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Nutrition in Special cases - Pregnancy and Lactation
 
Pregnancy
Adequate nutrition before and during pregnancy has a great impact on not only the health of the expectant mother but also give the infant a good foundation. It has been observed that when the child is malnourished in the fetal stage, he is prone to a host of diseases in his childhood and adulthood. Maternal nutrition is complex influence by many factors like genetic, social and economic. Physiological adaptations result in improved utilization of nutrients either through increased absorption, decreased excretion or alterations inn metabolism.

A woman who has been well nourished before conception begins her pregnancy with reserves of several nutrients so that the needs of the growing fetus can be met without affecting her health. The increase in nutritional requirements depends on the nature of metabolic pregnancy and nutrition reserves of the mother.
 
Nutritional Guidelines
Energy: Energy needs during pregnancy increase because of the additional energy required for growth and physical activity of the fetus, normal increase in maternal body size, additional work involved in carrying the weight of the fetus and extra maternal tissues and steady rise in the basal metabolic rate. Energy needs of a pregnant woman is around 300 kcal more than a normal adult lady. The caloric requirements of a pregnant woman is mostly increased in the latter half of the pregnancy. The increase in energy trimester wise id 10 kcal/day in the first trimester, 90 kcal/day in the second and 200kcal/day in the third. Any decrease in the activity of the mother decreases the caloric requirement. When the supply of calories are inadequate the fat reserves would be used to meet the high energy demands. This results in the increase of urinary excretion of ketones during the first trimester. The foetus does not accumulate any fat except in the cell walls and systems. All fat is synthesized from glucose except linoleic acid which is transferred from the mother to the child. Details of the requirements are mentioned in the Recommended Dietary Allowance (RDA).

Protein: the protein requirement of a pregnant lady is 15g more than that of any adult lady. This additional protein is essential for the growth of the fetus, increase in maternal tissues, increase in blood volume and other bodily fluids. If the protein requirements are not met during this stage it could risk the pregnancy or the fetus would grow at the mother’s expense or the fetus would not achieve maximal growth especially in the brain tissues.

Linolenic acid: it is an essential fatty acid. The requirements during pregnancy is 4 -4.5 energy %. That means the invisible fat coming from different foods should be 12.5 en % and the visible fat coming from oils and other fat sources should be 30g/day.

Iron: the total iron requirement for the entire pregnancy is 810 mg. the actual increase in iron is in the second and third trimester. But a single large dose of iron at the beginning of the pregnancy is an effective way to build up the iron stores to protect against depletion of reserves. Liver, dried beans, dried fruits, green leafy vegetables, eggs, iron fortified cereals and salt, rice flakes provide additional iron.

Fibre: Fibre is an important constituent of diet especially for the pregnant woman. This is because fibre helps prevent constipation which is a common dietary problem at this stage
Minerals:
Sodium: Normal sodium level should be provided to a pregnant woman to prevent any defective disorders and deficiency. During pregnancy there is an increase in extra cellular fluid. Sodium deficiency can cause an increased risk of eclampsia, prematurity and low birth weight of infants. But sodium is restricted in case of oedema (water retention) and hypertension (increased blood pressure).

Iodine: Iodine deficiency in mother can lead to abortion, still births, congenital defects, infant deaths, cretinism and psychomotor defects. Iodized salt is a good source of iodine.

Zinc: Zinc deficiency during the antinatal period can have adverse effects on the infant like foetal mortality, malformations, problems with the central nervous system and reduced intra uterine growth rate. Low zinc levels increase the chances of low birth weight and preterm delivery.
Fat Soluble Vitamins
Vitamin A: Vitamin A requirements are the same as any adult woman. But if the pregnant woman itself is vitamin A deficient then the appropriate supplementation should be give to meet both the mother’s and fetus’s demand.

Vitamin D: It is essential as it enhances maternal calcium absorption. Maternal deficiency of Vitamin D leads to low levels of calcium in the infant. Excessive calcium can lead to many complications like atherosclerosis, calcium deposits in the various vital organs and mental retardation in infants.

Vitamin E: Vitamin E deficiency can cause pregnancy failure.

Vitamin K: It is essential for normal blood clotting. It is extremely essential to prevent neonatal hemorrhage.

Water Soluble Vitamins
As the water soluble vitamins are not stored in the body has to rely on the daily consumption only. Generally the maternal water soluble vitamins tend to fall and the foetal levels rise by 50 –100% during pregnancy.

Vitamin B1 (Thiamine): For a pregnant woman the requirement is increased by 0.2mg/day than an adult woman. The relationship between energy and B1 is that per 1000 calories 0.5 mg of the vitamin is required. B1 also helps relieve nausea.

Vitamin B2 (Riboflavin) : In pregnant woman the dietary allowance is increased by 0.2 mg/day. The requirements are high due to growth in the maternal body size and foetus and accessory tissues. Studies have shown lack of B2 interferes with the cartilage formations leading to skeletal malfunctions.

Vitamin B3 (Niacin): Niacin requirement is increased by 2 mg/day. The body metabolism of conversion of amino acids into niacin is very efficient during pregnancy.

Folic Acid: The folic acid demands of a pregnant woman are four times the normal adult demands (400 µg/day). The recommended demands are based on on its role to promote normal foetal growth and preventing anemia. Folic acid deficiency results in malformations and neural tube defects like spinal bifida. Folic acid deficiency can lead to absence of brain. Women bearing children should be encouraged to include folic acid sources like dark green leafy vegetables, legumes, orange juice, soya, wheat germ, almonds and peanuts. Ideally the supplementation should begin when the women plans conception itself.

