Tuesday, January 25, 2011

Nutrition In Pregnancy And Lactation

Well balanced diet and adequate nutrition are vital throughout, however, the diet you consume becomes more important during pregnancy. Healthy eating has a significant effect on the pregnancy outcome.

Nutrition Requirements

The total calorie requirement increases during pregnancy. However, the pregnant women need not literally eat for two. An additional 300 calories is all that one requires per day during pregnancy.

Protein requirement increases during pregnancy since the tissues of the growing fetus are made from protein and hence an additional 15g per day.
Incorporate more protein in the diet by including eggs, poultry (well-cooked) and fish (low mercury content and the ones allowed by the FDA mentioned below) as well as milk and milk products (pasteurized) and pulses and legumes.

Iron requirements increase during pregnancy to meet the demands of the fetus and the increase in the mother’s blood volume. 

Folic acid:
Folic acid is a very important vitamin and the requirement increases to 400 mcg during pregnancy that women in the child-bearing age, especially those trying to conceive take 400 mcg and those who are pregnant take 600-800 mcg supplemental folic acid per day.

Vitamin B6:
There is no research that strongly supports that vitamin B6 supplementation helps in morning sickness. However, Vitamin B6 could help to relieve symptoms of morning sickness in some women. Consult your doctor before starting supplement use. Incorporating cereals, nuts and legumes increases the vitamin B6 intake.

Vitamin A:
Vitamin A requirements remain the same as a non-pregnant woman. Adequate amounts of the vitamin should be acquired by incorporating yellow-orange fruits and vegetables as well as green leafy vegetables, milk and milk products, eggs, fish and poultry. However excess vitamin A is teratogenic (harmful to the fetus and causes birth anomalies). Hence supplementation is a complete no unless otherwise advised by the doctor.

Omega-3 fats:
Omega-3 fats, mainly Docosahexanoic acid (DHA), is vital for the fetal brain development. Sources include fish – salmon, sardines, tuna, herring, hilsa and fish oil.
Flaxseeds, walnuts, pumpkin seeds, contain high amounts of Omega-3 fats.

Nutrition Tips

Do not consume raw meat, fish and eggs to avoid ingestion of harmful bacteria and viruses.

Sea food:
High levels of mercury in fishes could cause damage to the infant’s developing brain. The Food and Drug Administration (FDA) recommends that pregnant women avoid shark, mackerel, swordfish and tilefish. Shrimp, tuna, salmon, catfish and pollock can be consumed in limited amounts.
However, certain fishes are an excellent source of omega-3 fatty acids (EPA and DHA) such as Salmon, sardines, tuna, herring, hilsa which are important for the development of the brain of the growing fetus. Tinned and canned fish varieties to be avoided.

Dairy products:
Milk, paneer, cheese, curds – supply calcium, protein and calories and can all be incorporated in the meals, however, unpasteurized milk and products made from unpasteurized milk should not be consumed.

Meat – poultry:
Avoid undercooked meat since it could contain various bacteria and viruses causing food-borne illnesses. E.g. listeriosis (bacterial infection affecting Central Nervous System).

Alcohol can pass through the placenta and enter the fetus’ system and hence should be completely avoided. Alcohol intake by the mother can cause several deformities as well as impair the brain development in the child. Low birth weight could also be a result of moderate alcohol intake.

Caffeine also hinders the fetal development and needs to be restricted mainly during the first trimester. 

Smoking and tobacco chewing are to be avoided since it can harm the fetus. 

Consult your doctor before taking any medication.
General Guidelines

  • Eat a well balanced diet to meet you calorie, protein and micronutrient requirements.
  • Consume a plethora of fruits and vegetables since they not only provide you with the antioxidants to fight stress but also provide fibre that ensures regular bowel movements and prevents constipation.
  • Consume three regular meals and 2 to 3 equally spaced snacks through out the day. 
  • In case of morning sickness, have dry carbohydrate containing foods such as toast, biscuits, chapatti, oats etc. at dawn. These help neutralize stomach acid and decrease the nausea. Also avoid strong odours such as garlic, onion etc that could exacerbate symptoms.
  • Avoid any food that causes nausea or leads to discomfort.
  • Ensure that poultry, fish and eggs are well-cooked to avoid bacterial or viral infection.
  • Consume more of nutrient dense foods than calorie dense foods.
  • Avoid fried foods.

