Outcome of PregnancyEarly Medical Practice Two assumptions, now known to be false, governed practice:  1. The parasite theory: whatever the fetus needs, it draws from maternal stores despite the maternal diet  2. The maternal instinct theory: whatever the fetus needs, the pregnant woman instinctively craves and consumes Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2
  3. 3. Maternal Nutrition and the Outcome of Pregnancy – Cont’dHealthy Pregnancy A healthy pregnancy has often been defined by the birth weight of the newborn Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3
  4. 4. Maternal Nutrition and the Outcome of Pregnancy – Cont’dFactors Determining Nutritional Need Maternal nutrition is critically important to both the mother and newborn Age, gravida, and parity determine nutritional requirements of the woman during her pregnancy Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4
  5. 5. Maternal Nutrition and the Outcome of Pregnancy – Cont’dComplex Physiologic Interactionsof Gestation Three distinct biologic entities are involved during gestation:  1. The woman  2. The fetus  3. The placenta, which nourishes fetal growth Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5
  6. 6. Basic Concepts Involved Three basic concepts form a fundamental framework for assessing maternal nutritional needs and for planning supportive prenatal care for the woman:  1. Perinatal concept  2. Synergism concept  3. Life continuum concept Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6
  7. 7. Preconception Nutrition Preconception counseling and optimal preconception nutrition may increase the odds for a healthy pregnancy and desirable infant outcome Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7
  8. 8. Preconception Nutrition – Cont’dExercise Women who exercise before pregnancy should continue a reasonable exercise regimen during pregnancy Kilocalories (kcalories or kcal) must be consumed to meet the energy cost of exercise and to promote appropriate maternal weight gain and fetal growth and development Adequate hydration is also vital Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8
  9. 9. Nutritional Demands of Pregnancy Kcalories must be sufficient to perform the following two functions:  1. Supply the increased energy and nutrient demands created by the increased metabolic workload, including some maternal fat storage and fetal fat storage to ensure an optimal newborn size for survival  2. Spare protein for tissue building Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9
  10. 10. Nutritional Demands of Pregnancy – Cont’d Approximately 340 additional kcal/day are needed during the second trimester Approximately 450 additional kcal/day during the third trimester Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10
  11. 11. Nutritional Demands of Pregnancy – Cont’dProtein Approximately 71 g/day is needed  More protein is necessary for the following: • Rapid fetal growth • Enlargement of the uterus, mammary glands, and placenta • Increase in maternal circulating blood volume Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11
  12. 12. Nutritional Demands of Pregnancy – Cont’dProtein – cont’d Approximately 71 g/day is needed – cont’d  More protein is necessary for the following: – cont’d • Formation of amniotic fluid • Storage reserves for labor, delivery, and lactation  Milk, egg, cheese, and meat are complete protein foods Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12
  13. 13. Nutritional Demands of Pregnancy – Cont’d An adequate supply of essential fatty acids is needed  Linoleic acid: 13 g/day  Alpha-linolenic acid: 1.4 g/day Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13
  14. 14. Nutritional Demands of Pregnancy – Cont’dCarbohydrates At least 175 g/day during pregnancy Whole grain breads, cereals, fresh fruits, and vegetables should be consumed Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14
  15. 15. Nutritional Demands of Pregnancy – Cont’d Total daily dietary kcalorie intake should comprise:  15% protein  30% fat  55% carbohydrate Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15
  16. 16. Nutritional Demands of Pregnancy – Cont’dCalcium 1000 mg of calcium per day Essential element for the construction and maintenance of bones and teeth An important factor in the blood-clotting mechanism and normal muscle action Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16
  17. 17. Nutritional Demands of Pregnancy – Cont’dIodine 70 µg/day during pregnancy Vital for thyroid hormone synthesis and prevention of goiter Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17
  18. 18. Nutritional Demands of Pregnancy – Cont’dIron 27 mg of iron per day A daily supplement of 30 to 60 mg of iron may be prescribed Maternal iron is needed to supply iron to the developing placenta and fetal liver Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18
  19. 19. Nutritional Demands of Pregnancy – Cont’dIron – cont’d Major food source of iron is liver Other food sources include meat, legumes, dried fruit, green leafy vegetables, eggs, and enriched bread and cereals Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19
  20. 20. Nutritional Demands of Pregnancy – Cont’dZinc Increases from 8 to 11 mg/day Vital for enzymatic reactions Essential to growth and development due to its role in deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) synthesis and protein production Seafood, eggs, and meat are primary sources of zinc Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20
  21. 21. Nutritional Demands of Pregnancy – Cont’dVitamin A 770 µg of retinol activity equivalents (RAE) Essential factor in cell differentiation, organ formation, maintenance of strong epithelial tissue, tooth formation, and normal bone growth Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21