Vitamin B12 (Cobalbumin): The vitamin requirement is same for adults and pregnant woman. The fetus has priority over B12 over mother, the foetal blood has twice the amount of B12 even when the maternal levels are depleted. The capacity of a woman to absorb the vitamin is enhanced. Vegetarian mothers have more chances of of getting B12 deficiency.

Vitamin C: The vitamin recommendation is the same as an adult woman. In pregnancy the vitamin content of foetal blood is thrice as much as the maternal blood. Low Vitamin C levels are associated with the premature rupture of foetal membranes and increased neonatal death rates.
Share of Nutrients in Pregnancy
  • Nutrients given to fetus at the expense of mother – folic acid, iron, Vitamin C and B12
  • Nutrients for which the mother and fetus compete – B1, B2, B6 and D
  • Nutrients for which mother has priority over fetus – Vitamin A and Iodine
  • Nutrients stored in fetus – Vitamin A and Iron
  • Nutrients not stored in fetus – Vitamin C, D and Calcium
 
Dietary Guidelines
  • Eat small and frequent meals. Avoid fasting or missing a meal.
  • More fibre should be introduced in the diet to prevent constipation by adding whole fruits and vegetables.
  • Diet should be rich in calcium. Calcium supplements may also be taken.
  • Iron rich foods should be taken to prevent anemia and but up the foetal reserves of iron.
  • Diet should contain the right amount of sodium. Sodium should be restricted if odema or hypertension is present.
  • Inclusion of green leafy vegetables in the diet as much as possible.
  • Plenty of water should be taken.
  • Fatty rich foods, fried foods, excessive seasoning, strongly flavored vegetables may be restricted in case of nausea and distress.
  • Fluids should be taken between meals rather than along with meals.
  • Adequate amount of calories should be taken so that enough fat is deposited during pregnancy which is required for lactation later.
Dietary Problems during Pregnancy
  • Nausea and Vomiting
  • Constipation
  • Oedema (water retention ) and leg cramps
  • Heartburn
  • Avoidances and Cravings
Complications that can occur during Pregnancy
  • Anaemia
  • Pregnancy induced Hypertension
  • Hypertension
  • Gestational Diabetes
Lactating Women
The nutritional link between the mother and the child continues even after birth. The newborn baby depends for almost six months on breast milk for his existence. Lactating mother’s nutritional requirements should meet her own needs, provide nutrients for the infants and furnish the energy for the mechanics of milk production. Nutritional values exceed during lactation compared to pregnancy. During the six months of exclusive breast feeding the infant double the birth weight. Analysis of the breast milk has shown that there is a considerable difference in its composition from woman to woman and it greatly depends on the nutritional status of the lactating mother. Successful lactation is dependent not only on adequate nutrition but also upon sufficient rest, freedom from anxiety and desire to nurse the baby.
 
Nutritional Requirements
Energy: Energy requirements are higher by 550 kcal for the first six months and 400 kcal during the next six months then it is back to the Recommended Dietary Allowance (RDA) for adults. Women produce 650 – 1000 ml of milk and per 100 ml the caloric value is 65. The metabolic work involved in the milk production requires 400kcal. The additional energy is drawn from the maternal adipose tissue laid down during pregnancy.

Protein: During lactation protein requirement has been computed on the basis of secretion of milk of 9.4 g/day during 0 – 6 months and 6.6 during 6 – 12 months. Assuming the conversion of dietary protein into milk protein is 70% and a 25% is the individual variation. If energy or protein is lacking there would be a reduction in milk volume rather than quality. The availability of more than required energy or protein does not enhance the amount of protein in milk or its volume.

Fats: Although the amount of fat in breast milk is not influenced by maternal fat intake, the composition of the milk fat reflects the composition of the mother’s diet. The requirement of linoleic acid during lactation increases to 5.7 energy %. Invisible fat requirement is 17.5 en% and visible fat should be 45g.

Calcium: The increased amount of calcium that is required during gestation for mineralization of the foetal skeleton is now diverted into the mother’s milk production. The requirement is 1000 mg of calcium this need can be met with 500 ml of milk or its products.

Iron: The iron requirement during lactation remains the same as an adult woman. The baby is born with a relatively large reserve of iron as milk is not a good source. Even if the mother’s diet is iron rich this iron is not transferred to the child.

Vitamin A: The quantity of vitamin A in 650 ml of human milk is 300mcg. So the recommendation is 650mcg.

Vitamin B: As the calorie and protein requirements are increased during lactation, B vitamin requirements are also increased.

Vitamin C: The additional needs during lactation are calculated on the basis of the vitamin C secreted in milk. As cooking destroys 50 % of the vitamin C present in foods, the recommendation is 40g more than what is required.

Fluid: An increased intake of fluids is necessary for adequate milk production.
 
Dietary Guidelines
  • The diet should include foods that increase lactation like milk, almonds, garlic, garden cress seeds and foods of animal origin. Special recipes that have been given to mother for decades like ‘sooth ka ladu’ and ‘goond ka ladu’ should be promoted as these increase lactation.
  • Weight gain beyond desirable body size should be avoided. When the baby is weaned the mother should reduce her diet to avoid developing obesity.
  • Constipation is a common occurrence at this stage and it can be avoided by consuming fibre sources like whole fruits, vegetables especially salads.
  • No food should be withheld from the mother unless it causes distress to the child.
  • If the mother is under 17 and has had multiple gestation, additional care should be taken in meeting nutritional needs.
  • If the mother losses weight rapidly during lactation then caloric intake should be increased.
  • Lactating mother should also perform moderate levels of exercise (Physical activity; types of exercise), care should be taken that the exercise is not too strenuous or else it may adversely affect lactation.
 
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