Myth1: ‘Eating for two’ myth
Technically, you are eating for two. But your baby is only a few kgs (3 – 3.5 kgs at birth) and it does not really need as much as you. The calorie and nutrient intake needs to be increased but you just need an additional 300 calories, especially in the latter two trimesters.

Myth 2: ‘Don’t need vitamins till pregnant’ myth
Adequate vitamin intake prior to conception is vital. Folic acid supplements (400-600 mcg/day) are recommended to women who are trying to conceive.

Myth 3: ‘Food craving indicate nutritional deficiency’
Cravings are very common during pregnancy and there is no evidence to support that one craves for foods that are deficient or that their body needs. E.g. most often pregnant women crave for sweets, ice-creams etc. that contain only calories and trace amount of other nutrients. These cravings are a result of hormonal changes.

Myth 4: ‘Cant have coffee’ myth
Caffeine can pass through the placenta and harm the child if consumed in large amounts but 1-2 cups of coffee a day won’t do any harm. However, it is best to stick to one cup per day.

Myth 5: ‘Do not eat papaya’ myth 
Papaya is a rich source of beta-carotene (vitamin A precursor) as well as vitamin C and limited amounts (2-3 slices) of papaya per day are good for you. However, do not overdo papaya because excess of any food is not recommended. In case of a known allergy to papaya, it should be completely avoided.

Myth 6: ‘Hemoglobin levels should be normal’ myth
Hemoglobin levels in women should be 12-14g/dl. However, during pregnancy there is haemodilution – there is expansion in the blood volume and hence there is a physiological decrease in the levels of hemoglobin. However, strive to maintain your hemoglobin levels at 11g /dl. Consume iron rich foods such as fish, poultry and meat (only thoroughly cooked), dates, green leafy vegetables, ragi and poha. Supplementation with iron (100 mg elemental iron per day) has been recommended during pregnancy.
Nutrition In Lactation

Extended breastfeeding has been a way with Indians through time immemorial. However, more and more women are switching to shorter periods of breastfeeding in the past few decades due to a number of career-oriented and social influences. These reasons do not have a scientific base and should not be promoted.
 How Is Human Breast Milk Produced?

Post-partum (after delivery) as the estrogen and progesterone levels decrease and the oxytocin levels increase, lactation is facilitated.
Suckling of the neonate on the mother’s breast leads to the stimulation of certain sensory nerves in the areola (the dark area around the nipple) and the nipple that signal the hypothalamus that in turn stimulates the pituitary gland. The anterior pituitary gland then secretes a hormone – prolactin which activates milk production in the mammary glands.
At the same time the posterior pituitary gland secretes oxytocin that causes mammary contraction and thereby causing milk ejection from the breast. There is a classic tingling sensation when the milk is ejected. This is known as the ‘let-down’ reflex - meaning the milk is ready to flow. 

 When to start breast feeding?

     The infant should be put to the mother’s breast within ½ - 1 hour post-partum in case of a normal delivery against traditional beliefs and within 4 - 6 hours post-partum in case of a cesarean section.

Indian Academy of Pediatrics, American Academy of Pediatrics, Academyof Breast Medicine, World Health Organization and United Nations Children’s Fund recommend exclusive breastfeeding for the first 6 months and continued breastfeeding till 1 year of age. Breast feeding can be continued past 1 year of age if the mother and the infant are both keen on it.
Advantages / Benefits

Research shows that exclusive breastfeeding for the first 6 months decreases the incidence and severity of various infectious diseases compared to formula fed or partially breast fed infants.