  22. 22. Nutritional Demands of Pregnancy – Cont’dVitamin A – cont’d Good sources: Liver, egg yolk, butter and fortified margarine, dark green and yellow vegetables, and fruits Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22
  23. 23. Nutritional Demands of Pregnancy – Cont’dB Vitamins Special need for thiamin, riboflavin, niacin, pyridoxine, cobalamin, pantothenic acid, and folate during pregnancy Coenzyme factors in a number of metabolic activities related to energy production, tissue protein synthesis, and function of muscle and nerve tissue Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23
  24. 24. Nutritional Demands of Pregnancy – Cont’dFolate 600 µg/day during pregnancy 500 µg/day during lactation Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24
  25. 25. Nutritional Demands of Pregnancy – Cont’dVitamin C 85 mg/day for the pregnant woman Essential to the formation of intercellular cement substance in developing connective tissues and vascular systems Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25
  26. 26. Nutritional Demands of Pregnancy – Cont’dVitamin D 5 µg cholecalciferol (200 IU/day) Used to promote the absorption and utilization of calcium and phosphorus Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26
  27. 27. General Daily Food Pattern Two useful general principles:  1. Eat an appropriate quantity of food  2. Eat regularly, avoiding fasting or skipping meals, especially breakfast Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27
  28. 28. Alternative Food Patterns With the increasing ethnic diversity in the United States, it is especially important to use the woman’s personal cultural food patterns in dietary counseling Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28
  29. 29. Dietary Supplements “Prenatal vitamins” are often prescribed for pregnant women Supplements include a variety of vitamins and minerals and are intended to add to nutrient intake from foods rather than replace food and nutrient consumption Herbal and botanical supplement use during pregnancy is discouraged Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29
  30. 30. Weight Gain During Pregnancy An average weight gain during normal pregnancy is about 11 to 16 kg (25 to 35 lb) Normal weight women with body mass index (BMI) of 19.8 to 26.0: 11.5 to 16 kg (25 to 35 lb) Underweight women with BMI of less than 19.8: 13 to 18 kg (28 to 40 lb) Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30
  31. 31. Weight Gain During Pregnancy – Cont’d Overweight women with BMI of greater than 26.0 to 29.0: 7 to 11.5 kg (15 to 25 lb) Obese women with BMI of greater than 29.0: minimum of 7 kg (15 lb) Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31
  32. 32. Quality of Weight Gain Foods consumed should be nutrient dense, not full of empty kcalories Analysis of the total tissue gained in an average pregnancy shows that the largest component, 62%, is water Fat accounts for 31% and protein for 7% Weight reduction should never be undertaken during pregnancy Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32
  33. 33. Rate of Weight Gain Approximately 1 to 2.3 kg (2 to 5 lb) is an average weight gain during the first trimester An average weight gain of about 0.5 kg (1 lb)/week during the remainder of the pregnancy is usual Some women may need to gain more Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33
  34. 34. Rate of Weight Gain – Cont’dSodium Intake 1.5 to 2.3 g/day Limiting sodium beyond this general use is contrary to physiologic need in pregnancy and is unfounded Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34
  35. 35. Functional Gastrointestinal ProblemsNausea and Vomiting Usually mild and short term, the so-called “morning sickness” of early pregnancy At least 50% of all pregnant women experience this condition Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35
  36. 36. Functional Gastrointestinal Problems – Cont’dHyperemesis Approximately 3.5:1000 pregnancies Severe form of persistent nausea and vomiting occurs that does not respond to usual treatment May develop into the more serious pernicious form of hyperemesis gravidarum Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36
  37. 37. Functional Gastrointestinal Problems – Cont’dConstipation Contributes to discomfort and concern Placental hormones relax the gastrointestinal muscles The pressure of the enlarging uterus on the lower portion of the intestine may make elimination somewhat difficult Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37
  38. 38. Functional Gastrointestinal Problems – Cont’dConstipation – cont’d Increased fluid intake, the use of naturally laxative foods containing dietary fiber, and exercise may help Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 38
  39. 39. Functional Gastrointestinal Problems – Cont’dHemorrhoids Common complaint during the latter part of pregnancy May cause considerable discomfort, burning, and itching Problem is usually controlled by the dietary suggestions given for constipation Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 39
  40. 40. Functional Gastrointestinal Problems – Cont’dHeartburn and Gastric Pressure Discomforts occur especially after meals and are usually caused by the pressure of the enlarging uterus crowding the stomach Usually remedied by dividing the day’s food into a series of small meals Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 40
  41. 41. High-Risk PregnanciesPlan Personal Care Once early assessment identifies risk factors, practitioners can then give more careful attention to these women A food plan can be developed with the woman to ensure an optimal intake of energy and nutrients to support her pregnancy Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41
  42. 42. High-Risk Pregnancies – Cont’dRecognize Special Counseling Needs Several special needs require sensitive counseling Include the age and parity of the woman; any use of harmful agents such as alcohol, cigarettes, drugs, or pica; and socioeconomic problems Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 42
  43. 43. High-Risk Pregnancies – Cont’dAge and Parity Nulligravida (no prior pregnancy) who is 15 years of age or younger  Especially at risk because her own growth is incomplete  Sufficient weight gain and the quality of her diet are particularly important Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 43
  44. 44. High-Risk Pregnancies – Cont’dAge and Parity – cont’d Primigravida (first pregnancy) older than 35 years also requires special attention  May be more at risk for hypertension and need more attention to the rate of weight gain and amount of sodium used Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 44
  45. 45. High-Risk Pregnancies – Cont’dSocial Habits Alcohol  Fetal alcohol syndrome (FAS), which is currently a leading cause of mental retardation Cigarettes  Cause fetal damage and special problems of placental abnormalities Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 45
  46. 46. High-Risk Pregnancies – Cont’dSocial Habits – cont’d Drugs  Abnormal fetal heart rate  Fetal damage  Poor prenatal weight gain  Very short (less than 3 hours) or prolonged labor  Operative delivery  Other perinatal problems Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 46
  47. 47. Complications of PregnancyAnemia Associated with the normal maternal blood volume increase of 40% to 50% and a disproportionate increase in red cell mass of about 20% Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 47
  48. 48. Complications of Pregnancy – Cont’dIron Deficiency Anemia Iron requirement typically exceeds the available reserves in the average woman Daily supplement or higher therapeutic dose may be required Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 48
  49. 49. Complications of Pregnancy – Cont’dFolate Deficiency Anemia Fetus is sensitive to folate inhibitors and therefore has increased metabolic requirements for folate Dietary Reference Intake (DRI) standard recommends 600 µg of folate per day during pregnancy Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 49
  50. 50. Complications of Pregnancy – Cont’dHemorrhagic Anemia Anemia caused by blood loss is more likely to occur during labor and delivery than during pregnancy Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 50
  51. 51. Pregnancy-Induced Hypertension Disease that principally affects young women with their first pregnancy Diets poor in kcalories, protein, calcium, magnesium, potassium, and dietary fiber have been associated with risk of pregnancy- induced hypertension (PIH) Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 51
  52. 52. Pregnancy-Induced Hypertension – Cont’dClinical Symptoms Abnormal and excessive edema, albuminuria, and, in severe cases, convulsions or coma, a state called eclampsia Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 52
  53. 53. Pregnancy-Induced Hypertension – Cont’dTreatment Regular diet with adequate dietary protein and calcium and one that is rich in fruits and vegetables, providing magnesium, potassium, and dietary fiber Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 53
  54. 54. Multiple Fetuses Energy intake must be increased beyond the needs of a singleton pregnancy such that the recommended weight gain for multiple fetuses is achieved Adequate folate intake is critical to reduce risks of low birth weights Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 54
  55. 55. Multiple Fetuses – Cont’d Supplemental iron may be necessary Additional calcium and vitamin D are needed Zinc, copper, and pyridoxine supplementation may also be required Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 55
  56. 56. Maternal Disease Conditions Some of these problems can be prevented by initial screening and continued monitoring by the prenatal nurse, with referral to the clinical nutritionist for a plan of care:  Hypertension  Diabetes mellitus  Phenylketonuria (PKU)  Acquired immunodeficiency syndrome (AIDS)  Eating disorders Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 56
  57. 57. Nutrition During Lactation Approximately 71% of mothers initiate breast- feeding Exclusive breast-feeding by well-nourished mothers can be adequate for periods ranging from 2 to 15 months Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 57
  58. 58. Nutrition During Lactation – Cont’d The basic nutritional needs for lactation include the following additions to the mother’s prepregnancy needs:  Energy: Caloric increase is 330 kcal/day (plus 170 kcal/day from maternal stores) for first 6 months and 400 kcal/day in the second 6 months  Protein: 71 g/day during first 6 months  Calcium: 1000 mg/day Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 58
  59. 59. Nutrition During Lactation – Cont’d The basic nutritional needs for lactation include the following additions to the mother’s prepregnancy needs: – cont’d  Vitamins: DRI for Vitamin C during lactation is 120 mg/day  Fluids: A pale yellow color of the urine suggests adequate fluid intake  Dietary supplements: Continue the woman’s prenatal nutrient supplements during lactation Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 59
  60. 60. Nutrition During Lactation – Cont’d The basic nutritional needs for lactation include the following additions to the mother’s prepregnancy needs: – cont’d  Rest and relaxation: Both parents may benefit from counseling focused on reducing the stresses of their new family situation  Maternal medical conditions: Some conditions exist for which it is recommended that women in the United States not breast-feed Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 60

×