 Benefits for Mothers

  • Release of oxytocin during lactation causes decreased postpartum bleeding and rapid uterine involution.
  • High oxytocin levels delays the onset of menstrual losses known as‘lactational amenorrhea’. The amount of iron concentrated in the breast milk is much lesser than that lost through menstruation – it thereby retains iron in the mother’s body and decreases the risk for iron deficiency anemia.
  • Moreover, lactational amenorrhea provides natural contraception and child spacing.
  • The extra fat accumulated during the second and third trimester of pregnancies is used up during the active production of breast milk during the lactational phase and thereby allowing a rapid return to the pre-pregnancy weight.
  • There is a decreased risk of breast, ovarian and endometrial cancer that can be attributed to reduction in the repetitive ovarian cycles and raised estrogen levels. A local physiologic action on the mammary gland tissues could also contribute to the reduced risk of breast cancer.
  • Since considerable amount ov calcium is lost in the breast milk one might think that it could lead to weak bones. However, research shows that the bone mineral density returns to pre-pregnancy levels or even higher during the lactaional phase. It thus offers a significant protection against osteoporosis and the incidence of hip fractures in the post menopausal stage.
  • There is also a decreased risk for developing rheumatoid arthritis. Recent research demonstrates a 50% decrease in risk or rheumatoid arthritis in those women who breastfed for >13 months and a 25% decreased risk in those who nursed for 12 months.
  • In women with gestational diabetes, breastfeeding helps maintain sugar control.
  • In women with type I diabetes prior to pregnancy, breastfeeding helps maintain sugar and cholesterol levels and keeps the weight under check.
  • Breastfeeding allows the development of a unique emotional bond between mother and the infant due to direct skin-to-skin contact and physical proximity. It also provides the infant with a feeling of security and protection.
Hunger Signs

Early signs of hunger include increased alertness and physical activity, mouthing and rooting. It is very important to pick up these early signs of hunger. Do not wait till the infant starts crying since crying is a late indicator of hunger.
Also it is very important to feed the infant on demand rather than having a set pattern/schedule unless the infant has not been breastfed for 4 hours.

How Do You Know That Your Infant Is Getting Enough?

The mother can produce enough milk for the infant’s requirements during the first 6 months. However post 6 months supplementary feeds need to be started.

Signs that the infant is getting enough milk

  • Constantly gains weight after the initial weight loss in the first few days
  • Passes urine 6-8 times a day
  • Passes 2-5 stools a day

       During each feed, first offer the infant one breast and don’t switch till the infant stops suckling on that breast. Then offer the other breast and let the infant take as much as it wants.
       This is important because when the infant is put to the breast, thin watery milk is produced – fore-milk (contains sugar and protein) that satisfies the infant’s thirst. The latter milk or hind milk (contains fat) is thicker in consistency and acts on the baby’s hunger.
Contraindications To Breastfeeding

  • HIV positive mothers should ideally not breastfeed their infants. However, in developing countries where there is a high incidence of infant mortality due to infections and malnutrition the benefits of breastfeeding outweigh the risk of HIV transmission. Check with your doctor or lactation consultant before taking a decision.
  • Active untreated TB
  • Human T-cell lympotrophic virus type I and type II
  • Herpes simplex lesions
  • Galactosemia – Galactosemia is an inborn error of carbohydrate metabolism wherein an enzyme – galactose 6- phosphate dehydorgenaserequired for the digestion of galactose is not produced in the infant’s body.
On digestion, milk sugar lactose is broken down to glucose and galactose. Hence it is not recommended to breastfeed an infant with galactosemia.
  • Exposure to chemotherapeutic agents
  • Exposure to diagnostic or therapeutic radioactive isotopes causes radioactivity in breast milk.
In case of temporary contraindications, breast milk should be pumped out to maintain breast milk production.
Non-Contraindications To Breastfeeding

§         Hepatitis B
§         Hepatitis C virus
§         Fever
§         Tobacco smoking is not an absolute contraindication but the mother should not smoke anywhere near the child and quit at the earliest. If smoking is continued, it is best advised post feeding the child rather than just before feeding.
§         Alcohol should be avoided during lactation since it easily passes into and concentrates the breast milk. It also inhibits milk production.
§         Jaundice of the new-born and hyperbilirubinemia
Nutrition requirements

Adequate amount of calories are essential during lactation since the mother has to produce enough milk for the infant apart from her requirements.
An additional 550 calories during the first 6 months and an additional 400 calories during the latter 6 months have been suggested to meet the calorie requirements.
Also, the fat stored during pregnancy is used up to meet the calorie requirements during lactation.

Protein requirements are increased by additional 25g per day during the first 6 months and 18g per day during the next 6 months. 

Milk is rich source of calcium and hence calcium supplementation is very important during lactation. In case of inadequate supply of calcium, the uses its calcium reserves to produce milk. Hence, 1000mh of calcium is recommended per day.

Iron requirement remain the same as that of a non-pregnant, non-lactating woman since the iron saved due to lactational amenorrhea is enough to meet the increased demands. Also human milk contains very little iron and hence an additional supplementation is not recommended unless advised by the doctor.
However, incorporate iron rich foods such as dates, green leafy vegetables, garden cress seeds, animal products.

Vitamin A:
Vitamin A needs are increased since milk produced by the mother is a good source of the vitamin. Thus an additional 350mcg of vitamin A has been advised. Consume plenty of yellow-orange fruits and vegetables that are a rich source of beta-carotene. Milk and milk products also contain vitamin A. however, supplementation is not advised.

 Nutrition Tips

§         Drink at least 2.5-3 L water daily since substantial part of the water consumed is used for milk production.
§         Drinking 1 glass of water each time after breast feeding is advisable.
§         Avoid alcohol intake since alcohol has a dehydrating effect. Alcohol can also pass through the breast milk and harm the infant.
§         Nicotine in all forms - tobacco chewing and smoking – has to be avoided.
§         Caffeine and carbonated beverages are also not recommended.
§         Consult your physician prior to taking any pills/medication.
§         Do not consume any foods that provoke symptoms in the infant such as discomfort, crying, improper sleep etc. after feeds.
§         Spicy foods could cause discomfort. Cabbage, Cauliflower, Brussel sprouts could also cause gas and abdominal discomfort.

Myth 1: ‘Do not give the baby the first thick yellow milk (colostrum)’ myth
This is not correct. In fact the first milk called the colostrum is rich in immune bodies that provide protection and immunity to the new-born. It also contains the right kind of protein and fat composition that the baby can digest.

Myth 2: ‘Stop breast feeding as soon as the baby is 1 year old’ myth
Indian Academy of Pediatrics, American Academy of Pediatrics, Academyof Breast Medicine, World Health Organization and United Nations Children’s Fund promote Exclusive Breast Feeding during the first six months of age and continued breast feeding during the next 6 months. However, this does not mean that you stop feeding into the next year of your baby’s life. You can continue to breast feed till 2 years or when the child weans off himself.

Myth 3: ‘The child becomes very dependent on the mother if he/she is breastfed for too long’ myth
In fact, if the child is breast fed, his security needs are taken care of at an early age and the child grows up to be more confident.

Myth 4: ‘Can’t make enough milk’ myth
Most healthy mothers will make enough milk as long as the baby is healthy and a proper latch-on technique is used. You will know that your baby is getting enough when he/she passes urine at least 6-8 times and 2-5 stools a day. Even, if the mother is not healthy, milk production is given top priority and high quality milk is produced by making use of the mother’s body stores.   

Myth 5: ‘Breast feeding will not allow me to lose weight’ myth
          Nursing your new-born causes involution of your uterus and milk production uses up the fat stored in your body through pregnancy and thereby helps you to shed weight faster. Some amount of exercise is recommended to go back to your pre-pregnancy weight and shape.

Myth 6: ‘Small breasts do not allow to produce enough milk’ myth
Breast size has no influence on the amount or quality of milk produced. Lactation is determined by hormones.

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